Int. J. Oral Maxillofac. Surg.

2009; 38: 321–325

doi:10.1016/j.ijom.2009.01.006, available online at http://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

Changes in acoustic airway S. Haarmann1,5, A. S. Budihardja2,5,

K.-D. Wolff3,5, K. Wangerin4
1
Department of Oral and Maxillofacial

profiles and nasal airway

Surgery, Evangelisches Krankenhaus,
Hattingen, Germany; 2Department of Oral
and Maxillofacial Surgery, Gajahmada
University, Yogyakarta, Indonesia;

resistance after Le Fort I 3

Department of Oral and Maxillofacial-Plastic
Surgery, Technische Universität München,
Germany; 4Department of Oral and
Maxillofacial Surgery, Marienhospital

osteotomy and functional Stuttgart, Germany; 5At the time this

manuscript was written, Department of Oral
and Maxillofacial- Plastic Surgery Ruhr

rhinosurgery: A prospective University of Bochum, Germany

study
S. Haarmann, A. S. Budihardja, K.-D. Wolff, K. Wangerin: Changes in acoustic
airway profiles and nasal airway resistance after Le Fort I osteotomy and functional
rhinosurgery: A prospective study. Int. J. Oral Maxillofac. Surg. 2009; 38: 321–325.
# 2009 International Association of Oral and Maxillofacial Surgeons. Published by
Elsevier Ltd. All rights reserved.

Abstract. The aim of this study was to investigate the changes in nasal airways after
Le Fort I osteotomy and functional rhinosurgery. 49 patients were included in this
study to assess intranasal anatomical and functional changes resulting from a Le
Fort I osteotomy. The data were classified according to the three-dimensional
positioning of the maxilla: in group I the maxilla was impacted; in group II the
maxilla was inferior; and in group III only sagittal maxillary movement was
performed. Presurgical and 5 months postsurgical rhinological inspection, anterior
rhinomanometry and acoustic rhinometry were carried out. Additional
rhinosurgery, such as resection of the inferior concha or septoplastic intervention,
was performed to avoid functional problems in nasal breathing, particularly when
the maxilla was impacted. Rhinomanometric assessment showed a significant
improvement in nasal breathing in the whole group and each single group. Acoustic
rhinometry revealed an increase in typical cross-sectional intranasal areas. The
Keywords: Le Fort I osteotomy; rhinosurgery;
authors conclude that concerns about the respiratory consequences of this surgical nasal airway; rhinomanometry.
procedure appear unwarranted when functional rhinosurgery is undertaken
concomitantly, particularly in patients with increased preoperative nasal airway Accepted for publication 16 January 2009
resistance. Available online 23 February 2009

0901-5027/040321 + 05 $36.00/0 # 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
322 Haarmann et al.

In the past decades, Le Fort I osteotomy Table 1. Group I: Le Fort I osteotomy with 150 Pa. Indications for nasal surgery were
has been increasingly used for the correc- impaction. increased nasal resistance, an obvious
tion of dentofacial deformities. In orthog- Group I deviation of the septum, concomitance of
nathic surgery this versatile technique is Impaction of maxilla [3.7 mm (0.53)] n = 21 a bony groin or a hypoplastic inferior tur-
widely used to correct maxillary hypopla- Resection of the inferior concha 16 bine after decongestion with 0.01% napha-
sia and hyperplasia, and in the manage- Shortening of the nasal septum 18 zoline tamponade for 15 min. Lateral
ment of skeletal anterior open-bite, as seen Contouring of pyriform aperture 10 cephalometric radiographs, models and
in the long-face syndrome13,28. Correction Correction of the septum 2 orthopantomograms were taken and ana-
of these deformities often involves ante- lysed preoperatively. To ensure complete
rior, inferior or superior repositioning of wound healing and a stable bony consoli-
the maxilla and a combination of these Table 2. Group II: Le Fort I osteotomy with dation all patients underwent the same
movements25. Maxillary movement inferior repositioning of the maxilla. procedure 5 months after surgery.
always affects nasal breathing by chan- Group II In only 2 patients, interpositional bone
ging the intranasal dimensions. Numerous Inferior repositioning of maxilla [2.7 mm grafts were harvested from the hip (crista
measurements of nasal airway resistance (0.38)] n = 21 illiaca anterior) to stabilize the maxilla in
before and after Le Fort I osteotomy have Resection of the inferior concha 6 the canine region without affecting the
been made since the introduction of the Shortening of the nasal septum 10 nasal floor.
‘down-fracture’ technique by Obwegeser Contouring of pyriform aperture 3
as a standard method in orthognathic sur- Correction of the septum 4
Nasal airflow measurements
gery2,10,14,15,17,19,25,26,27,29,30,31. Operative
displacement of the maxilla was originally To assess the nasal airflow of each patient
described by WASSMUND32 and AXHAUSEN1. Table 3. Group III: Le Fort I osteotomy with and to provide an objective quantification
None of these studies described the no vertical maxillary displacement. of nasal airway resistance, a technique
metric changes of the nasal cavity in rela- Group III known as anterior active mask rhinoma-
tion to the surgical maxillary movement No vertical maxillary displacement nometry was used. Rhinomanometry is a
because flow measurement only reflects Only anterior sagittal movement [(2.1 mm well established and reliable technique
nasal resistance caused by the narrowest 0.4)] n = 7 that measures nasal patency in terms of
site of the nose. Acoustic rhinometry was Resection of the inferior concha 1 nasal airflow and resistance to airflow. The
introduced by Hilberg et al. in 1989 as an Shortening of the nasal septum 4 pressure–flow relationship detected during
objective method for examining the nasal Contouring of pyriform aperture 4 respiration reflects the functional status of
cavity18. It determines the cross-sectional Correction of the septum 4 the nasal airway. For this study the Rhin-
areas of the nose depending on the dis- nomanometer ATMOS 2000 (Medizin-
tance to the nostril. Software calculates the technik GmbH, Lenzkirch, Germany)
cross-sectional areas on the basis of reflec- external nose. Metric maxillary movement was used. Using a mask technique and a
tion time, change in frequency and ampli- was determined by lateral cephalometric pressure nozzle, placed to occlude one
tude of sound waves applied to the nose. radiographs and orthodontic treatment nostril, it was possible to measure the
Using this method intranasal airway plans. The data were classified according pressure difference between the non-
changes can be localized. to the positioning of the anterior maxilla: occluded nasal airway and the atmo-
Studies that combine both methods are in group I (n = 21) the maxilla was sphere. The pressure difference (P) and
rare. In 1997, Kunkel and Hochban were impacted; in group II (n = 21) the maxilla transnasal airflow (V) were measured at
the first to describe the effect of maxillary was inferior; and in group III (n = 7) only the same time. The recorded values were
movement on nasal volume using acoustic sagittal maxillary movement was per- visualized by a dual channel recorder.
rhinometry but without performing nasal formed. In group I the average amount Transnasal airflow (ml/s) and pressure
resistance measurements19. Erbe et al. of impaction was 3.7 mm (0.53) with a values (Pa) are normally used to calculate
combined acoustic and aerodynamic maximum of 12 mm; in group II there was the uninasal resistance using Ohm‘s law.
assessment in 2001, but only 21 patients, inferior repositioning of 2.7 mm (0.38) Nasal resistance (R) is equal to the ratio of
in whom the maxilla was impacted and with a maximum of 7 mm; in group III pressure drop across the nose (DP) over
advanced, were included in the study14. only sagittal anterior movement the volume rate of nasal airflow (V). Each
The aim of this study was to investigate (2.1 0.4 mm) with a maximum of nasal cavity was investigated individually.
changes in nasal airways after Le Fort I 4 mm was performed. Functional rhino- By transferring the pressure nozzle to the
osteotomy and concomitant functional surgery was performed in all groups, other nostril the resistance value for the
nasal surgery using anterior rhinomano- including resection of the inferior concha, contralateral side was obtained. The
metry and acoustic rhinometry. shortening the nasal septum, contouring values were used to calculate the total
the pyriform aperture and correction of the nasal airway resistance. According to
nasal septum (Tables 1–3). the recommendations of the International
Material and Methods
One week before surgery, all patients Committee on Standardization of Rhino-
49 patients, aged 17–74 years (mean age underwent a standardized examination manometry the authors used the flow mea-
24.8 years), were included in this prospec- including anterior rhinological examina- surements at DP = 150 because at this
tive study. They underwent orthognathic tion, anterior rhinomanometry and acoustic pressure difference there is a laminar air-
surgery at the Department of Oral and rhinometry. Conspicuous findings, such as flow during inspiration.
Maxillofacial Surgery, Marienhospital a deformity of the septum and hyperplasia To evaluate the intranasal dimensions
Stuttgart, Germany, between May 2002 of the concha, were documented. Normal and to detect changes in geometry the
and February 2003. None of the patients nasal breathing was assumed at a total nasal authors used acoustic rhinometry, intro-
had had previous surgery on the internal or airflow of 800 ml/s and pressure values of duced by Hilberg et al (1989) as an
Changes in acoustic airway profiles and nasal airway resistance after Le Fort I osteotomy and functional rhinosurgery 323

objective method for examining the nasal

cavity18. This technique is based on the
principle that a sound pulse propagating in
the nasal cavity is reflected by local
changes in acoustic impedance. These
measurements were obtained with the
acoustic rhinometer Rhinoklack 10001
(Stimotron, Medizinische Geräte GmbH,
Wendelstein, Germany).
A sound source emits a pressure wave
of 55 dB for 0.2 ms which is conducted to
the airway through a tube (100 cm length,
2 cm diameter) via a standardized nose-
piece 7.5 cm in length. The amplitude and
traveling time of the incident and reflected
pressure waves are recorded during a time
window of 10 ms to calculate an area–
distance function of the nasal cross-sec-
tional dimensions. To avoid the risk of
expanding the anterior valve area with the
conical nosepieces the authors applied Fig. 1. Pre- and postoperative measurements in cross-sectional area (cm2) in the isthmus area.
anatomical adapters that have a minor
sound leakage between the rim of the
nostril and the adapter. A series of records The cross-sectional areas of the nose ior to the sinus ostia, acoustic rhinometry
was taken 20 min after topical deconges- and airflow increased significantly after overestimates the cross-sectional area5.
tion with naphazolin for each nostril, to Le Fort I osteotomy. Consequently, the The most significant finding in this
exclude changes caused by mucosal swel- volume of the anterior nose also increased. study was an objective improvement in
ling. The smallest cross-sectional area on patients’ nasal airway function after max-
the measurement curve can be identified illary movement via Le Fort I osteotomy,
as I-notch and reflects the nasal isthmus regardless of the direction of movement.
Discussion
area. The second restriction in the nose, C- A significant increase in cross-sectional
notch, corresponds to the head of the lower Rhinomanometry and acoustic rhinometry areas was seen at the isthmus nasi and in
nasal concha and the intumescentia septi. are reliable and objective methods of the region of the concha nasalis inferior in
Statistical analysis was carried out determining functional and geometric cases where maxillary impaction (group
using Student’s t-test. Results are pre- changes in the nasal cavity after Le Fort I), inferior positioning (group II) or only
sented as mean standard error of the I osteotomy4,6–9,24. The cross-sectional sagittal movement (group III) were per-
mean (SEM). Values of p < 0.05 were areas determined by acoustic rhinometry formed. Anterior nasal volume and airflow
considered significant. correlate well with computed tomography increased significantly in all three groups.
(CT) data particularly in the anterior nasal This improvement seems to be an unex-
cavity. There is some evidence that poster- pected finding, but it can be explained by
Results
Statistically significant changes in intra-
nasal dimensions and functional para-
meters were measured with both
rhinometric methods used in the present
study (p < 0.05). Acoustic rhinometry
revealed an increase of typical cross-sec-
tional intranasal areas. Postoperatively the
isthmus nasi and concha nasalis were
enlarged. Rhinomanometric assessment
showed a significant improvement in nasal
breathing in the whole group and in each
single group.
The results of cross-sectional and nasal
resistance measurements using acoustic
rhinometry and rhinomanometry preo-
peratively and 5 months postoperatively
are shown in Figs. 1–3.
The changes in cross-sectional areas of
the isthmus nasi and concha nasalis ante-
rior are shown in Figs. 1 and 2. Pre- and
postoperative nasal-resistance values are
shown in Fig. 3. Fig. 4 shows the changes Fig. 2. Pre- and postoperative measurements in cross-sectional area (cm2) in the concha inferior
in the anterior nasal volume after surgery. area.
324 Haarmann et al.

In all the patients in this study, an alar

cinch suture with non-absorbable material
was undertaken. In accordance with the
laws of aerodynamics, the pressure differ-
ence in laminar flow is inversely propor-
tional to the diameter to the power of four,
and in the case of turbulent flow even to
the fifth power, thus respiratory resistance
can react highly sensitively to small struc-
tural changes21,22,24. The dimensions and
shape of the airway lumen and airflow
velocity determine the magnitude of resis-
tance to airflow. Resistance to airflow
varies inversely and exponentially with
lumen cross-sectional area and, since
lumen dimensions are small in the nasal
valve region, valve resistance is very sen-
sitive to structural and/or vascular mural
displacements23. After surgery, the most
anterior dimensions of the nose increased.
Fig. 3. Pre- and postoperative measurements of anterior nasal volume (cm3). This can be explained by rhinosurgery and
additional surgical procedures, such as
transversal widening of the maxilla or
functional changes, especially in the ante- nasal valve might reduce nasal airway contouring of the apertura piriformis,
rior nose. resistance by opening the nasal valve. which were performed at the same time33.
The nasal valve area is the narrowest Data from acoustic rhinometry show an Surgical correction of mechanical air-
portion of the nasal passage accounting increase in diameter of the valve area way obstruction is commonly attempted
for most airflow resistance6,11. The nasal paradoxically when superior movement using septoplasty or turbinate resection.
valve area is teardrop shaped, bounded by of the maxilla is made. Maxillary advance- These procedures have been devised to
the nasal septum, the caudal ends of the ment tends to increase the nasolabial increase nasal airflow7. After turbinect-
lateral cartilage, the soft fibro fatty tissue angle, increasing the vertical axis of the omy of the inferior nasal concha the entire
overlying the pyriform aperture, and the valve area. This results in a more favour- nasal flow can change its flow pattern
floor of the nose20. All these anatomical able inflow of air into the nasal cavity and resulting in a better ventilated nasal cav-
structures were affected by Le Fort I osteot- respiratory resistance14. An increase in the ity12. It is widely accepted that inferior
omy and additional rhinosurgery. Small width of the alar base is commonly turbinectomy is a safe and effective pro-
changes in the nasal valve area can produce observed especially after maxillary impac- cedure to relieve nasal obstruction caused
significant changes in nasal airflow3,16,20. tion surgery. Supplementary surgical pro- by chronic obstructive inferior turbinates.
Maxillary movement leads to changes cedures, such as an alar cinch, may also The main structure contributing to nasal
in external nose dimensions, most com- improve nasal breathing by changing the obstruction is the inferior turbinate, which
monly an increase in the alar base width. external nares from narrow slits to more contains most of the nasal erectile tissue.
This widening of the basal portion of the ovoid forms postoperatively3. Turbinectomy was undertaken in many
patients (Tables 1–3), but mostly per-
formed in group I, when impaction of
the maxilla made enlargement of the inter-
ior nose space necessary.
According to the authors’ data it seems
obvious that functional changes to the
internal and external nose, performed
directly by rhinosurgery or indirectly by
maxillary movement, tend to improve
nasal breathing. This study indicates that
in the 49 patients studied, Le Fort I osteot-
omy usually decreases nasal resistance.
This finding corroborates other previous
aerodynamic studies suggesting that max-
illary repositioning opens internal nose
dimensions, thus reducing nasal resis-
tance, whether or not the nasal floor is
elevated by Le Fort I osteot-
omy15,17,27,28,29,30.
In conclusion, this study showed that
superior positioning of the maxilla did not
increase resistance to nasal breathing in
Fig. 4. Pre- and postoperative measurements of airflow (cm3/s). the patients studied, whether or not the
Changes in acoustic airway profiles and nasal airway resistance after Le Fort I osteotomy and functional rhinosurgery 325

surgical procedure elevated the floor of the 8. Cole P, Fastagand O, Forsyth R. 21. Mlynski B, Grutzenmacher S,
nose. Concern about the respiratory Variability in nasal resistance measure- Mlynski B, Plontke S, Mlynski G.
effects of this surgical procedure appears ments. J Otolaryngol 1980: 9: 309–315. Acoustic rhinometry and paranasal cav-
unwarranted when additional functional 9. Constantin MB, Clardy BR. The rela- ities: a systematic study in box models.
tive importance of septal and nasal valvular Laryngoscope 2003: 113: 290–294.
rhinosurgery is undertaken. In cases of surgery in correcting airway obstruction in 22. Numminen J, Ahtinen M, Huhtala H,
maxillary impaction, functional rhinosur- primary and secondary rhinoplasty. Plast Laranne J, Rautiainen. Correlation
gery should be considered routinely, if Reconstr Surg 1995: 98: 38–54. between rhinometric measurement meth-
nasal breathing is reduced preoperatively. 10. de Mol van Otterloo JJ, Leezenberg ods in healthy young adults. Am J Rhinol
The combination of rhinomanometry and JA, Tuinzing DB, van der Kwast WA. 2002: 16: 203–208.
acoustic rhinometry allows better assess- The influence of the Le Fort I osteotomy 23. Numminen J, Ahtinen M, Huhtala H,
ment of the structure and function of the on nasal airway resistance. Rhinology Rautiainen M. Comparison of rhino-
nose. The methods complement each other 1990: 28: 107–112. metric measurements methods in intrana-
in their diagnostic outcome, particularly in 11. Delank KW, Keller R, Stoll W. Mor- sal pathology. Rhinology 2003: 41: 65–
phology and rhinologic importance of 68.
determining the area of airway resistance.
intumescentia septi nasi anterior. Laryn- 24. Numminen J, Dastidar P, Heinonen T,
gorhinotologie 1993: 72: 242–246. Rautiainen M. Reliability of acoustic
12. Elbrond O, Hilberg O, Felding JU, rhinometry. Respir Med 2003: 97: 421–
Funding Blegvad Andersen O. Acoustic rhino- 427.
No funding metry, used as a method to demonstrate 25. Obwegeser H. Surgical correction of
changes in the volume of the nasopharynx small or retrodisplaced maxillae. The
after adenoidectomy. Clin Otolaryngol ‘‘dish-face’’ deformity. Plast Reconstr
1991: 16: 84–86. Surg 1969: 43: 351–365.
Competing interests 13. Epker BN, Turvey TA, Fish LC. Indi- 26. Obwegeser H. Die einzeitige Vorbewe-
Nothing to declare. cations for simultaneous mobilization of gung des Oberkiefers und Rückbewegung
the maxilla and mandible for the correc- des Unterkiefers zur Korrektur der extre-
tion of dentofacial deformities. Oral Surg men ‘‘Progenie’’. Schweiz Mschr Zahn-
Oral Med Oral Pathol 1982: 54: 369–381. heilk 23 1970: 80: 547.
Ethical approval
14. Erbe M, Lehotay M, Göde U, Wigand 27. Spalding PM, Vig PS, Spalding P,
No ethical approval required. ME, Neukam FW. Nasal airway changes Fonseca RJ. The effects of maxillary
after Le Fort I impaction and advancement: surgery on nasal respiration. Int J Adult
anatomical and functional findings. Int J Orthodon Orthognath Surg 1991: 6: 191–
References Oral Maxillofac Surg 2001: 30: 123–129. 199.
15. Götzfried HF, Masing H. On the 28. Stoker NG, Epker BN. The posterior
1. Axhausen G. Zur Behandlung veralteter, improvement of nasal breathing follow- maxillary ostectomy: a retrospective
disloziert geheilter Oberkieferbrüche. ing mid-face osteotomies, and possible study of treatment results. Int J Oral Surg
Dtsch Zahn Mund Kieferheilk 1934: 1: reasons for the phenomenon. J Maxillofac 1974: 3: 153–157.
334. Surg 1984: 12: 29–32. 29. Timms DJ. The effect of Le Fort I max-
2. Bell WH. Le Fort I osteotomy for cor- 16. Grymer L, Hilberg OF, Pedersen OF, illary impaction on nasal airway resis-
rection of maxillary deformities. J Oral Ramussen TR. Acoustic rhinometry: tance. Am J Orthod 1984: 86: 439.
Surg 1975: 33: 412–426. evaluation of the nasal cavity with septal 30. Turvey TA, Hall DJ, Warren DW.
3. Betts NJ. Changes in the Nasal and Labial deviations, before and after septoplasty. Alterations in nasal airway resistance
Soft Tissue After Surgical repositioning Laryngoscope 1989: 99: 1180–1187. following superior repositioning of the
of the maxilla, thesis. University of 17. Guenthner TA, Sather AH, Kern EB. maxilla. Am J Orthod 1984: 85: 109–
Michigan 1999. The effect of Le Fort I maxillary impac- 114.
4. Cakmak O, Coskun M, Büyüklü F, tion on nasal airway resistance. Am J 31. Vig PS, Sarver DM, Hall DJ, Warren
Ozluoglu LN. Value of acoustic rhino- Orthod 1984: 85: 308–315. DW. Quantitative evaluation of nasal air-
metry for measuring nasal valve area. 18. Hilberg O, Jackson AC, Swift DL, flow in relation to facial morphology. Am
Laryngoscope 2003: 113: 295–302. Pedersen OF. Acoustic rhinometry: eva- J Orthod 1981: 79: 263–272.
5. Cankurtaran M, Celik H, Coşkun M, luation of nasal cavity geometry by 32. Wassmund M. Frakturen und Luxationen
Hizal E, Cakmak O. Acoustic rhinometry acoustic reflection. J Appl Physiol des Gesichtsschädels. Meusser. Leipzig
in healthy humans: accuracy of area esti- 1989: 66: 295–303. 1927.
mates and ability to quantify certain ana- 19. Kunkel M, Hochban M. The influence 33. Weinhold I, Mlynski G. Numerical
tomic structures in the nasal cavity. of maxillary osteotomy on nasal airway simulation of airflow in the human nose.
Ann Otol Rhinol Laryngol 2007: 116: patency and geometry. Mund Kiefer Eur Arch Otorhinolaryngol 2003: 12:
906–916. Gesichtschir 1997: 1: 194–198. 122–125.
6. Cole P. Stability of nasal airflow resis- 20. Lang C, Grutzenmacher S, Mlynski
tance. Clin Otolaryngol 1989: 14: 177– B, Plontke S, Mlynski G. Investigating
182. the nasal cycle using endoscopy, rhinor- Address:
7. Cole P. Acoustic rhinometry and rhino- esistometry, and acoustic rhinometry. Andi Setiawan Budihardja.
manometry. Rhinol Suppl 2000: 16: 29–34. Laryngoscope 2003: 113: 284–289. E-mail: [email protected]