Sinusitis after Maxillectomy with Free Flap Reconstruction: Incidence and Clinical Approach

Background: Patients who undergo maxillectomy with free flap reconstruction often have post-operative sinonasal complaints likely arising from anatomic obstruction as well as impaired mucociliary clearance in patients receiving adjuvant radiotherapy. Characteristics of sinonasal disease in this population, including incidence, associated factors, and clinical options, have not been well described.

Methods: A retrospective review was performed including all patients who underwent maxillectomy and free flap reconstruction at Mount Sinai Hospital with at least six months of postoperative care documented in the electronic medical record using a Current Procedural Terminology (CPT) code search. Demographic and clinical characteristics were recorded including type of free flap reconstruction, incidence postoperative sinonasal complaints, and therapeutic interventions. Statistical analysis was performed using Fisher's exact test with statistical significance set at p = 0.05.

Results: A total of 59 patients met study criteria and were included in statistical analysis. 22 patients (37.3%) had documented sinonasal complaints postoperatively. Of these patients, 11 patients (50%) subsequently underwent endoscopic sinus surgery. Six of the 11 patients (54.5%) who did not undergo surgery had an isolated episode of acute bacterial rhinosinusitis successfully treated with oral antibiotics. Among the 22 patients with sinonasal complaints, 19 patients (86.3%) had nasal obstruction, 14 (63.6%) had rhinorrhea, and 10 (45.5%) had facial pain or pressure. There was a higher incidence of both sinonasal complaints and surgical intervention in patients who underwent adjuvant radiation, but this was not statistically significant. (42.2 vs. 21.4%, p = 0.21; 22.2 vs. 7.1%, p = 0.27). There was no significant difference in incidence of post-operative sinusitis in patients undergoing bony compared with soft tissue reconstruction (40.0 vs. 31.6%, p = 0.78; 14.3 vs. 36.0%, p = 0.29). In terms of bony maxillary reconstruction, 23 patients underwent a fibula free flap compared with 16 scapula free flaps and 1 iliac crest free flap. In terms of soft tissue reconstruction, 10 patients underwent anterolateral thigh free flap (ALT) compared with 5 radial forearm free flaps, 3 latissimus free flaps, and 1 supraclavicular free flap. Among patients undergoing surgery, four had undergone anterolateral thigh free flap (40%) compared with three each for scapula (18.8%) and fibula free flaps (12%) and one radial forearm free flap.

Conclusion: Sinonasal complaints are common following free flap reconstruction for a maxillectomy defect and should be screened for at postoperative visits. Patients most commonly present with nasal obstruction and may require surgical intervention for episodes not responding to oral antibiotic therapy. Both sinonasal complaints and surgical intervention were considerably more common in patients undergoing adjuvant radiation, but did not reach statistical significance in our analysis.

Publication History

Article published online:
12 February 2021