Sustained bilateral middle ear effusions post orthognathic surgery successfully treated with grommet insertion

A 22-year-old woman underwent a Le Fort I maxillary osteotomy to correct a class III malocclusion with maxillary hypoplasia after prior orthodontic treatment. The maxillary movements during the osteotomy consisted of a 4 mm advancement and 2 mm posterior impaction. The surgery was uneventful. Post-operatively, the patient gained an excellent aesthetic and functional result. Four months post orthognathic surgery, the patient commented on reduced hearing in both ears since her operation. There were no symptoms of otalgia, otorrhoea, tinnitus or vertigo. The patient had no history of prior otological problems and had no medical co-morbidities. After a two-year period, when the patient was seen in her local otolaryngology department and recommended various treatments (which she declined), she requested a second opinion and was seen in the otolaryngology department of the hospital where her original surgery had been performed. The patient’s auditory symptoms persisted during this time and it was noted that she also suffered from bilateral nasal congestion with hyposmia. On examination, both external auditory canals were healthy. Both tympanic membranes appeared congested suggestive of middle ear effusions. Anterior rhinoscopy revealed a mildly deviated nasal septum to the left but with good airflow bilaterally. Nasendoscopy revealed rhinitic nasal mucosa without middle meatal pathology and a healthy post nasal space. Pure tone audiometry (PTA) revealed mild bilateral conductive hearing loss (Figure 1a). Tympanometry revealed bilateral flattened (type B) traces confirming bilateral middle ear effusions. It was decided to proceed with bilateral grommet insertion to improve her middle ear ventilation and hearing. The patient was also commenced on a trial of topical nasal steroids to treat her rhinitis as well as possibly improving her Eustachian tube function. The patient underwent bilateral grommet insertion under general anaesthetic approximately 30 months after the onset of her auditory symptoms. An antero-inferior myringotomy was performed on both tympanic membranes and thick glue-like fluid was suctioned from both middle ear cavities. Shah grommets were then inserted bilaterally. Examination of the post nasal space was unremarkable. The patient was well postoperatively and was discharged with a one-week course of antibiotic/steroid ear drops. The patient was reviewed back in the otolaryngology clinic six weeks after grommet insertion. Her hearing had improved and this was confirmed on PTA (Figure 1b). On examination, both grommets were noted to be in situ and patent. Her nasal congestion was also noted to be improved.