Pulmonary embolism in the maxillofacial scenario
Year: 2025
Type: article
Abstract: Dear Editor, In the field of maxillofacial surgery, with the increasing scope and ability to perform complex surgeries and the advent of general anesthesia, comes an array of complications that are mostly limited to the surgical site, some of which are potentially life-threatening. Some of these complications are preventable, yet some lead to the early death of a patient. One such complication is pulmonary embolism, which is a sequel of venous thrombosis and eventual clot propagation to lung vessels, blocking the blood supply, increasing cardiovascular burden, and finally resulting in death. The incidence of pulmonary embolism after major surgeries is most common after orthopedic and gynecological surgeries, but in the case of maxillofacial surgeries, the incidence is rare, about 0.4%.[1] Few patient-related and surgery-related factors can make a patient high-risk for developing a pulmonary embolism. These include lengthy surgeries, prolonged immobilization, major trauma, malignancy, the presence of a central venous catheter, a previous history of thromboembolic events or pulmonary embolism itself, old age, obesity, pregnancy, smoking, and individuals on oral contraceptives or hormone replacement therapy. In some acute cases in high-risk individuals, pulmonary embolism can be a silent killer leading to early mortality even before the appearance of symptoms and diagnosis of the embolus. There are reports of the incidence of deep venous thromboembolism and/or pulmonary embolism after dental implant placement, tooth extraction leading to cervical thrombophlebitis, maxillofacial trauma, orthognathic surgery, oral oncologic surgery, and reconstruction. Even though the incidences are scarce, the results can be fatal yet preventable. Signs and symptoms of pulmonary embolism include dyspnea, chest pain, hemoptysis, syncope, and sinus tachycardia. Deep vein thrombosis, usually of the lower extremity, precedes pulmonary embolism. Sudden onset chest pain, lowered oxygen saturation values, lower extremity pain, and swelling should raise the suspicion of pulmonary embolism in a postoperative patient. The investigation of choice includes D-dimer assay, ultrasonography, magnetic resonance venography (MRV), computed tomographic venography (CTV), and pulmonary angiography. PREVENTIVE STRATEGIES Not all deep venous thromboembolic events lead to pulmonary embolism if they are adequately prevented. Preoperative Measures: Categorize patients based on their risk of venous thromboembolic events and pulmonary embolism. Optimize blood coagulation problems beforehand to prevent embolism. Multidisciplinary consultation, that is, with hematologists and thoracovascular specialists, is necessary for individuals at risk. Habit counseling plays a part, as habit history is quite prevalent in oral cancer individuals. Intraoperative Measures: Use intermittent pneumatic compression to facilitate effective venous return from the lower extremities. Ensure optimal fluid input and reduce intraoperative time by adopting a two-team approach in cases where resection and reconstruction are planned simultaneously. Postoperative Measures: Encourage early mobilization. Mechanical prophylaxis includes using high-thigh compression stockings to increase venous return. Medical prophylaxis includes administering low molecular weight heparin as thromboembolism prophylaxis. In the field of maxillofacial surgery, even though the overall incidence of pulmonary embolism is the very low, the majority are associated with oncologic surgeries due to their long duration. However, the prevalent use of low molecular weight heparin and low-dose aspirin as flap thromboembolism preventive measures in case of microvascular reconstruction helps prevent venous thromboembolism and pulmonary embolism. In other surgeries, prophylaxis is restricted to individuals who fall under high risk, yet no clear consensus is available in this area for maxillofacial surgeries.[2] MANAGEMENT OPTIONS Pulmonary embolism is managed based on the hemodynamic stability of the patient. Therapeutic options range from long-term oral anticoagulants to surgical embolectomy. Prompt identification and early referral to a cardiothoracic specialist prevent morbid outcomes. CONCLUSION With the ever-increasing ability of a maxillofacial surgeon to perform high-end surgeries like microvascular reconstruction, complex cases of orthognathic surgeries, and panfacial trauma, comes the responsibility to effectively deal with rare complications like pulmonary embolism. Even though it can occur after minor surgical procedures, one should weigh the risk factors considering both patient and surgical factors. Considering pulmonary embolism as a potential complication and implementing preventive strategies can help reduce the incidence and morbidity resulting from it.
Authors: Uma Shanker Pal, M. V. Sowmya
Language: English
Subfield: Internal Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W7117315459