Bilateral pneumothorax after orthognatic surgery
A 28-year-old female with clinical history and instrumental evaluation before surgery, negative for metabolic and clinical pathologies [], was treated with a Le Fort I osteotomy and BSSO sec. Gotte6 because of a dentoskeletal 3rd class. Surgical procedure started with difficulties in the endonasal intubation and consequent bleeding from turbinates. During surgery there was a bleeding from the left side of the retro molars venous vessel, probably cut during mandibular osteotomy. Haemorrhage was stopped by electro-coagulation and positioning of a fibrin glue patch. Surgery ended with inter-maxillary rigid fixation. The patient was transferred to an Intensive Care Unit for 24 h. She was estubated the day after at 8:45 a.m., with good cardio-pulmonary compensation. Postoperative thorax X-ray was negative []. She was transferred back to our department at 12:00 p.m. with no clinical sign of airway impairment.\nAt 4:00 p.m. sudden dispnea associated with moderate emphysema of the cheek and peri-orbital area was seen. At 6:00 p.m. severe and sudden decrease of arterial saturation occurred, and the patient became confused; increase of the emphysema was observed that was progressively extending to the neck and the upper third of the anterior thorax. The patient was immediately transferred to the Intensive Care Unit. Removal of intermaxillary fixation (IMF), oral intubation, and a thorax X-ray showed a right tension pneumothorax, with mediastinum left shifting []. The intercostal drain (Pleurevac) was positioned into the right side []. A thorax X-ray after 4 h and a computed tomography (CT) showed a contralateral pneumothorax. This was treated with another intercostal drain (Pleurevac).\nThorax X-ray was performed every 2 days; after 7 days it was possible to restore the IMF. Both drainages were kept in site for 18 days. No further consequences, no neurological sequelae, no infections, and no other osteotomies sequelae were seen.