Delayed progressive haematoma after Le Fort I osteotomy: A possible severe complication in orthognatic surgery
A 23-year-old man was referred to the Department of Maxillofacial Surgery, University of Verona, Italy for the surgical correction of a class III asymmetric malocclusion []. The patient underwent a Le Fort I osteotomy, with impaction of the maxilla associated with an Epker mandibular bilateral sagittal split ramus osteotomy, with maxillary advancement and rigid internal fixation of the mandible with four miniplates (Osteomed), and four miniplates for the upper maxilla as well. Intermaxillary elastic traction was applied.\nThe patient had a medical history of one wisdom tooth extraction, performed under local anaesthesia. No allergies or congenital or systemic disease were reported. Preoperative vital parameters were: temperature, 36.4°C; heart rate, 62 bpm; blood pressure, 120/65 mmHg; respiration rate, 17 breaths per minute and 100% oxygen saturation. Preoperative laboratory tests showed RBC, 4.86 E + 12/L; Hb, 14.1 g/dL; Ht, 43.1%; coagulation tests were normal (prothrombin time 1.05 INR, activated partial thromboplastin time 1.18 and fibrinogen 241 mg/dL, Clauss method 7.11 μmol/L. The patient received a single-shot antimicrobial prophylaxis using 1 gm of Amoxicillin, in addition to a single dose of corticosteroids (1 gm of Methylprednisolone) one hour before the operation.\nThe surgical procedure was performed in general hypotensive anaesthesia, with the following parameters: Blood pressure, 100/70 mmHg; heart rate, 80 beats per minute and 100% oxygen saturation. Sevoran, Fentanile, Remifentanyle, 1500 ml of crystalloids and 500 ml of colloids were infused. No intraoperative complications occurred.\nThe first post-surgery day, the patient developed a gradual dispnea together with neck swelling. A CAT scan with contrast agent was performed, showing a parapharyngeal thickening, with dislocation and compression of upper airways; laboratory values were Ht, 34.9 %; Hb, 12.3 g/dL; RBC count, 3.81 E + 12/L. After 5 hours, a progressive worsening of the general condition led to immediate intubation. Laboratory results in the emergency room were Ht, 28.2%; Hb, 9.9 g/dL; RBC count, 3.06 E + 12/L; prothrombin time, 1.20 INR, activated partial thromboplastin time, 1.18 and fibrinogen, 452 mg/dL. The patient was sedated with midazolam and diprivan and was given amoxicillin vial gm, 1 fl every 8 hour a day and methylprednisolone vial 125: 1 vial 3/die. The same night, a CAT scan showed a wider extension of the haematoma on the upper and lower airways, together with a decrease in the diameter of the parapharyngeal space [Figure and ]. The patient underwent a bilateral carotid arteriography [], and a slight bleeding from the palatine branches of the left ascending pharyngeal artery which was probably closed by the arterial spasm induced by the catheter was revealed. Other CAT slices didn't show a significant difference in comparison with the first CAT.\nOn the second postoperative day, the patient's general condition improved with a progressive normalization of laboratory tests values. On the fourth postoperative day, the CAT scan confirmed a decrease in the parapharyngeal thickening. After 3 days of clinical observation, intubation was removed. Total recovery from haematoma was achieved within two months and the final clinical check showed a healthy appearance with good occlusion.