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Pneumothorax after orthognathic surgery
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British Journal of Oral and Maxillofacial Surgery 48 (2010) 180–181
Short communication
Pneumothorax after orthognathic surgery Michaela L. Goodson ∗ , Ravi Manemi, Antony W. Paterson Cumberland Infirmary, Newton Road, CA2 7HY01228 523 444, Carlisle, United Kingdom Accepted 26 August 2009 Available online 16 December 2009
Abstract We report the case of an 18-year-old girl who had pneumothorax two days after bimaxillary osteotomy to correct a severe Class II malocclusion. Chest radiograph showed left-sided pneumothorax with complete collapse of the underlying lung and mediastinal shift to the left. A chest drain was inserted and she made an uneventful recovery. The aetiology may be iatrogenic or spontaneous, but we have found no previous reports of pneumothorax after orthognathic surgery. © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Pneumothorax; Osteotomy; Complications
Introduction Pneumothorax may be defined as air in the potential space between the visceral and parietal pleura of the lung that has entered from the chest wall or through the lung parenchyma across the visceral pleura. Pneumothorax may be traumatic, spontaneous with or without underlying lung disease, or iatrogenic after trauma such as barotrauma after positive pressure ventilation.1 Spontaneous pneumothoraces can be primary or secondary. Primary pneumothorax occurs with no underlying lung disease usually in people aged 18–40 years with an incidence of 7.4–18 cases/100 000/year for men, and 1.2–6 cases/100 000/year for women. Secondary pneumothorax usually occurs in older adults with underlying disease such as chronic obstructive pulmonary disease and collagen vascular diseases including Marfan syndrome.2,3 In young people rupture of congenital blebs or bullae can cause spontaneous pneumothorax. Until rupture occurs no clinical signs or symptoms are obvious, but if the pleural space is invaded by gas, the lung collapses until equilibrium is achieved, or the defect is sealed.
∗
Corresponding author. Tel.: +44 7764683800.
While 10% of pneumothoraces are asymptomatic patients often complain of acute chest pain and difficulty breathing. There is a reduction in vital capacity, tachycardia, tachypnoea, and a decrease in partial pressure of oxygen with an inability to maintain oxygen saturations.4,5 We report the case of a patient with pneumothorax after bimaxillary osteotomy. We do not know of any other reports of similar cases, although pneumomediastinum has been reported after operations on the lower neck, and after facial trauma.6–8
Case report A tall 18-year-old medically fit white girl who did not smoke tobacco had bimaxillary osteotomy after two years of orthodontic treatment to correct a severe Class II Division 1 malocclusion. The operation was uneventful and she was nursed on the ward postoperatively. Two days after operation she developed acute central chest pain, shortness of breath, tachycardia, and tachypnoea, and oxygen saturations above 80% on room air could not be maintained. Auscultation showed reduced entry of air in the base of the left lung, dullness to percussion, and reduced movement on the left side of the chest. Electrocardiogram showed only tachycardia. Differential diagnosis included collapse, con-
0266-4356/$ – see front matter © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2009.08.038
M.L. Goodson et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 180–181
181
Fig. 1. Chest radiographs: (A) at presentation showing left pneumothorax with mediastinal shift; (B) after insertion of a chest drain; and (C) resolution of pneumothorax.
fan syndrome as she was very tall, but clinically she did not show any other features of the condition, and there was no family history. She made a good recovery and was discharged by the respiratory team who advised her that similar episodes might recur in the future. She was told to avoid flying for six weeks and to avoid scuba diving long term. The case highlights the importance of investigating patients who complain of unusual symptoms after orthognathic surgery. Often they are a group who are highly motivated and medically fit and, in our case, disastrous consequences might have ensued without prompt intervention. Fig. 2. Computed tomogram of collapsed left lung.
References solidation, haemopneumothorax, or pulmonary embolism. A left-sided pneumothorax with complete collapse of the underlying lung with mediastinal shift to the left was shown on chest radiograph and confirmed by computed tomography (Figs. 1 and 2). She was transferred to the high dependency unit and a chest drain was inserted. She required continuous positive airway pressure over night and fractional inspired oxygen (FIO2 ) of 60% to maintain saturations above 95%. Two days later the left lung had expanded, the chest drain was removed, and she was discharged. Follow up was by the oral and maxillofacial team and chest physicians.
Discussion The likely cause of pneumothorax in this case was either mechanical ventilation (directly related to peak airway pressures during general anaesthesia) or primary spontaneous pneumothorax. It was also suggested that she might have had secondary spontaneous pneumothorax associated with Mar-
1. Carron M, Gagliardi G, Michielan F, Freo U, Ori C. Occurrence of pneumothorax during noninvasive positive pressure ventilation through a helmet. J Clin Anesth 2007;19:632–5. 2. Chang AK, Mukherji P. Pneumothorax, iatrogenic, spontaneous and pneumomediastinum (updated 2009, July 7). Available from URL: http://www.emedicine.com/emerg/topic469.htm. 3. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: American College of Chest Physicians Delphi consensus statement. Chest 2001;119:590–602. 4. Currie GP, Alluri R, Christie GL, Legge JS. Pneumothorax: an update. Postgrad Med J 2007;83:461–5. Erratum in: Postgrad Med J 2007;83:722. 5. Henry M, Arnold T, Harvey J, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003;58(Suppl. 2):ii39–52. 6. Madan SC, Rosenthal SP, Bochetto JF. Pneumomediastinum and pneumothorax following lower neck surgery. Arch Surg 1969;98:153–9. 7. López-Peláez MF, Roldán J, Mateo S. Cervical emphysema, pneumomediastinum, and pneumothorax following self-induced oral injury: report of four cases and review of the literature. Chest 2001;120:306–9. 8. Aiken D, Smith HF. Pneumomediastinum and pneumothorax following block dissection of the neck. Br J Surg 1953;40:325–31.
British Journal of Oral and Maxillofacial Surgery 48 (2010) 180–181
Short communication
Pneumothorax after orthognathic surgery Michaela L. Goodson ∗ , Ravi Manemi, Antony W. Paterson Cumberland Infirmary, Newton Road, CA2 7HY01228 523 444, Carlisle, United Kingdom Accepted 26 August 2009 Available online 16 December 2009
Abstract We report the case of an 18-year-old girl who had pneumothorax two days after bimaxillary osteotomy to correct a severe Class II malocclusion. Chest radiograph showed left-sided pneumothorax with complete collapse of the underlying lung and mediastinal shift to the left. A chest drain was inserted and she made an uneventful recovery. The aetiology may be iatrogenic or spontaneous, but we have found no previous reports of pneumothorax after orthognathic surgery. © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Pneumothorax; Osteotomy; Complications
Introduction Pneumothorax may be defined as air in the potential space between the visceral and parietal pleura of the lung that has entered from the chest wall or through the lung parenchyma across the visceral pleura. Pneumothorax may be traumatic, spontaneous with or without underlying lung disease, or iatrogenic after trauma such as barotrauma after positive pressure ventilation.1 Spontaneous pneumothoraces can be primary or secondary. Primary pneumothorax occurs with no underlying lung disease usually in people aged 18–40 years with an incidence of 7.4–18 cases/100 000/year for men, and 1.2–6 cases/100 000/year for women. Secondary pneumothorax usually occurs in older adults with underlying disease such as chronic obstructive pulmonary disease and collagen vascular diseases including Marfan syndrome.2,3 In young people rupture of congenital blebs or bullae can cause spontaneous pneumothorax. Until rupture occurs no clinical signs or symptoms are obvious, but if the pleural space is invaded by gas, the lung collapses until equilibrium is achieved, or the defect is sealed.
∗
Corresponding author. Tel.: +44 7764683800.
While 10% of pneumothoraces are asymptomatic patients often complain of acute chest pain and difficulty breathing. There is a reduction in vital capacity, tachycardia, tachypnoea, and a decrease in partial pressure of oxygen with an inability to maintain oxygen saturations.4,5 We report the case of a patient with pneumothorax after bimaxillary osteotomy. We do not know of any other reports of similar cases, although pneumomediastinum has been reported after operations on the lower neck, and after facial trauma.6–8
Case report A tall 18-year-old medically fit white girl who did not smoke tobacco had bimaxillary osteotomy after two years of orthodontic treatment to correct a severe Class II Division 1 malocclusion. The operation was uneventful and she was nursed on the ward postoperatively. Two days after operation she developed acute central chest pain, shortness of breath, tachycardia, and tachypnoea, and oxygen saturations above 80% on room air could not be maintained. Auscultation showed reduced entry of air in the base of the left lung, dullness to percussion, and reduced movement on the left side of the chest. Electrocardiogram showed only tachycardia. Differential diagnosis included collapse, con-
0266-4356/$ – see front matter © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2009.08.038
M.L. Goodson et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 180–181
181
Fig. 1. Chest radiographs: (A) at presentation showing left pneumothorax with mediastinal shift; (B) after insertion of a chest drain; and (C) resolution of pneumothorax.
fan syndrome as she was very tall, but clinically she did not show any other features of the condition, and there was no family history. She made a good recovery and was discharged by the respiratory team who advised her that similar episodes might recur in the future. She was told to avoid flying for six weeks and to avoid scuba diving long term. The case highlights the importance of investigating patients who complain of unusual symptoms after orthognathic surgery. Often they are a group who are highly motivated and medically fit and, in our case, disastrous consequences might have ensued without prompt intervention. Fig. 2. Computed tomogram of collapsed left lung.
References solidation, haemopneumothorax, or pulmonary embolism. A left-sided pneumothorax with complete collapse of the underlying lung with mediastinal shift to the left was shown on chest radiograph and confirmed by computed tomography (Figs. 1 and 2). She was transferred to the high dependency unit and a chest drain was inserted. She required continuous positive airway pressure over night and fractional inspired oxygen (FIO2 ) of 60% to maintain saturations above 95%. Two days later the left lung had expanded, the chest drain was removed, and she was discharged. Follow up was by the oral and maxillofacial team and chest physicians.
Discussion The likely cause of pneumothorax in this case was either mechanical ventilation (directly related to peak airway pressures during general anaesthesia) or primary spontaneous pneumothorax. It was also suggested that she might have had secondary spontaneous pneumothorax associated with Mar-
1. Carron M, Gagliardi G, Michielan F, Freo U, Ori C. Occurrence of pneumothorax during noninvasive positive pressure ventilation through a helmet. J Clin Anesth 2007;19:632–5. 2. Chang AK, Mukherji P. Pneumothorax, iatrogenic, spontaneous and pneumomediastinum (updated 2009, July 7). Available from URL: http://www.emedicine.com/emerg/topic469.htm. 3. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: American College of Chest Physicians Delphi consensus statement. Chest 2001;119:590–602. 4. Currie GP, Alluri R, Christie GL, Legge JS. Pneumothorax: an update. Postgrad Med J 2007;83:461–5. Erratum in: Postgrad Med J 2007;83:722. 5. Henry M, Arnold T, Harvey J, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003;58(Suppl. 2):ii39–52. 6. Madan SC, Rosenthal SP, Bochetto JF. Pneumomediastinum and pneumothorax following lower neck surgery. Arch Surg 1969;98:153–9. 7. López-Peláez MF, Roldán J, Mateo S. Cervical emphysema, pneumomediastinum, and pneumothorax following self-induced oral injury: report of four cases and review of the literature. Chest 2001;120:306–9. 8. Aiken D, Smith HF. Pneumomediastinum and pneumothorax following block dissection of the neck. Br J Surg 1953;40:325–31.