Bi-lateral pneumothorax after orthognatic surgery.

Surgical problems as consequences of orthognatic surgery can be: upper airway impairment, hemorrage, infections, mobility of the splitted bones, nervous lesions. It is extremely rare to observe sub-cutaneous henfisema in association to bi-lateral pneumothorax. A 28 yrs. female, clinical history and instrumental evaluation negative for metabolic andclinical pathologies. She was treated with a Le Fort I osteotomy and BSSO sec. Gotte. Pre-surgical difficulties of the endonasal intubation with consequent bleeding. Intrasurgical left bleeding diring BSSO from the retromolas venous vessel.lntermaxillary fixation. The patient was transfered in Intensive Care Unit for 24 hours. Back to our Department at 12.00 am clinically well stabilized. At 4 pm sudden dispnea associated
to moderate henfisema of the cheek and periorbital area. At 6 pm severe and sudden decrease of arterious saturation, patient conffused, increase of the henfisema that is now extended to the neck and the upper third of the anterior thorax. Immediate tranfer to the intensive care unit. Removal of IMF, oral intubation, a thorax xray shows right tension pneumothorax, that is treated with an intercostal drain. A thorax xray after 4 hours and a TC show a controlateral pneumothorax. This is treated with an intercostal drain. Both drainages are kept in site for 18 days. No further consequences.
No neurological sequelae, no infections, no other osteotomies sequelae. Thorax henfisema after orthognatic sugery is extremely rare and is reported as a progression of high pressure air penetration through the deep fascia of the neck. So for tension pneumothorax complicated with a bi-lateral pneumothorax that was secondary to the henfisema. Sudden post-surgical dispnea associated to sub-cutaneous henfisema of the neck and of the thorax must be adequately observed with the aim of monitoring further severe sequelae. The anaesthetic management of the emergency difficult airway in any post-surgical orthognatic treatment can be extremely difficult requiring a carefully planned multi-disciplinary approach.