Clinical management of angioneurotic oedema patient post-orthognathic surgery

Abstract

Angioneurotic oedema is an acute swelling involving the submucosal or subcutaneous tissues; it is most often located in the oral and maxillofacial region, which can result in upper airway obstruction. Its aetiology is frequently associated with immunoglobulin-mediated hypersensitivity reactions that elicit a heightened inflammatory response. The objective of this study was to report the case of a patient who developed an episode of angioneurotic oedema following combined orthognathic surgery. Pharmacological and nonpharmacological interventions used in the treatment of this important clinical condition are described and discussed.

Introduction

In 1876, Milton clinically described the occurrence of a ‘giant urticaria’, naming it angioedema . This condition is characterized by diffuse swelling, and the most commonly affected areas are the face, tongue, pharynx, and larynx, which can lead to upper airway obstruction . In the acquired form of angioneurotic oedema, which is idiopathic and closely resembles classic allergic reactions, the therapeutic use of epinephrine and steroid supplements, such as hydrocortisone, is associated with a good response to treatment . In cases with a history of oedema, usually involving C 1 inhibitor (C 1 -INH) deficiency, prophylactic therapy is recommended .

Postoperative oedema is expected after oral and maxillofacial surgery, which can affect the tongue and pharyngeal region, resulting in upper airway obstruction. If the angioneurotic oedema is associated with clinical conditions, respiratory function may be compromised . Considering the seriousness of this condition, immediate diagnosis and treatment is of paramount importance to avoid life-threatening complications.

Case report

A 21-year-old white woman, weighing 58 kg, with no history of systemic alterations or allergies, presented with oral and maxillofacial asymmetry, characterized by mandibular retrusion and right-sided deviation. She had a left unilateral cleft lip and palate that had been treated previously. Owing to maxillomandibular discrepancy, the patient underwent orthognathic treatment. During surgery, a mandibular sagittal split ramus osteotomy (Puricelli osteotomy) was performed on the left side; a mandibular vertical ramus osteotomy on the right side; and a maxillary alveolar segmental osteotomy on the right side.

After surgery, the patient was transferred to the recovery room and remained intubated and sedated, receiving analgesic (fentanyl), antiemetic (ondansetron hydrochloride) and antipyretic (dipyrone) medication, according to prescription. Extra care, such as the application of heat/cold modalities, was also performed as a routine procedure to help reduce postoperative oedema.

Immediately after surgery, visible facial swelling was consistent with the procedure performed. The enhanced swelling observed in the lips and periorbital region, in both sides, during the postoperative period led to a clinical diagnosis of angioneurotic oedema ( Fig. 1 ). The patient was then administered hydrocortisone (100 mg i.v. at 8-h intervals) and epinephrine (3 mg diluted in 3 ml saline solution, via nasal nebulization, at 12-h intervals). About 7 h after the patient was started on hydrocortisone, the oedema was intense, but with initial signs of reduction. 2 days after surgery, the established therapeutic management significantly reduced the oedema. Hydrocortisone and epinephrine administration was continued, and the administration of anti-inflammatory drugs was started (tenoxicam, 20 mg i.v. once a day). This drug regimen reduced the angioneurotic oedema, unblocking airways and allowing safe extubation of the patient on the third day. 5 days after surgery, the patient was discharged with reduced facial oedema consistent with the postoperative status of the procedure performed ( Fig. 2 ). Figure 3 shows the patient 16 months after surgery.

Fig. 1
Heightened inflammatory reaction in the lips and periorbital region, in both sides (surgeons/authors: EP and DP).

Fig. 2
Regression of facial angioneurotic oedema. Remaining oedema consistent with the postoperative status of the orthognathic surgery performed.

Fig. 3
Postoperative aspect after 16 months.

Case report

A 21-year-old white woman, weighing 58 kg, with no history of systemic alterations or allergies, presented with oral and maxillofacial asymmetry, characterized by mandibular retrusion and right-sided deviation. She had a left unilateral cleft lip and palate that had been treated previously. Owing to maxillomandibular discrepancy, the patient underwent orthognathic treatment. During surgery, a mandibular sagittal split ramus osteotomy (Puricelli osteotomy) was performed on the left side; a mandibular vertical ramus osteotomy on the right side; and a maxillary alveolar segmental osteotomy on the right side.

After surgery, the patient was transferred to the recovery room and remained intubated and sedated, receiving analgesic (fentanyl), antiemetic (ondansetron hydrochloride) and antipyretic (dipyrone) medication, according to prescription. Extra care, such as the application of heat/cold modalities, was also performed as a routine procedure to help reduce postoperative oedema.

Immediately after surgery, visible facial swelling was consistent with the procedure performed. The enhanced swelling observed in the lips and periorbital region, in both sides, during the postoperative period led to a clinical diagnosis of angioneurotic oedema ( Fig. 1 ). The patient was then administered hydrocortisone (100 mg i.v. at 8-h intervals) and epinephrine (3 mg diluted in 3 ml saline solution, via nasal nebulization, at 12-h intervals). About 7 h after the patient was started on hydrocortisone, the oedema was intense, but with initial signs of reduction. 2 days after surgery, the established therapeutic management significantly reduced the oedema. Hydrocortisone and epinephrine administration was continued, and the administration of anti-inflammatory drugs was started (tenoxicam, 20 mg i.v. once a day). This drug regimen reduced the angioneurotic oedema, unblocking airways and allowing safe extubation of the patient on the third day. 5 days after surgery, the patient was discharged with reduced facial oedema consistent with the postoperative status of the procedure performed ( Fig. 2 ). Figure 3 shows the patient 16 months after surgery.

Feb 7, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Clinical management of angioneurotic oedema patient post-orthognathic surgery
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