I. INTRODUCTION

A. Demographics of OMFS and ENT Patients

Patients undergoing oral and maxillofacial surgery (OMFS) and ENT procedures vary in age from infants to elderly. Most procedures are scheduled and not emergent; thus, patients may be optimized from a medical perspective preoperatively. Acute life-threatening conditions that compromise the airway include infections or bleeding. Patients with acute infections have the potential for serious complications, particularly because many head and neck infections may affect airway patency. This is also true of intraoral bleeding or bilateral mandibular fractures. In these patients, often awake, fiberoptic intubation is a necessity, and patients may require prolonged intubation for airway protection and/or admission to the Surgical Intensive Care Unit for airway monitoring.

B. Disposition from the Operating Room

Postoperatively, most oral and maxillofacial surgery patients are extubated in the operating room and transferred to the postanesthesia care unit. Patients undergoing major maxillofacial operations such as orthognathic surgery or reconstruction after maxillofacial trauma are often admitted overnight for observation. Patients undergoing minor procedures, such as sinus surgery or dentoalveolar surgery, may be discharged home after recovery from anesthesia. Patients with intraoral incisions, who have had a bone graft, are maintained on a clear liquid diet for 48 hours postoperatively. Those patients undergoing maxillary or mandibular surgery requiring osteotomies or open reduction and internal fixation of fractures are maintained on a blended, “no chew” diet for 6 weeks postoperatively.

OMFS and ENT patients may require an ICU stay with or without intubation. Such cases include those with concern for severe airway edema, patients with prolonged intubation for long cases, extensive maxillofacial trauma, tongue lacerations, or obstructive sleep apnea. Rarely, patient may be placed in maxillomandibular fixation for immobilization.

II. COMMON POSTOPERATIVE PROBLEMS

A. Pain

Postoperative pain is expected after any surgical procedure, including maxillofacial surgery. The degree of pain depends on the type and extent of operation, individual pain tolerance, preoperative pain including severity, duration, and etiology (such as myofascial pain, headaches, temporomandibular joint [TMJ] pain, or trauma), and preoperative narcotic requirement. As well, systemic diseases such as fibromyalgia, connective tissue or autoimmune disorders, vascular disease, and diabetes may affect postoperative pain. Patients undergoing TMJ surgery, orthognathic surgery, surgical repair of facial fractures, or incision and drainage of extensive maxillofacial infections may have high levels of postoperative pain. Traumatic fractures are often less painful once
the fractures have been immobilized. Postoperatively, pain is often well controlled initially with intraoperative local anesthesia, but as this wears off, intravenous and oral pain medications must be titrated for effect. Narcotic pain medications are often required in the postoperative period.

B. Nausea/Vomiting

Postoperative nausea is the most common postoperative complication of maxillofacial surgery, occurring in as many as 40% of patients and often resulting in vomiting. Risk factors include female gender, history of motion sickness, vertigo, migraines, and prior postoperative nausea and vomiting (PONV). TMJ and ear surgery can cause postoperative vertigo, which may contribute to nausea. Medications that may contribute include volatile anesthetic, narcotics, and antibiotics. Nasal intubation, maxillary osteotomies, turbinectomies, nasoseptoplasty, and sinus surgery cause postoperative bleeding with nasal and pharyngeal drainage. Some of this bloody drainage is swallowed, which causes significant irritation to the gastrointestinal tract, resulting in nausea. Postoperative placement of orogastric or nasogastric tube to suction the stomach before extubation may reduce postoperative nausea. Adverse consequences of nausea/vomiting may include wound dehiscence, bleeding, hematoma, dehydration, and aspiration. Anesthesia literature suggests multimodal approach to prevention and management of PONV.

C. Swelling

Postoperative swelling of the tissues is expected following maxillofacial surgery. Procedures involving the mandible, particularly those with extensive dissection on the lingual aspect, may cause swelling of the floor of mouth or oropharynx and, in rare cases, concern for airway compromise. Contributing factors may include length of operation, extent of dissection, surgical trauma, and patient factors, such as anticoagulation. Swelling usually peaks at 24 to 48 hours postoperatively. It begins to improve over 3 to 4 weeks, but may take longer in certain cases, such as orthognathic surgery. In cases where severe airway edema is expected, extubation may be delayed until the edema subsides. Depending on the procedure, methods to minimize postoperative edema may include applying ice to the face for the first 48 hours, keeping the head of bed elevated for 1 week, and administration of perioperative steroids.

D. Ecchymosis

Postoperative skin discoloration is common after surgery, particularly in maxillofacial surgery. This is a result of extravasation of blood subcutaneously. Ecchymosis will evolve from purple to green to yellow, similar to a bruise, will resolve in 2 to 4 weeks, and moves inferiorly with gravity.

E. Hematoma/Hemorrhage