Deep vein thrombosis in ear, nose and throat surgery* By J. M. GRAHAM, J. M. P. ROBINSON, P. B. ASHCROFT and R. GLENNIE (London)
Introduction EFFECTIVE methods of detecting deep vein thrombosis have been available for the last ten years. In this time much has been learnt about the pathogenesis and incidence of the condition. Measurement of I125 fibrinogen uptake is at present the most suitable technique for research into the incidence of thigh and calf vein thrombosis (Evans and Negus, 1971). Previous studies have shown that the risk of deep vein thrombosis is higher after certain operations. Lambie et al. (1970) reported a 44 per cent incidence in a group of patients after major gynaecological, abdominal or hip operations. Milne et al. (1971) reported a 33 per cent incidence after major abdominal operations and Kemble (1971) quoted figures of 42 per cent after splenectomy, 35 per cent after major hip operations and 31 per cent after retropubic prostatectomy. Because no studies had been carried out into the incidence of deep vein thrombosis after ear, nose and throat operations, it was decided to survey patients in this field, dividing them into the two broad subgroups of the specialty. Method The diagnosis of deep vein thrombosis was based on the result of the I125 fibrinogen uptake test. The technique of administration of fibrinogen and saturation of the thyroid gland with inorganic Iodine was that described by Negus et al. (1968). In this study I125 fibrinogen, supplied by the Radiochemical Centre, Amersham, was used and the measurement of radioactivity was made with a Model 253 Isotope Localization Monitor (D. A. Pitman), which can be used to express the counts over each point in the leg as a percentage of the precordial activity. Counts were made from the first postoperative day until discharge or the fourteenth postoperative day, whichever was earlier. Deep vein thrombosis was diagnosed if there was a sustained increase of 15 per cent or more at a single site over a twenty-four hour period. No attempt was made to confirm positive •Read at the Section of Laryngology Meeting, Royal Society of Medicine, on 2 May 1975.
427
J. M. Graham, J. M. P. Robinson, P. B. Ashcroft and R. Glennie findings by phlebography as the accuracy of this method of diagnosis compared with phlebography is now established (Negus et al., 1968). A record was kept of the patient's age and sex, the duration of anaesthesia, and the occasional use of the leg as an intravenous drip site. Patients Consecutive patients having major head and neck or ear operations were selected. We studied sixty-eight patients (forty-five men and twentythree women) undergoing head and neck operations; their average age was fifty-seven years (range twenty-five to eighty-three years). Thirty-five patients undergoing ear operations were also studied (seventeen men and eighteen women), their average age being fifty years (range thirty-five to seventy-five years). Of the head and neck surgery patients, fifty-two had malignant disease and the scale of operation ranged from external ethmoidectomy to total laryngectomy, radical neck dissection and excision of base of tongue. One patient died on the seventh postoperative day from bronchopneumonia; postmortem examination confirmed the presence of thrombosis, in the right calf, which had been detected four days previously. There was no sign of emboli in the lungs. Results Deep vein thrombosis was not detected in any patient undergoing an ear operation. The incidence of deep vein thrombosis in patients having head and: neck operations was 27-5 per cent (eighteen patients). The clot was in the j left leg in six patients, in the right leg in seven patients and five were bilateral. In no patient was there evidence of propagation of clot from the calf. Only six (33 per cent) of these eighteen patients developed clinical evidence of thrombosis, noted between the third and sixth postoperative days. The average time of detection was two days after operation (range one to eight days, 80 per cent were in the first three days). Figure 1 shows the shorter duration of the ear operations compared with the head and neck operations. Figure 2 shows the difference in age between the two groups of patients. Figure 3 shows a clear relationship between the incidence of thrombosis and length of operation. Those that did develop thrombosis spent a mean of 4*25 hours on the operating table, compared with a mean of 3 hours in those who did not. Figure 4 shows the incidence of thrombosis compared with age. 428
Deep vein thrombosis in ear, nose and throat surgery 2018161412-
HEAD AND NECK OPERATIONS
10-
I- 4
10
e o
HOURS
tr w a 2 Z 3 * 4
EAR OPERATIONS
1012 141618 FIG. I.
Duration of head and neck operations (above axis) and of ear operations (below axis).
In twelve patients an intravenous drip was inserted at the ankle. Of these patients seven developed thrombosis in the midcalf of the ipsilateral leg. This thrombus was clearly separate from the high count at the drip site. In a further two patients a thrombus was detected in the opposite calf. Excluding from the sixty-eight head and neck patients the group of twelve in whom the leg was used for an intravenous drip, the incidence was only 16 per cent (nine out of fifty-four patients). 429
J. M. Graham, J. M. P. Robinson, P. B. Ashcroft and R. Glennie HEAD AND NECK OPERATIONS
12
8 -I
6 -j
hZ
4 -
-
0
30
4 )
50
60
70
UJ m 2 • Z
80
J
1
a:
90 AGE
4 EAR OPERATIONS
68i n.
FIG. 2. Ages of head and neck patients (above axis) and ear patients (below axis).
20 1816Z 14u
< 12DVT
10bl CD
HOURS FIG. 3.
Duration of operation and incidence of deep vein thrombosis (shaded areas) in patient* after head and neck operations.
430
Deep vein thrombosis in ear, nose and throat surgery 14,
DVT
20
30
40
50
'
60
'
70
80
'
90
AGE FIG. 4. Age^of patients and incidence of deep vein thrombosis (shaded areas) after head and neck operations.
Discussion The absence of detectable thrombosis in the thirty-six patients undergoing ear operations was unexpected. Ear surgery is usually carried out on relatively young, otherwise healthy patients. Nevertheless these procedures often last over an hour and many patients are subsequently confined to bed for several days by vertigo. Excluding the group with an ankle drip, the incidence of deep vein thrombosis after head and neck operations was lower than the incidence reported following major abdominal surgery. The reason for this is not clear. The higher incidence of thrombosis following the use of the ankle as a drip site during anaesthesia shows that this site should be avoided. The practice has now stopped in this hospital. Deep vein thrombosis had not previously been considered to be a risk in E.N.T. surgery. A search through the records of the Royal National Throat, Nose and Ear Hospital showed only four recorded cases of pulmonary embolism in the last ten years; therefore thromboembolic disease has not been a major cause of mortality in this hospital. Nevertheless the demonstration of a high rate of venous thrombosis after major head and neck operations makes it important for surgeons working in this field to be aware of the latest developments in prophylaxis (Lancet 1971, Leader). Summary 1. One hundred and three patients undergoing head and neck or ear operations were screened for deep vein thrombosis using I125 labelled fibrinogen. 2. No thrombosis was detected in thirty-five patients undergoing ear operations.
J. M. Graham, J. M. P. Robinson, P. B. Ashcroft and R. Glennie 3. Nine (16 per cent) of fifty-six patients who underwent head and neck operations subsequently developed deep vein thrombosis. In a further twelve patients undergoing head and neck operations the ankle was used as a drip site and seven of these patients developed thrombosis in that leg. Acknowledgements
We are grateful to Professor D. F. N. Harrison for his encouragement and support in this project and to Professor L. P. Le Quesue for his helpful comments during preparation of the manuscript. We acknowledge with thanks the support of the consultants of The Royal National Throat, Nose and Ear Hospital who allowed us to investigate their patients, and the assistance of Sister Cheatham. We also thank Mr. D. Connolly for preparing the illustrations, and Miss. S. Damps for typing the manuscript. REFERENCES EVANS, D. S., and NEGUS, D. (1971) British Journal of Hospital Medicine, 5, 729. FLANC, C , KAKKAR, V. V., and CLARKE, M. B. (1968) British Journal of Surgery,
55, 742. HILLS, N. H., PFLUG, J. J., JEYASINGH, K., BOARDMAN, L., and CALNAN, J. S. (1972)
British Medical Journal, i, 131. KEMBLE, J. V. H. (1971) British Journal of Hospital Medicine, 5, 721. LAMBIE, J. M., MANAFFEY, R. G., BARBER, D. C., KARMODY, A. M., SCOTT, M. M.,
andMATHESON, N. A. (1970) British Medical Journal, ii, 142. Lancet, Leading article (1971) ii, 693. MILNE, R. M., GRIFFITHS, J. M. T., GUNN, A. A., and RUCKLEY, C. V. (1971) Lancet,
2, 445NEGUS, D., PINTO, D. J., L E QUESNE, L. P., BROWN, N., and CHAPMAN, M. (1968)
British Journal of Surgery, 55, 835. NEGUS, D. (1972) British Journal of Surgery, 59, 830. J. M. Graham, Royal National Throat, Nose & Ear Hospital, 330 Gray's Inn Road, London WCi.
432
Introduction EFFECTIVE methods of detecting deep vein thrombosis have been available for the last ten years. In this time much has been learnt about the pathogenesis and incidence of the condition. Measurement of I125 fibrinogen uptake is at present the most suitable technique for research into the incidence of thigh and calf vein thrombosis (Evans and Negus, 1971). Previous studies have shown that the risk of deep vein thrombosis is higher after certain operations. Lambie et al. (1970) reported a 44 per cent incidence in a group of patients after major gynaecological, abdominal or hip operations. Milne et al. (1971) reported a 33 per cent incidence after major abdominal operations and Kemble (1971) quoted figures of 42 per cent after splenectomy, 35 per cent after major hip operations and 31 per cent after retropubic prostatectomy. Because no studies had been carried out into the incidence of deep vein thrombosis after ear, nose and throat operations, it was decided to survey patients in this field, dividing them into the two broad subgroups of the specialty. Method The diagnosis of deep vein thrombosis was based on the result of the I125 fibrinogen uptake test. The technique of administration of fibrinogen and saturation of the thyroid gland with inorganic Iodine was that described by Negus et al. (1968). In this study I125 fibrinogen, supplied by the Radiochemical Centre, Amersham, was used and the measurement of radioactivity was made with a Model 253 Isotope Localization Monitor (D. A. Pitman), which can be used to express the counts over each point in the leg as a percentage of the precordial activity. Counts were made from the first postoperative day until discharge or the fourteenth postoperative day, whichever was earlier. Deep vein thrombosis was diagnosed if there was a sustained increase of 15 per cent or more at a single site over a twenty-four hour period. No attempt was made to confirm positive •Read at the Section of Laryngology Meeting, Royal Society of Medicine, on 2 May 1975.
427
J. M. Graham, J. M. P. Robinson, P. B. Ashcroft and R. Glennie findings by phlebography as the accuracy of this method of diagnosis compared with phlebography is now established (Negus et al., 1968). A record was kept of the patient's age and sex, the duration of anaesthesia, and the occasional use of the leg as an intravenous drip site. Patients Consecutive patients having major head and neck or ear operations were selected. We studied sixty-eight patients (forty-five men and twentythree women) undergoing head and neck operations; their average age was fifty-seven years (range twenty-five to eighty-three years). Thirty-five patients undergoing ear operations were also studied (seventeen men and eighteen women), their average age being fifty years (range thirty-five to seventy-five years). Of the head and neck surgery patients, fifty-two had malignant disease and the scale of operation ranged from external ethmoidectomy to total laryngectomy, radical neck dissection and excision of base of tongue. One patient died on the seventh postoperative day from bronchopneumonia; postmortem examination confirmed the presence of thrombosis, in the right calf, which had been detected four days previously. There was no sign of emboli in the lungs. Results Deep vein thrombosis was not detected in any patient undergoing an ear operation. The incidence of deep vein thrombosis in patients having head and: neck operations was 27-5 per cent (eighteen patients). The clot was in the j left leg in six patients, in the right leg in seven patients and five were bilateral. In no patient was there evidence of propagation of clot from the calf. Only six (33 per cent) of these eighteen patients developed clinical evidence of thrombosis, noted between the third and sixth postoperative days. The average time of detection was two days after operation (range one to eight days, 80 per cent were in the first three days). Figure 1 shows the shorter duration of the ear operations compared with the head and neck operations. Figure 2 shows the difference in age between the two groups of patients. Figure 3 shows a clear relationship between the incidence of thrombosis and length of operation. Those that did develop thrombosis spent a mean of 4*25 hours on the operating table, compared with a mean of 3 hours in those who did not. Figure 4 shows the incidence of thrombosis compared with age. 428
Deep vein thrombosis in ear, nose and throat surgery 2018161412-
HEAD AND NECK OPERATIONS
10-
I- 4
10
e o
HOURS
tr w a 2 Z 3 * 4
EAR OPERATIONS
1012 141618 FIG. I.
Duration of head and neck operations (above axis) and of ear operations (below axis).
In twelve patients an intravenous drip was inserted at the ankle. Of these patients seven developed thrombosis in the midcalf of the ipsilateral leg. This thrombus was clearly separate from the high count at the drip site. In a further two patients a thrombus was detected in the opposite calf. Excluding from the sixty-eight head and neck patients the group of twelve in whom the leg was used for an intravenous drip, the incidence was only 16 per cent (nine out of fifty-four patients). 429
J. M. Graham, J. M. P. Robinson, P. B. Ashcroft and R. Glennie HEAD AND NECK OPERATIONS
12
8 -I
6 -j
hZ
4 -
-
0
30
4 )
50
60
70
UJ m 2 • Z
80
J
1
a:
90 AGE
4 EAR OPERATIONS
68i n.
FIG. 2. Ages of head and neck patients (above axis) and ear patients (below axis).
20 1816Z 14u
< 12DVT
10bl CD
HOURS FIG. 3.
Duration of operation and incidence of deep vein thrombosis (shaded areas) in patient* after head and neck operations.
430
Deep vein thrombosis in ear, nose and throat surgery 14,
DVT
20
30
40
50
'
60
'
70
80
'
90
AGE FIG. 4. Age^of patients and incidence of deep vein thrombosis (shaded areas) after head and neck operations.
Discussion The absence of detectable thrombosis in the thirty-six patients undergoing ear operations was unexpected. Ear surgery is usually carried out on relatively young, otherwise healthy patients. Nevertheless these procedures often last over an hour and many patients are subsequently confined to bed for several days by vertigo. Excluding the group with an ankle drip, the incidence of deep vein thrombosis after head and neck operations was lower than the incidence reported following major abdominal surgery. The reason for this is not clear. The higher incidence of thrombosis following the use of the ankle as a drip site during anaesthesia shows that this site should be avoided. The practice has now stopped in this hospital. Deep vein thrombosis had not previously been considered to be a risk in E.N.T. surgery. A search through the records of the Royal National Throat, Nose and Ear Hospital showed only four recorded cases of pulmonary embolism in the last ten years; therefore thromboembolic disease has not been a major cause of mortality in this hospital. Nevertheless the demonstration of a high rate of venous thrombosis after major head and neck operations makes it important for surgeons working in this field to be aware of the latest developments in prophylaxis (Lancet 1971, Leader). Summary 1. One hundred and three patients undergoing head and neck or ear operations were screened for deep vein thrombosis using I125 labelled fibrinogen. 2. No thrombosis was detected in thirty-five patients undergoing ear operations.
J. M. Graham, J. M. P. Robinson, P. B. Ashcroft and R. Glennie 3. Nine (16 per cent) of fifty-six patients who underwent head and neck operations subsequently developed deep vein thrombosis. In a further twelve patients undergoing head and neck operations the ankle was used as a drip site and seven of these patients developed thrombosis in that leg. Acknowledgements
We are grateful to Professor D. F. N. Harrison for his encouragement and support in this project and to Professor L. P. Le Quesue for his helpful comments during preparation of the manuscript. We acknowledge with thanks the support of the consultants of The Royal National Throat, Nose and Ear Hospital who allowed us to investigate their patients, and the assistance of Sister Cheatham. We also thank Mr. D. Connolly for preparing the illustrations, and Miss. S. Damps for typing the manuscript. REFERENCES EVANS, D. S., and NEGUS, D. (1971) British Journal of Hospital Medicine, 5, 729. FLANC, C , KAKKAR, V. V., and CLARKE, M. B. (1968) British Journal of Surgery,
55, 742. HILLS, N. H., PFLUG, J. J., JEYASINGH, K., BOARDMAN, L., and CALNAN, J. S. (1972)
British Medical Journal, i, 131. KEMBLE, J. V. H. (1971) British Journal of Hospital Medicine, 5, 721. LAMBIE, J. M., MANAFFEY, R. G., BARBER, D. C., KARMODY, A. M., SCOTT, M. M.,
andMATHESON, N. A. (1970) British Medical Journal, ii, 142. Lancet, Leading article (1971) ii, 693. MILNE, R. M., GRIFFITHS, J. M. T., GUNN, A. A., and RUCKLEY, C. V. (1971) Lancet,
2, 445NEGUS, D., PINTO, D. J., L E QUESNE, L. P., BROWN, N., and CHAPMAN, M. (1968)
British Journal of Surgery, 55, 835. NEGUS, D. (1972) British Journal of Surgery, 59, 830. J. M. Graham, Royal National Throat, Nose & Ear Hospital, 330 Gray's Inn Road, London WCi.
432
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