Gossypiboma during orthognathic surgery: A case report

Saleh Zaid Alshehri; Mohammed Ghazi Alkindi; Osama A Ibraheim; Razan A Ababtain; Randa Alfotawi

doi:10.1016/j.ijscr.2020.09.117

Gossypiboma during orthognathic surgery: A case report

Int J Surg Case Rep. 2020:75:429-432. doi: 10.1016/j.ijscr.2020.09.117. Epub 2020 Sep 23.

Authors

Saleh Zaid Alshehri¹, Mohammed Ghazi Alkindi², Osama A Ibraheim³, Razan A Ababtain⁴, Randa Alfotawi⁵

Affiliations

¹ Residant at Department of Oral and Maxillofacial Surgery, College of Dentistry, King Saud University, Riyadh 11433, Saudi Arabia.
² Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, King Saud University, P.O. Box 60169, Riyadh 11545, Saudi Arabia.
³ Department of Anesthesiology, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh 11433, Saudi Arabia.
⁴ Residant at Maxillofacial Surgery, National Guard for Health Affairs, Riyadh, Saudi Arabia.
⁵ Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, King Saud University, P.O. Box 60169, Riyadh 11545, Saudi Arabia. Electronic address: ralfotawei@ksu.edu.sa.

Abstract

Introduction: Dislodgment of nasopharyngeal temperature probes and/or unretrieved device fragments (UDFs) or gossypibome at a patient's hypopharynx is rare complication after orthognathic surgery that may occur as a result of surgical manipulation or may be a consequence of factors related to the insertion and handling of the probe after extubation. However, the exact mechanism of this complication is unknown. To the best of our knowledge, this is the 1st reported case of a missing temperature probe after orthognathic surgery.

Case presentation: We report the case of a patient who suffered from dislodgment of a 12-cm temperature probe after orthognathic surgery. The surgery was uneventful. At the end of the surgery, the probe was believed to have been completely removed from the nasal cavity. The nasopharyngeal cavity was visually inspected while the patient was still under anaesthesia and the trachea was still intubated. Extubation was successful, and the patient was moved to the recovery area. The patient was discharged from the hospital one day after resuming an oral fluid diet. At the follow-up visit on the 4th postoperative day, the patient presented with mild symptoms of a sore throat and cough. At the follow-up visit in the 3rd postoperative week, the patient reported one episode of vomiting and severe coughing, and the patient ultimately retrieved the 12-cm temperature probe from her mouth.

Discussion: After conducting a systematic literature review, we discuss surgical cases involving UDFs or gossypiboma. We also describe changes in our clinical practice after this event, and we envision that these modifications will have a positive influence on patient care. We believe that alternative routes for inserting temperature probes with covers would be suitable for orthognathic surgery.

Conclusion: Vigilance should be maintained during patient extubation by both teams (surgeons and anaesthetists) to assure that part of the probe always remains visible outside the oral/nasal cavity as well as complete removal of the device to avoid this life-threating complication.

Keywords: Aspiration; Complications; Gossypiboma; Hazard; Orthognathic surgery; Temperature probe; Unretrieved device fragment (UDF).

Publication types

Case Reports