Elsevier

American Journal of Otolaryngology

Volume 30, Issue 4, July–August 2009, Pages 230-233
American Journal of Otolaryngology

Original contribution
Deep venous thrombosis and pulmonary embolism in otolaryngologic patients

https://doi.org/10.1016/j.amjoto.2008.06.004Get rights and content

Abstract

Purpose

The objective of this study is to present incidence of deep venous thrombosis and pulmonary embolism in otolaryngologic patients and make recommendations on appropriate thromboprophylaxis.

Methods

The methods used in this study are as follows: 5-year retrospective review in a tertiary care otolaryngology practice and computer-based search from 2000 to 2005. Cases were segregated into ambulatory vs inpatient procedures and malignant vs nonmalignant diagnoses.

Results

Six DVTs were identified, 5 with a diagnosed malignancy. One resulted in pulmonary embolism. Inpatient surgeries (1540) and outpatient surgeries (4582) were performed. Eight hundred twenty-four of these were for malignancies (542 inpatient). The incidence of DVT was 0.1%. The incidence in patients with malignancy was 0.6%.

Conclusions

Otolaryngology should be considered a specialty with low thromboembolism risk. Based on this study and recommendations by the American College of Chest Physicians (Northbrook, IL), we recommend early mobilization with the possible adjunct of pneumatic compression stockings in most low-risk otolaryngologic procedures, including most of the outpatient procedures. Moderate-risk patients should be considered for either mechanical or pharmacologic prophylaxis. High-risk patients and patients undergoing high-risk procedures are candidates for pharmacologic thromboprophylaxis.

Introduction

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are common complications in surgical patients. The incidence of DVT in hospitalized patients varies from 10% to 70%, depending upon subspecialty [1]. The mortality associated with progression to pulmonary embolus is high [2]. Studies estimate that PE may account for up to 10% to 15% of all hospital deaths [3], [4]. Pulmonary embolism is the most common preventable cause of hospital death [1], [2].

Fortunately, the incidence of DVT and PE are significantly reduced with appropriate use of thromboprophylaxis. So clear is the evidence supporting the use of thromboprophylaxis that the Agency for Healthcare Research and Quality recently listed the use of prophylaxis to prevent venous thromboembolism (VTE) as a top ranked patient safety goal, and routine thromboprophylaxis use is increasingly becoming a pay-for-performance measure [1]. Prophylaxis can take the form of either pharmacologic therapy or combining pharmacologic therapy with mechanical prophylaxis, with intensity of therapy conforming to level of risk. Two general methods exist for stratifying patient risk and determining appropriate therapy. One involves assessing each patient individually, determining their level of risk and tailoring therapy on a case-by-case basis. A more practical method, supported by the American College of Chest Physicians (ACCP) (Northbrook, IL), involves grouping patients and prescribing therapy based upon level of risk of VTE within the specialty or for a specific type of procedure [1]. Services including orthopedics, vascular surgery, gynecology, urology, and general surgery have well-defined levels of VTE risk. Patients within a specialty are risk stratified depending upon the type of surgery, age of the patient, presence of malignancy, and history of prior thromboembolic events. With these data, the ACCP provides specialty-specific guidelines for thromboprophylaxis.

There are limited data on the incidence of thromboembolic events for postsurgical otolaryngologic patients. Moreano et al [4] published a study out of the University of Iowa, Iowa City, IA, reporting an overall incidence of 0.3% for DVT and an overall incidence of 0.2% for PE. Head and neck subspecialty, increasing patient age, and nonuse of pneumatic compression devices were identified as independent risk factors. Because these are the only published data on incidence of DVT and PE within the field of otolaryngology, our knowledge of the true incidence and contributing risk factors is limited. In this study, we add to the data on incidence of thromboembolic disease in otolaryngology and make recommendations on the appropriate method of thromboprophylaxis for otolaryngologic surgical patients.

Section snippets

Methods

This is a 5-year retrospective review of incidence of recognized DVT and PE in a tertiary care otolaryngologic practice. The study protocol was reviewed and approved by the institutional review board. A computer-based search was performed covering all ambulatory and inpatient surgical otolaryngological patients from the year 2000 to 2005 at Lahey Clinic in Burlington, MA. This provided a list of all surgical otolaryngological patients and their diagnostic codes at discharge. This list of

Results

Details of the patients with DVT are given in Table 1. Six DVTs were identified of a total of 6122 surgical otolaryngological patients, providing an overall incidence of 0.1%. Of the 6 patients, 5 had a diagnosed malignancy. Patient age varied widely from 38 to 92 years (mean, 66 years).

One of the 6 DVTs progressed to PE. The overall incidence of PE in our population is 0.02%. The patient with PE did not have a malignancy (Table 1).

Inpatient surgeries (1540) and outpatient surgeries (4582) were

Discussion

The incidence of DVT and frequency of progression of DVT to PE is not well established for otolaryngologic patients. Review of the literature revealed a limited number of articles addressing incidence of and prophylaxis against DVT and PE. Graham et al [5] published the first article on the topic in 1976 after reviewing 103 otolaryngologic patients. Twenty-two years later, Moreano et al [4] reviewed the records of 12 805 patients. The overall incidence of DVT and PE in their study was 0.3% and

Conclusion

The incidence of DVT and PE in surgical otolaryngologic patients is lower than that seen in other surgical specialties. A conservative approach to appropriate thromboprophylaxis would be to parallel recommendations made for cases of a similar level of invasiveness in other surgical specialties. The following recommendations are based off our knowledge of the incidence of DVT/PE in otolaryngologic patients and the recommendations made by the ACCP. Low-risk patients undergoing either ambulatory

References (12)

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Presented as a poster presentation at Combined Sections Meeting, Marco Island, Florida, February 14-18, 2007.

Investigation performed at Lahey Clinic Medical Center.

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