Severe Chemosis following Fronto-Orbital Advancement

Abstract

Sir: We write to you concerning an episode of severe bilateral chemosis following cranial vault remodeling by fronto-orbital advancement. Anecdotally, we have previously noticed this morbidity in a patient with a tracheostomy collar. The severe postoperative chemosis at that time was felt to possibly be attributable to a tracheostomy collar that was far too tight, and release of the collar with suturing of the tube in place relieved that patient's condition. A recent episode of severe chemosis following fronto-orbital advancement in a 2-year-old boy with Pfeiffer syndrome who had a tracheostomy collar was encountered (Fig. 1, above). This was noticed very early in the morning of postoperative day 1. His tracheostomy collar was removed, and the tube was secured in place with permanent nylon suture. A generous amount of Lacri-Lube (Allergan, Inc., Irvine, Calif.) was applied to the protruding conjunctivae bilaterally, and the head of the patient's bed was elevated. The pediatric ophthalmology team evaluated the patient, and they agreed with the chemosis management plan.Fig. 1.: (Above) Twenty-four-hour postoperative view demonstrating severe bilateral chemosis. (Below) At 72 hours postoperatively, there is nearly total resolution of chemosis after discontinuation of the tracheostomy collar, putting the head of the bed up, and generous application of Lacri-Lube.By 72 hours postoperatively, the chemosis had subsided completely on the left and was well on its way to recovery on the right (Fig. 1, below). The tracheostomy tube was left sutured in place, and the Lacri-Lube was discontinued. We assume that the patient's chemosis was caused by the combination of increased postoperative swelling, with jugular veins occluded by the tracheostomy collar. Venous hypertension has been demonstrated to result from occlusion of the jugular veins.1 Blindness and other ophthalmologic complications have been associated with venous hypertension.2,3 Although we have not definitively shown that there was venous occlusion caused by the tracheostomy collar, this remains a possibility. Especially in the setting of fronto-orbital advancement in the patient with Pfeiffer syndrome, where preexisting elevated intracranial pressures and extreme postoperative swelling are not uncommon, a tracheostomy collar that is too tight may decrease effective drainage of the conjunctivae and exacerbate a clinical scenario that portends to chemosis. We were unable to find any reports of this postoperative morbidity following craniofacial remodeling in the literature. As this was not our first experience with this, and our management was successful, we felt that sharing this experience would be worthwhile for other plastic surgeons performing pediatric craniofacial surgery. It is also hoped that other authors who have seen this will be inspired to share their experiences with the presentation of chemosis after craniofacial remodeling and their subsequent management of the problem. Daniel A. Hatef, M.D. Adeyiza O. Momoh, M.D. Larry H. Hollier, Jr., M.D. Department of Plastic Surgery Baylor College of Medicin Houston, Texas