Antithrombotic Therapy for Venous Thromboembolism and Prevention of Thrombosis in Otolaryngology–Head and Neck Surgery: State of the Art Review

Abstract

Objective The aim of this report is to present a cohesive evidence-based approach to reducing venous thromboembolism (VTE) in otolaryngology-head and neck surgery. VTE prevention includes deep venous thrombosis and pulmonary embolism. Despite national efforts in VTE prevention, guidelines do not exist for otolaryngology-head and neck surgery in the United States. Data Sources PubMed/MEDLINE. Review Methods A comprehensive review of literature pertaining to VTE in otolaryngology-head and neck surgery was performed, identifying data on incidence of thrombotic complications and the outcomes of regimens for thromboprophylaxis. Data were then synthesized and compared with other surgical specialties. Conclusions We identified 29 articles: 1 prospective cohort study and 28 retrospective studies. The overall prevalence of VTE in otolaryngology appears lower than that of most other surgical specialties. The Caprini system allows effective individualized risk stratification for VTE prevention in otolaryngology. Mechanical and chemoprophylaxis ("dual thromboprophylaxis") is recommended for patients with a Caprini score ≥7 or patients with a Caprini score of 5 or 6 who undergo major head and neck surgery, when prolonged hospital stay is anticipated or mobility is limited. For patients with a Caprini score of 5 or 6, we recommend dual thromboprophylaxis or mechanical prophylaxis alone. Patients with a Caprini score ≤4 should receive mechanical prophylaxis alone. Implications for Practice Otolaryngologists should consider an individualized and risk-stratified plan for perioperative thromboprophylaxis in every patient. The risk of bleeding must be weighed against the risk of VTE when deciding on chemoprophylaxis.

Thrombosis Risk Associated with Head and Neck Cancer: A Review

“…However, general strong evidence-based recommendations are available about VTE management in patients with cancer, especially those reported by the American Society of Clinical Oncology (ASCO), which can be considered as references [11,61]. Some good clinical practices for managing VTE in surgical H&N patients are also available and are given by societies of H&N surgeons or ENTs [62,63].…”

“…[11,61,70]. Some assessment tools have also been validated for H&N cancer surgery, such as the Caprini risk assessment model [58,62,71]. In cases of major surgery for cancer, which is almost always the case for H&N cancer, the ASCO clearly recommends thromboprophylaxis; the thromboprophylaxis must be started before surgery and be continued for 7–10 days after surgery.…”

“…The same societies also recommend pharmacological thromboprophylaxis by LMWH. Pharmacological thromboprophylaxis is not systematically provided by certain teams without the occurrence of additional VTE events following H&N cancer surgery [44,58,62,72,73]. This issue is addressed in the previous paragraph.…”

Comparison of venous thromboembolism risk stratification models in a high risk otolaryngology patient cohort

“…For high risk patients, postoperative chemoprophylaxis was recommended but not mandated by our institution and was administered according to the surgeon’s clinical judgment. To date, there are no established guidelines by the American Academy of Otolaryngology (AAO) for post-operative VTE prophylaxis (Cramer et al 2018). However, our institution’s protocol is consistent with the prevailing practices in our surgical subspecialty (Garritano & Andrews 2016).…”

Rationalizing post‐operative prophylactic anticoagulation in reconstructive head and neck cancer patients: a review

“…These patients are at a higher risk of developing VTE. [5][6][7] Yet, anticoagulant use in this group of patients can be challenging as thrombotic prophylaxis must be balanced against the risk of bleeding. This review will focus on the use of post-operative anticoagulation in reconstructive head and neck surgery primarily assessing the impact of anticoagulation on the rates of DVT and PE and secondarily assessing associated bleeding complications.…”