Emergency Management Protocols for Major Complications after Oral and Maxillofacial Surgery: Emphasis on Airway and Bleeding Control

Emergency Management Protocols for Major Complications after Oral and Maxillofacial Surgery: Emphasis on Airway and Bleeding Control | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Emergency Management Protocols for Major Complications after Oral and Maxillofacial Surgery: Emphasis on Airway and Bleeding Control Sungyeop Lee, Sung-Yun Hwang, Kyu-Bum Kim, Suyi Sim, Chiho Moon, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8901427/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Major postoperative complications following maxillofacial surgery, particularly severe bleeding and airway obstruction, remain life-threatening events despite advances in surgical trechniques and perioperative care[ 1 , 2 ]. Delayed response to these events can lead to fatal complications or even death. However, standardized institutiohnal protocols integrating bleeding control and airway management are lacking. Therefore, this study retrospectively analyzes cases of postoperative major hemorrhage and airway obstruction that occurred at a tertiary hospital, and through a review of the literature, aims to establish safer postoperative management guidelines. Methods In this study, “major surgery” primarily refers to procedures such as malignant tumor resection, orthognathic surgery, and fracture surgery. A retrospective cohort study was conducted including patients who underwent maxillofacial major surgery at a tertiary university dental hospital over a 15-year period. Major bleeding events were defined as postoperative hemorrhage requiring reoperation or angiography with embolization. Major airway events were defined as unplanned reintubation, emergency tracheostomy. Patients who underwent malignant tumor resection in the oral and maxillofacial region were included in the analysis. Among the patients who underwent malignant tumor resection, those who required emergency tracheostomy following surgery were classified as the case group, whereas those who underwent planned elective tracheostomy prior to surgery were assigned to the control group. Results Postoperative bleeding requiring intervention occurred in 20 cases, with 70% associated with major surgery. Five of the eight patients who underwent orthognathic surgery required emergency bleeding control operation for hemorrhage within 72 hours postoperatively. Most bleeding events occurred independently of patient-related coagulation disorders, indicating a stronger association with surgical extent and technique. Transarterial embolization was performed in 13 cases; however, only one case was related to emergency postoperative hemorrhage. Tracheostomy was performed in 24 cases, including 13 related to oral cancer surgery. Emergency tracheostomy was most commonly required in patients with malignant tumors or severe infections. The mean Cameron score was 6.00 in the five patients in the case group, whereas a mean score of 6.17 was observed in six patients in the control group[ 3 ]. Conclusion In oral and maxillofacial surgery, postoperative hemorrhage may occur regardless of patient comorbidities, necessitating careful perioperative bleeding control. Although not included in our institutional protocol, prior studies support angiographic evaluation with selective arterial embolization as a reliable option in cases at high risk for postoperative bleeding. Tracheostomy should be considered a proactive airway management strategy guided by tools such as the Cameron scoring system, particularly in elderly patients and those undergoing extensive surgery[ 3 ]. However, the score should not be used in isolation, and careful postoperative monitoring is required even in patients below the recommended threshold. A stepwise, integrated approach to postoperative bleeding and airway management, incorporating structured bleeding control, early airway protection, and timely consideration of transarterial embolization, may improve patient safety and outcomes. Bleeding control Embolization Airway obstruction Tracheostomy Figures Figure 1 Figure 2 Figure 3 Background Surgical management in the field of oral and maxillofacial surgery, including orthognathic surgery, oral cancer resection and reconstruction, trauma surgery, and treatment of severe infections, is anatomically closely associated with the airway and major vascular structures. Consequently, these procedures carry a relatively high risk of acute postoperative complications. In particular, acute airway obstruction and massive hemorrhage occurring immediately after surgery or during the inpatient period may result in catastrophic outcomes directly affecting patient survival, such as hypoxic brain injury or death, if prompt recognition and immediate intervention are not achieved[ 4 ]. Massive hemorrhage following oral and maxillofacial surgery is often unpredictable due to extensive surgical dissection, the rich vascular supply of the maxillofacial region, and osteotomy sites associated with tumor resection or orthognathic surgery. In addition, postoperative airway obstruction may arise from hematoma formation, edema, active bleeding, retention of secretions, or exacerbation of underlying respiratory diseases. Although it may initially present as relatively mild respiratory discomfort, it can rapidly progress to severe respiratory failure within a short period[ 5 ]. In such situations, complex clinical decision-making is required, extending beyond simple local hemostasis to include airway securing, blood transfusion, imaging-based vascular evaluation, and, when necessary, transarterial embolization[ 6 , 7 ]. Despite these risks, comprehensive management guidelines or standardized response protocols for postoperative airway obstruction and hemorrhagic emergencies in oral and maxillofacial surgery have not yet been adequately established. Existing reports are largely limited to individual case reports or analyses of specific surgical populations, and studies proposing comprehensive, stepwise emergency response algorithms applicable to real-world clinical practice remain scarce. In particular, long-term data analyzing criteria for determining the timing of tracheostomy, indications distinguishing emergency versus elective tracheostomy, and the actual clinical application of interventions such as transarterial embolization are lacking. Given the nature of postoperative emergencies in oral and maxillofacial surgery, close multidisciplinary collaboration among surgeons, anesthesiologists, and nursing staff is essential, and pre-shared risk assessments and response strategies have a critical impact on patient outcomes. Therefore, an analysis of emergency occurrence patterns based on real-world clinical data, together with the establishment of management guidelines derived from these findings, may contribute to enhanced patient safety and reduced delays in emergency care. Accordingly, this study retrospectively analyzed cases requiring airway management and/or bleeding control during or after surgery among patients who underwent major oral and maxillofacial surgical procedures at a single university dental hospital between 2010 and 2025. Rather than analyzing each complication independently, this study focuses on establishing an integrated emergency response framework. In particular, patients who required urgent airway intervention were compared with those who underwent planned airway management to comprehensively evaluate background factors associated with emergency events, types of surgery, timing of complication onset, management strategies, and clinical outcomes. Furthermore, through comparative analysis with existing literature, this study aims to provide evidence supporting the development of more systematic and practical management guidelines for postoperative emergency complications in oral and maxillofacial surgery. Materials and Methods 1) Study Population and Study Period This retrospective study analyzed the medical records of patients who underwent elective surgery, emergency admission, or intensive care unit (ICU) management in the Department of Oral and Maxillofacial Surgery at Pusan National University Dental Hospital, Pusan National University Medical Hospital, Yangsan, over a 15-year period from August 2010 to July 2025. Among these patients, cases in which emergency interventions were required due to acute airway compromise or massive hemorrhage during or after surgery were included. A total of 57 cases were identified, consisting of 20 cases requiring bleeding control, 24 cases requiring tracheostomy, and 13 cases managed with transarterial embolization. 2) Classification of Experimental and Control Groups To minimize confounding by infectious etiologies, age and airway risk analyses were restricted to patients who underwent tracheostomy following malignant tumor resection. For the development of airway management guidelines, patients who underwent tracheostomy following oral cancer surgery were classified into the following groups and comparatively analyzed: Case group: Patients who underwent emergency tracheostomy due to unexpected acute respiratory distress occurring after malignant tumor resection surgery (n = 6). Control group: Patients who underwent planned elective tracheostomy before the completion of malignant tumor resection surgery based on preoperative or intraoperative risk assessment (n = 7). 3) Variables and Outcome Measures (1) Postoperative bleeding cases For cases involving postoperative hemorrhage, the following variables were investigated: type of surgery (malignant tumor resection, orthognathic surgery, or minor surgery), timing of hemorrhage occurrence expressed as postoperative day (POD), involved bleeding vessels, and the presence of underlying comorbidities such as coagulation disorders. In cases managed with transarterial embolization, the indication for embolization (vascular malformation, trauma, or postoperative bleeding) and the timing of the procedure were analyzed. (2) Airway management indicators To assess the risk of postoperative upper airway obstruction in patients undergoing oral cancer surgery, the Cameron scoring system was retrospectively applied[ 3 ]. The score was calculated as the sum of the following four components: a. Tumor site: Involvement of the floor of the mouth or the base of the tongue. b. Mandibulectomy: Performance of mandibular resection. c. Neck dissection: Bilateral neck dissection. d. Reconstruction: Use of a bulky flap. A total Cameron score of 5 points or higher indicates a high risk of postoperative airway obstruction and suggests the need for elective tracheostomy prior to surgery (Table 1 ). Table 1 Cameron scoring system[ 3 ] Cameron et al.(2009) Variables Score 1) Tumor site - Cutaneous 0 Oral cavity - Buccal mucosa 0 - Maxilla 0 - Mandibular alveolus 1 - Anterior tongue 1 - Floor of mouth 2 Oropharynx - Soft palate 3 - Anterior pillar 3 - Tonsillar pililar 4 - Posterior tongue 4 - Hypopharynx 4 2) Mandibulectomy - No 0 - Yes 1 3) Bilateral neck dissection - No 0 - Yes 3 4) Reconstruction - None 0 - RFFF 2 - Other 3 Tracheostomy recommended score ≥ 5 3) Other complications and outcomes Patient demographic characteristics, clinical circumstances at the time of emergency intervention, and post-intervention outcomes were comprehensively analyzed. 4) Statistical Analysis Differences in age and Cameron scores between the experimental and control groups were evaluated using an independent samples t-test. Statistical significance was set at p < 0.05 for all analyses. Results 1. Postoperative Bleeding Control During the study period, a total of 20 cases required bleeding control due to postoperative hemorrhage. Among these, 6 cases were associated with oral cancer resection and reconstruction, and 8 cases were related to orthognathic surgery. Bleeding following major surgery accounted for 70% of all postoperative hemorrhagic events. In patients who underwent oral cancer surgery, bleeding control was performed at a mean of 5.67 postoperative days (POD), whereas in patients who underwent orthognathic surgery, intervention was performed at a mean of 5.25 POD. Notably, five of the eight orthognathic surgery patients experienced bleeding within 72 hours after surgery, requiring surgical re-exploration and direct hemostasis of the bleeding site. In the oral cancer surgery group, rupture of the external jugular vein, superior thyroid artery, and lingual artery was identified in one case each. In addition, two cases of disseminated intravascular coagulation (DIC) and one case of arterial bleeding from the fibula flap donor site were included. Most patients were managed with direct surgical hemostasis; however, one patient with DIC unfortunately expired. Among the 14 patients who experienced postoperative bleeding following major surgery, two patients (both in the squamous cell carcinoma group) had underlying hypertension. Apart from these cases, no individual bleeding predispositions, such as anticoagulant use or coagulation factor abnormalities, were identified. 6 patients required emergency reoperation for postoperative bleeding related to minor outpatient procedures, and among these, two patients were receiving anticoagulant therapy due to underlying cardiac disease (Table 2 ). Table 2 Classification of patients requiring postoperative bleeding control Category n POD(Mean ± SD) Note Cancer op. 6 5.67 ± 6.86 - Jaw op. 8 5.25 ± 5.23 - Minor op. 6 - 2 patients were taking anticoagulant for heart disease 2. Airway Management and Tracheostomy Tracheostomy was performed in a total of 24 cases, of which 13 were associated with oral cancer surgery. Among the 16 cases requiring emergency tracheostomy, 9 were performed in patients with infectious conditions, including Ludwig’s angina and parapharyngeal space abscess. 6 cases were associated with malignant tumor resection, and one case was related to maxillofacial fracture. Of the 8 cases in which elective tracheostomy was performed, 7 were associated with malignant tumor resection, and one case was performed in a patient with medication-related osteonecrosis of the jaw (MRONJ) involving the maxillary sinus (Table 3 ). Table 3 Classification of patients undergoing postoperative tracheostomy Category Indication n Age (Mean ± SD) Emergency tracheostomy Abscess(Ludwig angina, parapharyngeal space abscess etc.) 9 - Fracture 1 - Cancer(case group) 6 70.67 ± 5.05 yrs Elective tracheostomy Maxillary MRONJ 1 - Cancer(control group) 7 57.57 ± 11.16 yrs Patients in the case group who underwent emergency tracheostomy due to postoperative acute airway compromise (n = 6) were, on average, 13.1 years older than those in the control group who underwent planned elective tracheostomy (n = 7). Although statistical power was limited due to the small sample size, it suggested a tendency toward older age in the emergency tracheostomy group. Except for one patient who was readmitted due to pneumonia after discharge, emergency tracheostomy in the case group was performed at a mean of 10.6 POD. When the Cameron scoring system was retrospectively applied, the control group had a mean score of 6.17, with 4 of 5 patients meeting or exceeding the recommended threshold of 5 points. The case group had a mean score of 6.00, and 5 of 6 patients scored more than 5 points. Among emergency tracheostomy cases associated with major surgery, 2 cases required simultaneous bleeding control for massive hemorrhage. No significant correlation was observed between preoperative airway assessment parameters, such as the Mallampati grade, and the occurrence of postoperative airway emergencies (Table 4 ). Table 4 Comparison of Cameron scores in patients undergoing tracheostomy after malignant tumor resection Category n Cameron score Note Case group(Emergency) 5 6.00 ± 1.58 4 of 5 scored ≥ 5 Excluding 1 unsuitable case Control group(Elective) 6 6.17 ± 1.94 5 of 6 scored ≥ 5 Excluding 1 unsuitable case 3. Transarterial Embolization A total of 13 cases underwent transarterial embolization. However, emergency embolization performed for the management of postoperative complications was limited to a single case involving emergency hemostasis in a patient with facial bone fracture, which was performed on the day of admission. Among the remaining 12 cases, 6 procedures were performed preoperatively for the treatment of hemangioma, and 6 were performed for venous malformation (Table 5 ). Table 5 Classification of patients undergoing prophylactic transarterial embolization Category n Hemangioma 6 Venous malformation 6 Fracture(Motorcycle TA) 1 Discussion This study aimed to systematically analyze cases of acute airway obstruction and massive hemorrhage, which represent life-threatening complications following oral and maxillofacial surgery, using 15 years of accumulated clinical data from a single university dental hospital, and to emphasize the need for practical emergency management guidelines applicable to real-world clinical settings. By analyzing the timing of postoperative emergencies, their association with surgical procedures, and the actual clinical application of airway management and bleeding control strategies, this study was able to identify critical decision-making points in postoperative management after oral and maxillofacial surgery. In this study, a substantial proportion of postoperative massive bleeding events occurred within 72 hours after orthognathic surgery or extensive malignant tumor resection. This finding suggests that the risk of hemorrhage is highest during the early recovery phase following major oral and maxillofacial surgery and supports the necessity for intensive monitoring during the first 3 postoperative days. In orthognathic surgery, bleeding was presumed to originate from osteotomy sites and exposed cancellous bone, whereas in malignant tumor surgery, extensive soft tissue dissection and a higher likelihood of vascular injury may result in more abrupt clinical deterioration once bleeding occurs. In addition, bleeding tended to develop when intraoperative hypotension under general anesthesia was followed by normalization of blood pressure after surgery, highlighting the importance of meticulous intraoperative hemostatic control. Notably, all 14 cases of postoperative bleeding following major surgery occurred independently of preexisting coagulation disorders. This finding suggests that postoperative hemorrhage may be influenced more by surgical extent, technique, and anatomical characteristics than by patient-related systemic factors, emphasizing the importance of procedure-based risk assessment when establishing bleeding management strategies. Furthermore, bleeding control was required up to postoperative 5 days on average in both cancer and orthognathic surgery patients, indicating that strict monitoring is necessary not only during the initial 72 hours but for at least one postoperative week. Although only one case in this cohort required transarterial embolization for postoperative bleeding, numerous studies have demonstrated a high hemostatic success rate with protocol-based embolization approaches[ 8 – 10 ]. Accordingly, future management guidelines should incorporate a stepwise embolization protocol that mandates prompt angiographic evaluation and transarterial embolization when local hemostasis fails or deep vascular injury is suspected (Fig. 1 ). Also, experimental hemodynamic studies have demonstrated that ligation of the external carotid artery alone can reduce arterial blood flow by approximately 73%. Furthermore, additional ligation of major external carotid branches, including the superior thyroid, lingual, and facial arteries, has been reported to further decrease hemorrhage by up to 85%, supporting the rationale for proximal arterial flow control in surgeries with a high risk of perioperative bleeding.[ 11 ] Airway protection represents one of the most critical components in the management of postoperative emergencies in oral and maxillofacial surgery. In this study, tracheostomy was performed in 24 cases, and the higher mean age observed in the case group suggests that elderly patients may be particularly vulnerable to postoperative airway compromise. Age-related reductions in soft tissue elasticity, the presence of underlying respiratory diseases, and diminished compensatory capacity for edema may all contribute to an increased risk of acute airway obstruction in older patients. When tracheostomy cases were analyzed according to emergency versus elective indications, emergency tracheostomy was most frequently performed in patients undergoing malignant tumor surgery or in those with severe infections. This finding indicates that, despite preoperative risk stratification, there remains a subset of patients in whom airway deterioration is difficult to predict. These results suggest that preoperative risk assessment should integrate not only the type of surgery but also tumor location, extent of infection, and the potential for postoperative soft tissue edema[ 12 – 14 ]. The Cameron scoring system, which was introduced to predict postoperative upper airway obstruction after oral cancer surgery, was also shown to be a meaningful indicator in this study[ 3 ]. The mean score of 6.71 in the elective tracheostomy group exceeded the recommended threshold of 5 points, consistent with the findings of Kim et al. (2024)[ 15 ]. Although alternative airway risk assessment tools such as TRACHY (Mohamedbhai et al., 2016) and CASST (Gupta et al., 2016) have been proposed[ 16 – 18 ], Kim et al. (2024) demonstrated that the Cameron scoring system most closely reflects real-world clinical decision-making[ 15 ]. In addition, the lack of correlation between the Mallampati grade and postoperative airway emergencies observed in this study suggests that postoperative airway compromise is determined not only by anatomical airway characteristics but also by surgical invasiveness and overall patient condition. In cases of acute postoperative upper airway obstruction, rapid airway stabilization must be prioritized. Continuous vital sign monitoring should be accompanied by immediate consideration of endotracheal intubation or emergency tracheostomy, depending on the clinical scenario. In patients with chronic upper airway obstruction, maintaining a nasotracheal tube (NTT) during hospitalization and closely monitoring for pneumonia is critical. In particular, for high-risk patients with potential airway compromise, such as those with oral cancer, many studies and clinical guidelines suggest that when the duration of endotracheal intubation is expected to approach approximately 7–10 days, selective tracheostomy should be considered during the preoperative evaluation to ensure airway stability rather than maintaining prolonged translaryngeal intubation[ 19 , 20 ](Fig. 2 ). In this study, only one case underwent transarterial embolization as a direct emergency hemostatic intervention. This reflects the institutional tendency to manage most postoperative bleeding through local hemostasis or surgical re-exploration, with embolization reserved as a final or salvage therapy. Nevertheless, accumulating evidence indicates that when persistent hemorrhage is anticipated or injury to major vessels is suspected, early interventional management, including the combination of surgical hemostasis and transarterial embolization, may offer superior outcomes with respect to both hemostatic efficacy and patient safety. From this perspective, the relatively limited use of prophylactic or early embolization during the study period represents a potential area for improvement. Future practice at our institution aims to incorporate a more proactive approach to embolization in appropriate clinical scenarios. Accordingly, future bleeding management strategies should maintain a stepwise approach while also considering earlier imaging-based evaluation and transarterial embolization in patients with anticipated repeated hemostatic failure or radiologic suspicion of vascular lesions, in parallel with surgical intervention. The findings of this study demonstrate that postoperative emergencies in oral and maxillofacial surgery tend to cluster within specific timeframes and patient populations, supporting the need for standardized response systems. Clarifying the indications for elective tracheostomy during preoperative risk assessment, promptly considering emergency embolization when initial hemostatic measures fail, and implementing intensive monitoring and multidisciplinary collaboration during the early postoperative period for high-risk patients may substantially reduce progression to life-threatening emergencies. This study has inherent limitations as a retrospective analysis conducted at a single institution, and some variables may have been constrained by the nature of medical record-based data. In addition, the relatively low incidence of emergency events limits the statistical power of certain analyses. Future multicenter studies and prospective data collection are warranted to develop more refined risk prediction models and detailed emergency response algorithms. In actual clinical settings, postoperative bleeding and airway obstruction often present concurrently or progress in a sequential manner, necessitating a unified and adaptive approach to emergency management. Accordingly, by integrating the aforementioned airway- and bleeding-focused protocols, we propose a final comprehensive algorithm designed to guide the management of complex postoperative emergencies in oral and maxillofacial surgery(Fig. 3 ). Nevertheless, this study provides practical clinical evidence regarding airway management and bleeding control after oral and maxillofacial surgery based on long-term real-world data. These findings may serve as foundational data for the development of standardized emergency management guidelines in the field of oral and maxillofacial surgery. Conclusion Postoperative airway obstruction and massive hemorrhage following oral and maxillofacial surgery are relatively uncommon; however, when they occur, they constitute critical emergencies that are directly life-threatening. Based on 15 years of clinical data from a single university dental hospital, this study confirmed that airway obstruction and massive hemorrhage following major oral and maxillofacial surgery represent decisive complications with a substantial impact on patient survival[ 21 ]. The analysis demonstrated that postoperative bleeding may occur regardless of patient-related comorbidities, and that the period around postoperative day (POD) 5 is clinically critical, particularly in patients undergoing orthognathic surgery or oral cancer surgery. The first 72 hours following orthognathic surgery and extensive malignant tumor resection were identified as a high-risk period for both hemorrhagic and airway-related complications, underscoring the importance of intensive postoperative surveillance and prompt emergency response during this interval. Furthermore, tracheostomy should not be regarded solely as a last-resort intervention in emergency situations, but rather as a key management strategy that should be proactively considered based on preoperative risk factor assessment and the application of tracheostomy scoring systems[ 22 , 23 ]. Accordingly, this study recommends the following standardized emergency management guidelines. First, in patients undergoing oral cancer surgery, the Cameron score should be applied preoperatively, and elective tracheostomy should be strongly considered in high-risk patients with scores of 5 or higher[ 3 , 24 ]. Even in patients with scores below 5, intensive airway monitoring is essential when advanced age or reconstructive procedures are present. Second, in cases of acute massive hemorrhage, immediate local hemostatic measures such as electrocauterization and vessel ligation should be performed, and when deep vascular injury is suspected or hemostasis is difficult to achieve, prompt angiographic evaluation and transarterial embolization should be incorporated into the management protocol. The emergency management algorithm proposed in this study is grounded in real-world clinical experience and facilitates rapid, standardized responses through coordinated collaboration among surgeons, anesthesiologists, and nursing staff. With further validation through multicenter and prospective studies, this algorithm has the potential to make a meaningful contribution to the management of high-risk patients and to the enhancement of patient safety following oral and maxillofacial surgery. Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board of Pusan National University Dental Hospital (IRB No.: 2025-11-006-006). Funding Not applicable. References Su N, Harroui S, Rozema F, Listl S, Lange J, Heijden GJMGV (2023) What do we know about uncommon complications associated with third molar extractions? A scoping review of case reports and case series. J Korean Association Oral Maxillofacial Surg 49(1):2–12. https://doi.org/10.5125/jkaoms.2023.49.1.2 Stretton C, Service J (2023) Postoperative considerations in patients following oral cancer resection and surgical reconstruction: a review. J Oral Maxillofac Anesth 2:16 Cameron M, Corner A, Diba A, Hankins M (2009) Development of a tracheostomy scoring system to guide airway management after major head and neck surgery. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8901427","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":609892430,"identity":"1f89b6f7-0030-48fe-9910-12a5519e1f5a","order_by":0,"name":"Sungyeop Lee","email":"","orcid":"","institution":"Pusan National University","correspondingAuthor":false,"prefix":"","firstName":"Sungyeop","middleName":"","lastName":"Lee","suffix":""},{"id":609892431,"identity":"ed6dcadf-0350-432e-b2bf-b33907b8ef55","order_by":1,"name":"Sung-Yun Hwang","email":"","orcid":"","institution":"Pusan National University","correspondingAuthor":false,"prefix":"","firstName":"Sung-Yun","middleName":"","lastName":"Hwang","suffix":""},{"id":609892434,"identity":"605cf3ed-ec6e-40b2-b86e-c343d7c41973","order_by":2,"name":"Kyu-Bum Kim","email":"","orcid":"","institution":"Pusan National University","correspondingAuthor":false,"prefix":"","firstName":"Kyu-Bum","middleName":"","lastName":"Kim","suffix":""},{"id":609892436,"identity":"18d904e8-b5bb-4afb-b544-f5ac977fea87","order_by":3,"name":"Suyi Sim","email":"","orcid":"","institution":"Pusan National University","correspondingAuthor":false,"prefix":"","firstName":"Suyi","middleName":"","lastName":"Sim","suffix":""},{"id":609892443,"identity":"99b35e00-72de-427e-ac6d-2e44a0e6eac1","order_by":4,"name":"Chiho Moon","email":"","orcid":"","institution":"Pusan National University","correspondingAuthor":false,"prefix":"","firstName":"Chiho","middleName":"","lastName":"Moon","suffix":""},{"id":609892444,"identity":"b3899c90-89eb-41f5-b26d-2b8e46e8c0f1","order_by":5,"name":"Jihye Ryu","email":"","orcid":"","institution":"Pusan National University","correspondingAuthor":false,"prefix":"","firstName":"Jihye","middleName":"","lastName":"Ryu","suffix":""},{"id":609892445,"identity":"42479e69-6243-4ac8-9672-951aed9988cc","order_by":6,"name":"Jae-Yeol LEE","email":"","orcid":"","institution":"Pusan National University","correspondingAuthor":false,"prefix":"","firstName":"Jae-Yeol","middleName":"","lastName":"LEE","suffix":""},{"id":609892446,"identity":"850bddaa-a20d-443e-a8d2-4157d54d5b85","order_by":7,"name":"Dae-Seok HWANG","email":"","orcid":"","institution":"Pusan National University","correspondingAuthor":false,"prefix":"","firstName":"Dae-Seok","middleName":"","lastName":"HWANG","suffix":""},{"id":609892448,"identity":"d0f9d291-162f-42b4-ac38-589e1e09091b","order_by":8,"name":"Yong-Deok KIM","email":"","orcid":"","institution":"Pusan National University","correspondingAuthor":false,"prefix":"","firstName":"Yong-Deok","middleName":"","lastName":"KIM","suffix":""},{"id":609892449,"identity":"19d10b3e-593c-4e88-a224-b9687062191e","order_by":9,"name":"Sang-Hun SHIN","email":"","orcid":"","institution":"Pusan National University","correspondingAuthor":false,"prefix":"","firstName":"Sang-Hun","middleName":"","lastName":"SHIN","suffix":""},{"id":609892451,"identity":"71feb562-720a-49c7-9d91-30af20791996","order_by":10,"name":"Uk‑Kyu Kim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYBACCQY2EGGDLEKcljRStTAwHCZBi+SMtOQPFn/O5xmcP/zsAUONHYPk7AP4tUhLpB2TkGy7XWxwI83cgOFYMoM0XwJ+LXIS6W0Mkg23EzfcYDADuvIAgxwPAYcBtTR/kPhzLnHD+ePfJBj+EaEF6LADEhJsBxI3HMgxk2BsO8AgTUiLZM+zNKBfkoslb+SUSST2JfNI9hDQInE8zfizxB+7PL7zx7dJfPhmJydxhoAWEGAGRkUCmAUkCTkLAhg/wLSMglEwCkbBKMAGAIQBPLAFGzaWAAAAAElFTkSuQmCC","orcid":"","institution":"Pusan National University","correspondingAuthor":true,"prefix":"","firstName":"Uk‑Kyu","middleName":"","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2026-02-17 13:10:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8901427/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8901427/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105198245,"identity":"98ff419a-e9d6-48f1-992d-74e27e816811","added_by":"auto","created_at":"2026-03-23 10:42:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":18034,"visible":true,"origin":"","legend":"\u003cp\u003eStepwise protocol for postoperative bleeding management in oral and maxillofacial surgery\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-8901427/v1/aad67c3ab972f760ffa73a7c.png"},{"id":105198150,"identity":"760246f8-86bb-4a73-b030-2913975edbc0","added_by":"auto","created_at":"2026-03-23 10:42:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":23722,"visible":true,"origin":"","legend":"\u003cp\u003eStepwise protocol for airway management in oral and maxillofacial surgery\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-8901427/v1/9598bac7462f98dffbea0c21.png"},{"id":105563639,"identity":"3846c585-8ad2-4d8b-abd0-8eb7c77cc490","added_by":"auto","created_at":"2026-03-27 12:47:19","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":32166,"visible":true,"origin":"","legend":"\u003cp\u003eStepwise protocol for postoperative bleeding and airway management in oral and maxillofacial surgery.\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-8901427/v1/04198c4ecf96d056eb162126.png"},{"id":106724581,"identity":"7a043107-0e31-4c32-9406-7fee7e1bcff7","added_by":"auto","created_at":"2026-04-12 18:28:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":739343,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8901427/v1/b2071adb-9f1f-473d-a5dd-7975da1610ea.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Emergency Management Protocols for Major Complications after Oral and Maxillofacial Surgery: Emphasis on Airway and Bleeding Control","fulltext":[{"header":"Background","content":"\u003cp\u003eSurgical management in the field of oral and maxillofacial surgery, including orthognathic surgery, oral cancer resection and reconstruction, trauma surgery, and treatment of severe infections, is anatomically closely associated with the airway and major vascular structures. Consequently, these procedures carry a relatively high risk of acute postoperative complications. In particular, acute airway obstruction and massive hemorrhage occurring immediately after surgery or during the inpatient period may result in catastrophic outcomes directly affecting patient survival, such as hypoxic brain injury or death, if prompt recognition and immediate intervention are not achieved[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMassive hemorrhage following oral and maxillofacial surgery is often unpredictable due to extensive surgical dissection, the rich vascular supply of the maxillofacial region, and osteotomy sites associated with tumor resection or orthognathic surgery. In addition, postoperative airway obstruction may arise from hematoma formation, edema, active bleeding, retention of secretions, or exacerbation of underlying respiratory diseases. Although it may initially present as relatively mild respiratory discomfort, it can rapidly progress to severe respiratory failure within a short period[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In such situations, complex clinical decision-making is required, extending beyond simple local hemostasis to include airway securing, blood transfusion, imaging-based vascular evaluation, and, when necessary, transarterial embolization[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Despite these risks, comprehensive management guidelines or standardized response protocols for postoperative airway obstruction and hemorrhagic emergencies in oral and maxillofacial surgery have not yet been adequately established. Existing reports are largely limited to individual case reports or analyses of specific surgical populations, and studies proposing comprehensive, stepwise emergency response algorithms applicable to real-world clinical practice remain scarce. In particular, long-term data analyzing criteria for determining the timing of tracheostomy, indications distinguishing emergency versus elective tracheostomy, and the actual clinical application of interventions such as transarterial embolization are lacking.\u003c/p\u003e \u003cp\u003eGiven the nature of postoperative emergencies in oral and maxillofacial surgery, close multidisciplinary collaboration among surgeons, anesthesiologists, and nursing staff is essential, and pre-shared risk assessments and response strategies have a critical impact on patient outcomes. Therefore, an analysis of emergency occurrence patterns based on real-world clinical data, together with the establishment of management guidelines derived from these findings, may contribute to enhanced patient safety and reduced delays in emergency care.\u003c/p\u003e \u003cp\u003eAccordingly, this study retrospectively analyzed cases requiring airway management and/or bleeding control during or after surgery among patients who underwent major oral and maxillofacial surgical procedures at a single university dental hospital between 2010 and 2025. Rather than analyzing each complication independently, this study focuses on establishing an integrated emergency response framework. In particular, patients who required urgent airway intervention were compared with those who underwent planned airway management to comprehensively evaluate background factors associated with emergency events, types of surgery, timing of complication onset, management strategies, and clinical outcomes. Furthermore, through comparative analysis with existing literature, this study aims to provide evidence supporting the development of more systematic and practical management guidelines for postoperative emergency complications in oral and maxillofacial surgery.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003ch3\u003e1) Study Population and Study Period\u003c/h3\u003e\n\u003cp\u003eThis retrospective study analyzed the medical records of patients who underwent elective surgery, emergency admission, or intensive care unit (ICU) management in the Department of Oral and Maxillofacial Surgery at Pusan National University Dental Hospital, Pusan National University Medical Hospital, Yangsan, over a 15-year period from August 2010 to July 2025. Among these patients, cases in which emergency interventions were required due to acute airway compromise or massive hemorrhage during or after surgery were included. A total of 57 cases were identified, consisting of 20 cases requiring bleeding control, 24 cases requiring tracheostomy, and 13 cases managed with transarterial embolization.\u003c/p\u003e\n\u003ch3\u003e2) Classification of Experimental and Control Groups\u003c/h3\u003e\n\u003cp\u003eTo minimize confounding by infectious etiologies, age and airway risk analyses were restricted to patients who underwent tracheostomy following malignant tumor resection. For the development of airway management guidelines, patients who underwent tracheostomy following oral cancer surgery were classified into the following groups and comparatively analyzed:\u003c/p\u003e\n\u003cp\u003eCase group: Patients who underwent emergency tracheostomy due to unexpected acute respiratory distress occurring after malignant tumor resection surgery (n\u0026thinsp;=\u0026thinsp;6).\u003c/p\u003e\n\u003cp\u003eControl group: Patients who underwent planned elective tracheostomy before the completion of malignant tumor resection surgery based on preoperative or intraoperative risk assessment (n\u0026thinsp;=\u0026thinsp;7).\u003c/p\u003e\n\u003ch3\u003e3) Variables and Outcome Measures\u003c/h3\u003e\n\u003cp\u003e(1) Postoperative bleeding cases\u003c/p\u003e\n\u003cp\u003eFor cases involving postoperative hemorrhage, the following variables were investigated: type of surgery (malignant tumor resection, orthognathic surgery, or minor surgery), timing of hemorrhage occurrence expressed as postoperative day (POD), involved bleeding vessels, and the presence of underlying comorbidities such as coagulation disorders. In cases managed with transarterial embolization, the indication for embolization (vascular malformation, trauma, or postoperative bleeding) and the timing of the procedure were analyzed.\u003c/p\u003e\n\u003cp\u003e(2) Airway management indicators\u003c/p\u003e\n\u003cp\u003eTo assess the risk of postoperative upper airway obstruction in patients undergoing oral cancer surgery, the Cameron scoring system was retrospectively applied[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The score was calculated as the sum of the following four components:\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003ea. Tumor site: Involvement of the floor of the mouth or the base of the tongue.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003eb. Mandibulectomy: Performance of mandibular resection.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003ec. Neck dissection: Bilateral neck dissection.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003ed. Reconstruction: Use of a bulky flap.\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e \u003cp\u003eA total Cameron score of 5 points or higher indicates a high risk of postoperative airway obstruction and suggests the need for elective tracheostomy prior to surgery (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCameron scoring system[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCameron et al.(2009)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1) Tumor site\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Cutaneous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOral cavity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Buccal mucosa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Maxilla\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Mandibular alveolus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Anterior tongue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Floor of mouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOropharynx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Soft palate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Anterior pillar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Tonsillar pililar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Posterior tongue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Hypopharynx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2) Mandibulectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3) Bilateral neck dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4) Reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- None\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- RFFF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTracheostomy recommended score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e3) Other complications and outcomes\u003c/h3\u003e\n\u003cp\u003ePatient demographic characteristics, clinical circumstances at the time of emergency intervention, and post-intervention outcomes were comprehensively analyzed.\u003c/p\u003e\n\u003ch3\u003e4) Statistical Analysis\u003c/h3\u003e\n\u003cp\u003eDifferences in age and Cameron scores between the experimental and control groups were evaluated using an independent samples t-test. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all analyses.\u003c/p\u003e"},{"header":"Results","content":"\n\u003ch3\u003e1. Postoperative Bleeding Control\u003c/h3\u003e\n\u003cp\u003eDuring the study period, a total of 20 cases required bleeding control due to postoperative hemorrhage. Among these, 6 cases were associated with oral cancer resection and reconstruction, and 8 cases were related to orthognathic surgery. Bleeding following major surgery accounted for 70% of all postoperative hemorrhagic events.\u003c/p\u003e \u003cp\u003eIn patients who underwent oral cancer surgery, bleeding control was performed at a mean of 5.67 postoperative days (POD), whereas in patients who underwent orthognathic surgery, intervention was performed at a mean of 5.25 POD. Notably, five of the eight orthognathic surgery patients experienced bleeding within 72 hours after surgery, requiring surgical re-exploration and direct hemostasis of the bleeding site.\u003c/p\u003e \u003cp\u003eIn the oral cancer surgery group, rupture of the external jugular vein, superior thyroid artery, and lingual artery was identified in one case each. In addition, two cases of disseminated intravascular coagulation (DIC) and one case of arterial bleeding from the fibula flap donor site were included. Most patients were managed with direct surgical hemostasis; however, one patient with DIC unfortunately expired.\u003c/p\u003e \u003cp\u003eAmong the 14 patients who experienced postoperative bleeding following major surgery, two patients (both in the squamous cell carcinoma group) had underlying hypertension. Apart from these cases, no individual bleeding predispositions, such as anticoagulant use or coagulation factor abnormalities, were identified.\u003c/p\u003e \u003cp\u003e6 patients required emergency reoperation for postoperative bleeding related to minor outpatient procedures, and among these, two patients were receiving anticoagulant therapy due to underlying cardiac disease (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClassification of patients requiring postoperative bleeding control\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePOD(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancer op.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.67\u0026thinsp;\u0026plusmn;\u0026thinsp;6.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJaw op.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.25\u0026thinsp;\u0026plusmn;\u0026thinsp;5.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinor op.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 patients were taking anticoagulant for heart disease\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e2. Airway Management and Tracheostomy\u003c/h3\u003e\n\u003cp\u003eTracheostomy was performed in a total of 24 cases, of which 13 were associated with oral cancer surgery.\u003c/p\u003e \u003cp\u003eAmong the 16 cases requiring emergency tracheostomy, 9 were performed in patients with infectious conditions, including Ludwig\u0026rsquo;s angina and parapharyngeal space abscess. 6 cases were associated with malignant tumor resection, and one case was related to maxillofacial fracture.\u003c/p\u003e \u003cp\u003eOf the 8 cases in which elective tracheostomy was performed, 7 were associated with malignant tumor resection, and one case was performed in a patient with medication-related osteonecrosis of the jaw (MRONJ) involving the maxillary sinus (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClassification of patients undergoing postoperative tracheostomy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEmergency tracheostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbscess(Ludwig angina, parapharyngeal space abscess etc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCancer(case group)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.67\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05 yrs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eElective tracheostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaxillary MRONJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCancer(control group)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.57\u0026thinsp;\u0026plusmn;\u0026thinsp;11.16 yrs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePatients in the case group who underwent emergency tracheostomy due to postoperative acute airway compromise (n\u0026thinsp;=\u0026thinsp;6) were, on average, 13.1 years older than those in the control group who underwent planned elective tracheostomy (n\u0026thinsp;=\u0026thinsp;7). Although statistical power was limited due to the small sample size, it suggested a tendency toward older age in the emergency tracheostomy group. Except for one patient who was readmitted due to pneumonia after discharge, emergency tracheostomy in the case group was performed at a mean of 10.6 POD.\u003c/p\u003e \u003cp\u003eWhen the Cameron scoring system was retrospectively applied, the control group had a mean score of 6.17, with 4 of 5 patients meeting or exceeding the recommended threshold of 5 points. The case group had a mean score of 6.00, and 5 of 6 patients scored more than 5 points. Among emergency tracheostomy cases associated with major surgery, 2 cases required simultaneous bleeding control for massive hemorrhage. No significant correlation was observed between preoperative airway assessment parameters, such as the Mallampati grade, and the occurrence of postoperative airway emergencies (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Cameron scores in patients undergoing tracheostomy after malignant tumor resection\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCameron score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase group(Emergency)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e6.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 of 5 scored\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/p\u003e \u003cp\u003eExcluding 1 unsuitable case\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl group(Elective)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e6.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 of 6 scored\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/p\u003e \u003cp\u003eExcluding 1 unsuitable case\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e3. Transarterial Embolization\u003c/h3\u003e\n\u003cp\u003eA total of 13 cases underwent transarterial embolization. However, emergency embolization performed for the management of postoperative complications was limited to a single case involving emergency hemostasis in a patient with facial bone fracture, which was performed on the day of admission. Among the remaining 12 cases, 6 procedures were performed preoperatively for the treatment of hemangioma, and 6 were performed for venous malformation (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClassification of patients undergoing prophylactic transarterial embolization\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemangioma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVenous malformation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracture(Motorcycle TA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e This study aimed to systematically analyze cases of acute airway obstruction and massive hemorrhage, which represent life-threatening complications following oral and maxillofacial surgery, using 15 years of accumulated clinical data from a single university dental hospital, and to emphasize the need for practical emergency management guidelines applicable to real-world clinical settings. By analyzing the timing of postoperative emergencies, their association with surgical procedures, and the actual clinical application of airway management and bleeding control strategies, this study was able to identify critical decision-making points in postoperative management after oral and maxillofacial surgery.\u003c/p\u003e \u003cp\u003eIn this study, a substantial proportion of postoperative massive bleeding events occurred within 72 hours after orthognathic surgery or extensive malignant tumor resection. This finding suggests that the risk of hemorrhage is highest during the early recovery phase following major oral and maxillofacial surgery and supports the necessity for intensive monitoring during the first 3 postoperative days. In orthognathic surgery, bleeding was presumed to originate from osteotomy sites and exposed cancellous bone, whereas in malignant tumor surgery, extensive soft tissue dissection and a higher likelihood of vascular injury may result in more abrupt clinical deterioration once bleeding occurs. In addition, bleeding tended to develop when intraoperative hypotension under general anesthesia was followed by normalization of blood pressure after surgery, highlighting the importance of meticulous intraoperative hemostatic control.\u003c/p\u003e \u003cp\u003eNotably, all 14 cases of postoperative bleeding following major surgery occurred independently of preexisting coagulation disorders. This finding suggests that postoperative hemorrhage may be influenced more by surgical extent, technique, and anatomical characteristics than by patient-related systemic factors, emphasizing the importance of procedure-based risk assessment when establishing bleeding management strategies. Furthermore, bleeding control was required up to postoperative 5 days on average in both cancer and orthognathic surgery patients, indicating that strict monitoring is necessary not only during the initial 72 hours but for at least one postoperative week.\u003c/p\u003e \u003cp\u003eAlthough only one case in this cohort required transarterial embolization for postoperative bleeding, numerous studies have demonstrated a high hemostatic success rate with protocol-based embolization approaches[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Accordingly, future management guidelines should incorporate a stepwise embolization protocol that mandates prompt angiographic evaluation and transarterial embolization when local hemostasis fails or deep vascular injury is suspected (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlso, experimental hemodynamic studies have demonstrated that ligation of the external carotid artery alone can reduce arterial blood flow by approximately 73%. Furthermore, additional ligation of major external carotid branches, including the superior thyroid, lingual, and facial arteries, has been reported to further decrease hemorrhage by up to 85%, supporting the rationale for proximal arterial flow control in surgeries with a high risk of perioperative bleeding.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAirway protection represents one of the most critical components in the management of postoperative emergencies in oral and maxillofacial surgery. In this study, tracheostomy was performed in 24 cases, and the higher mean age observed in the case group suggests that elderly patients may be particularly vulnerable to postoperative airway compromise. Age-related reductions in soft tissue elasticity, the presence of underlying respiratory diseases, and diminished compensatory capacity for edema may all contribute to an increased risk of acute airway obstruction in older patients.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWhen tracheostomy cases were analyzed according to emergency versus elective indications, emergency tracheostomy was most frequently performed in patients undergoing malignant tumor surgery or in those with severe infections. This finding indicates that, despite preoperative risk stratification, there remains a subset of patients in whom airway deterioration is difficult to predict. These results suggest that preoperative risk assessment should integrate not only the type of surgery but also tumor location, extent of infection, and the potential for postoperative soft tissue edema[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Cameron scoring system, which was introduced to predict postoperative upper airway obstruction after oral cancer surgery, was also shown to be a meaningful indicator in this study[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The mean score of 6.71 in the elective tracheostomy group exceeded the recommended threshold of 5 points, consistent with the findings of Kim et al. (2024)[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough alternative airway risk assessment tools such as TRACHY (Mohamedbhai et al., 2016) and CASST (Gupta et al., 2016) have been proposed[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], Kim et al. (2024) demonstrated that the Cameron scoring system most closely reflects real-world clinical decision-making[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In addition, the lack of correlation between the Mallampati grade and postoperative airway emergencies observed in this study suggests that postoperative airway compromise is determined not only by anatomical airway characteristics but also by surgical invasiveness and overall patient condition.\u003c/p\u003e \u003cp\u003eIn cases of acute postoperative upper airway obstruction, rapid airway stabilization must be prioritized. Continuous vital sign monitoring should be accompanied by immediate consideration of endotracheal intubation or emergency tracheostomy, depending on the clinical scenario. In patients with chronic upper airway obstruction, maintaining a nasotracheal tube (NTT) during hospitalization and closely monitoring for pneumonia is critical.\u003c/p\u003e \u003cp\u003eIn particular, for high-risk patients with potential airway compromise, such as those with oral cancer, many studies and clinical guidelines suggest that when the duration of endotracheal intubation is expected to approach approximately 7\u0026ndash;10 days, selective tracheostomy should be considered during the preoperative evaluation to ensure airway stability rather than maintaining prolonged translaryngeal intubation[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e](Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn this study, only one case underwent transarterial embolization as a direct emergency hemostatic intervention. This reflects the institutional tendency to manage most postoperative bleeding through local hemostasis or surgical re-exploration, with embolization reserved as a final or salvage therapy.\u003c/p\u003e \u003cp\u003eNevertheless, accumulating evidence indicates that when persistent hemorrhage is anticipated or injury to major vessels is suspected, early interventional management, including the combination of surgical hemostasis and transarterial embolization, may offer superior outcomes with respect to both hemostatic efficacy and patient safety. From this perspective, the relatively limited use of prophylactic or early embolization during the study period represents a potential area for improvement. Future practice at our institution aims to incorporate a more proactive approach to embolization in appropriate clinical scenarios.\u003c/p\u003e \u003cp\u003eAccordingly, future bleeding management strategies should maintain a stepwise approach while also considering earlier imaging-based evaluation and transarterial embolization in patients with anticipated repeated hemostatic failure or radiologic suspicion of vascular lesions, in parallel with surgical intervention.\u003c/p\u003e \u003cp\u003eThe findings of this study demonstrate that postoperative emergencies in oral and maxillofacial surgery tend to cluster within specific timeframes and patient populations, supporting the need for standardized response systems. Clarifying the indications for elective tracheostomy during preoperative risk assessment, promptly considering emergency embolization when initial hemostatic measures fail, and implementing intensive monitoring and multidisciplinary collaboration during the early postoperative period for high-risk patients may substantially reduce progression to life-threatening emergencies.\u003c/p\u003e \u003cp\u003eThis study has inherent limitations as a retrospective analysis conducted at a single institution, and some variables may have been constrained by the nature of medical record-based data. In addition, the relatively low incidence of emergency events limits the statistical power of certain analyses. Future multicenter studies and prospective data collection are warranted to develop more refined risk prediction models and detailed emergency response algorithms.\u003c/p\u003e \u003cp\u003eIn actual clinical settings, postoperative bleeding and airway obstruction often present concurrently or progress in a sequential manner, necessitating a unified and adaptive approach to emergency management. Accordingly, by integrating the aforementioned airway- and bleeding-focused protocols, we propose a final comprehensive algorithm designed to guide the management of complex postoperative emergencies in oral and maxillofacial surgery(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNevertheless, this study provides practical clinical evidence regarding airway management and bleeding control after oral and maxillofacial surgery based on long-term real-world data. These findings may serve as foundational data for the development of standardized emergency management guidelines in the field of oral and maxillofacial surgery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePostoperative airway obstruction and massive hemorrhage following oral and maxillofacial surgery are relatively uncommon; however, when they occur, they constitute critical emergencies that are directly life-threatening. Based on 15 years of clinical data from a single university dental hospital, this study confirmed that airway obstruction and massive hemorrhage following major oral and maxillofacial surgery represent decisive complications with a substantial impact on patient survival[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The analysis demonstrated that postoperative bleeding may occur regardless of patient-related comorbidities, and that the period around postoperative day (POD) 5 is clinically critical, particularly in patients undergoing orthognathic surgery or oral cancer surgery.\u003c/p\u003e \u003cp\u003eThe first 72 hours following orthognathic surgery and extensive malignant tumor resection were identified as a high-risk period for both hemorrhagic and airway-related complications, underscoring the importance of intensive postoperative surveillance and prompt emergency response during this interval. Furthermore, tracheostomy should not be regarded solely as a last-resort intervention in emergency situations, but rather as a key management strategy that should be proactively considered based on preoperative risk factor assessment and the application of tracheostomy scoring systems[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Accordingly, this study recommends the following standardized emergency management guidelines. First, in patients undergoing oral cancer surgery, the Cameron score should be applied preoperatively, and elective tracheostomy should be strongly considered in high-risk patients with scores of 5 or higher[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Even in patients with scores below 5, intensive airway monitoring is essential when advanced age or reconstructive procedures are present. Second, in cases of acute massive hemorrhage, immediate local hemostatic measures such as electrocauterization and vessel ligation should be performed, and when deep vascular injury is suspected or hemostasis is difficult to achieve, prompt angiographic evaluation and transarterial embolization should be incorporated into the management protocol.\u003c/p\u003e \u003cp\u003eThe emergency management algorithm proposed in this study is grounded in real-world clinical experience and facilitates rapid, standardized responses through coordinated collaboration among surgeons, anesthesiologists, and nursing staff. With further validation through multicenter and prospective studies, this algorithm has the potential to make a meaningful contribution to the management of high-risk patients and to the enhancement of patient safety following oral and maxillofacial surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of Pusan National University Dental Hospital (IRB No.: 2025-11-006-006).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSu N, Harroui S, Rozema F, Listl S, Lange J, Heijden GJMGV (2023) What do we know about uncommon complications associated with third molar extractions? A scoping review of case reports and case series. 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Risk Manage Healthc policy 18:2551\u0026ndash;2563. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/RMHP.S538063\u003c/span\u003e\u003cspan address=\"10.2147/RMHP.S538063\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnehosur VS, Karadiguddi P, Joshi VK, Lakkundi BC, Ghosh R, Krishnan G (2017) Elective Tracheostomy in Head and Neck Surgery: Our Experience. J Clin Diagn research: JCDR 11(5):ZC36\u0026ndash;ZC39. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7860/JCDR/2017/24117.9854\u003c/span\u003e\u003cspan address=\"10.7860/JCDR/2017/24117.9854\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenatar-Haserfaty J, Pic\u0026oacute;n-Molina M, Mel\u0026eacute;ndez-Salinas DA, Palacios-L\u0026oacute;pez C (2014) Rev Esp Anestesiol Reanim 61(7):369\u0026ndash;374. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.redar.2014.02.009\u003c/span\u003e\u003cspan address=\"10.1016/j.redar.2014.02.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Utilidad del score predictivo de Cameron para la realizaci\u0026oacute;n de traqueostom\u0026iacute;a electiva despu\u0026eacute;s de cirug\u0026iacute;a tumoral oral [Usefulness of the Cameron tracheostomy scoring system after oral tumor surgery]\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Bleeding control, Embolization, Airway obstruction, Tracheostomy","lastPublishedDoi":"10.21203/rs.3.rs-8901427/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8901427/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMajor postoperative complications following maxillofacial surgery, particularly severe bleeding and airway obstruction, remain life-threatening events despite advances in surgical trechniques and perioperative care[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Delayed response to these events can lead to fatal complications or even death. However, standardized institutiohnal protocols integrating bleeding control and airway management are lacking. Therefore, this study retrospectively analyzes cases of postoperative major hemorrhage and airway obstruction that occurred at a tertiary hospital, and through a review of the literature, aims to establish safer postoperative management guidelines.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this study, \u0026ldquo;major surgery\u0026rdquo; primarily refers to procedures such as malignant tumor resection, orthognathic surgery, and fracture surgery. A retrospective cohort study was conducted including patients who underwent maxillofacial major surgery at a tertiary university dental hospital over a 15-year period. Major bleeding events were defined as postoperative hemorrhage requiring reoperation or angiography with embolization. Major airway events were defined as unplanned reintubation, emergency tracheostomy. Patients who underwent malignant tumor resection in the oral and maxillofacial region were included in the analysis. Among the patients who underwent malignant tumor resection, those who required emergency tracheostomy following surgery were classified as the case group, whereas those who underwent planned elective tracheostomy prior to surgery were assigned to the control group.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePostoperative bleeding requiring intervention occurred in 20 cases, with 70% associated with major surgery. Five of the eight patients who underwent orthognathic surgery required emergency bleeding control operation for hemorrhage within 72 hours postoperatively. Most bleeding events occurred independently of patient-related coagulation disorders, indicating a stronger association with surgical extent and technique. Transarterial embolization was performed in 13 cases; however, only one case was related to emergency postoperative hemorrhage. Tracheostomy was performed in 24 cases, including 13 related to oral cancer surgery. Emergency tracheostomy was most commonly required in patients with malignant tumors or severe infections. The mean Cameron score was 6.00 in the five patients in the case group, whereas a mean score of 6.17 was observed in six patients in the control group[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn oral and maxillofacial surgery, postoperative hemorrhage may occur regardless of patient comorbidities, necessitating careful perioperative bleeding control. Although not included in our institutional protocol, prior studies support angiographic evaluation with selective arterial embolization as a reliable option in cases at high risk for postoperative bleeding. Tracheostomy should be considered a proactive airway management strategy guided by tools such as the Cameron scoring system, particularly in elderly patients and those undergoing extensive surgery[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, the score should not be used in isolation, and careful postoperative monitoring is required even in patients below the recommended threshold. A stepwise, integrated approach to postoperative bleeding and airway management, incorporating structured bleeding control, early airway protection, and timely consideration of transarterial embolization, may improve patient safety and outcomes.\u003c/p\u003e","manuscriptTitle":"Emergency Management Protocols for Major Complications after Oral and Maxillofacial Surgery: Emphasis on Airway and Bleeding Control","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-23 10:39:13","doi":"10.21203/rs.3.rs-8901427/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e08fbece-182c-4e73-8a49-72213dc6896f","owner":[],"postedDate":"March 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T12:43:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-23 10:39:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8901427","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8901427","identity":"rs-8901427","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}