Fatal pulmonary embolism after middle ear surgery: a case report

Khyati Ramesh Patel, Varsha Vyas, Kaushal Patel, Misha Mehta


Pulmonary thromboembolism is a complication of underlying venous thrombosis. Factors contributing to thrombus formation include venous stasis, hypercoagulable state, immobilisation, surgery and pregnancy. Authors present the challenges authors faced in diagnosing pulmonary embolism in a post-operative patient. 35-year-old female with complaint of decreased hearing for 2 years along with tinnitus and giddiness was admitted for stapedectomy. She also gave history of dyspnoea and pedal oedema one month back for which she was hospitalized and underwent investigations which were normal. Patient was discharged as her clinical symptoms improved. On postoperative day 5, she developed sudden dyspnoea after getting up and walking a few steps. Dyspnoea along with falling saturation and bradycardia progressed to cardiopulmonary arrest. Intensive care was started. Bilateral lower limb venous doppler showed deep venous thrombosis. Clinical diagnosis of pulmonary embolism was made, and patient was lysed with Tenecteplase 30 mg. Echocardiography showed signs of resolution of embolism after lysis, but gradually patient deteriorated and developed cardiogenic shock. Intra-aortic balloon pump was inserted via right femoral artery and inotropic support was continued. However, patient’s condition worsened, and she developed cardiopulmonary arrest the next day and could not be revived. Prevention of pulmonary embolism is a major clinical problem for which prophylactic measures like early ambulation in post-operative periods, elastic stockings, graduated compressive stockings for bed ridden patients and preventive anticoagulation therapy in high risk patients should be considered.


DVT prophylaxis, Post-operative complication, Pulmonary embolism, Thrombolysis, Thromboembolism

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Blann AD, Lip GY. Venous thromboembolism. BMJ. 2006 Jan 26;332(7535):215-9.

Spencer FA, Emery C, Lessard D, Anderson F, Emani S, Aragam J, et al. The Worcester Venous Thromboembolism study: a population‐based study of the clinical epidemiology of venous thromboembolism. J General Inter Med. 2006 Jul;21(7):722-7.

Goldhaber SZ. Deep venous thrombosis and pulmonary embolism. In: Braunwald E, Kasper DL, Hauser SL, Jameson JL, Loscal Fanci AS, eds. Harrison's Principles of Internal Medicine, 17th ed. New York: McGraw Hill; 2008:1651-1657.

Söhne M, ten Wolde M, Boomsma F, Reitsma JB, Douketis JD, Büller HR. Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. J Thromb Haemos. 2006 Mar;4(3):552-6.

Ray P, Delerme S, Jourdain P, Chenevier-Gobeaux C. Differential diagnosis of acute dyspnea: the value of B natriuretic peptides in the emergency department. QJM: Intern J Med. 2008 Nov 1;101(11):831-43.

Kucher N, Goldhaber SZ. Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism. Circulation. 2003 Nov 4;108(18):2191-4.

Stein PD, Terrin ML, Hales CA. Clinical, laboratory, roentgenographic and Electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest. 1991;100:598-603.

Elliott CG, Goldhaber SZ, Visani L, DeRosa M. Chest radiographs in acute pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. Chest. 2000 Jul 1;118(1):33-8.

Torbicki A, Pruszynski B, Chlebus M, Kuch-Wocial A, Gurba H, Pruszczyk P, et al. Noninvasive diagnosis of suspected severe pulmonary embolism: transesophageal echocardiography vs spiral CT. Chest. 1997 Sep 1;112(3):722-8.

Lodato JA, Ward RP, Lang RM. Echocardiographic predictors of pulmonary embolism in patients referred for helical CT. Echocardio. 2008 Jul;25(6):584-90.

Nazeyrollas P, Metz D, Chapoutot L, Chabert JP, Maillier B, Macs D, et al. Diagnostic accuracy of echocardiography-Doppler in acute pulmonary embolism. Inter J Cardiol. 1995 Jan 6;47(3):273-80.

Kline JA, Hernandez-Nino J, Newgard CD, Cowles DN, Jackson RE, Courtney DM. Use of pulse oximetry to predict in-hospital complications in normotensive patients with pulmonary embolism. Am J Med. 2003 Aug 15;115(3):203-8.

Anderson JT, Owings JT, Goodnight JE. Bedside noninvasive detection of acute pulmonary embolism in critically ill surgical patients. Archi Surg. 1999 Aug 1;134(8):869-75.

Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016 Feb 1;149(2):315-52.

Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb 1;141(2):e419S-96S.

Elpern E, Killeen K, Patel G, Senecal PA. The application of intermittent pneumatic compression devices for thromboprophylaxis. AJN Am J Nursing. 2013 Apr 1;113(4):30-6.