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\begin{document}

\title{An Unusual Clustered Series of Foreign Body Reactions to Oxidized
Regenerated Cellulose in Head and Neck surgery}



\author[1]{Lisa O Byrne}%
\author[1]{Gulwish Moghul}%
\author[1]{Henry Zhang}%
\author[1]{Yasmin Abbas}%
\author[1]{Jahangir Ahmed}%
\author[1]{Khalid Ghufoor}%
\affil[1]{Royal London Hospital}%


\vspace{-1em}



  
  \date{May 07, 2024}


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\emph{An Unusual Clustered Series of Foreign Body Reactions to Oxidised
Regenerated Cellulose in Head and Neck surgery}

\textbf{-} \emph{A Case series of four post-operative patients}

\emph{Key Points}

\begin{itemize}
\tightlist
\item
  Oxidised Regenerated Cellulose (ORC) is a widely used topical
  haemostatic agent with just three case reports of complications in
  head and neck patients.
\item
  We report a case series over a three-month period including four
  patients whom all had serious complications related to ORC use.
\item
  This series includes the only case-report of a patient who
  necessitated emergent return to theatre secondary to life-threatening
  airway compromise.
\item
  Topical absorbable haemostats and other foreign body materials used in
  surgery should always be considered in the differential diagnosis of
  post-op complications.
\end{itemize}

\emph{Introduction}

Oxidised regenerated cellulose is a popular absorbable haemostatic agent
in use for decades. It is a bio-absorbable oxidised cellulose polymer
made of polyanydroglucuronic acid. In addition to its haemostatic
properties, it has been known to prevent adhesions and has a wide range
of bactericidal properties particularly against Streptococcus
Pneumoniae, Methicillin Resistant Staphylococcus Aureus and Pseudomonas
Aeruginosa.11\textsuperscript{1} Schonauer C, Tessitore E, Barbagallo G,
Albanese V, Moraci A. The use of local agents: bone wax, gelatin,
collagen, oxidised cellulose.~\emph{Eur Spine J} . 2004;13 Suppl 1(Suppl
1):S89-96.

It is routinely used in Head and Neck surgery for the reasons described
above. However, it has been known to mimic tumor recurrence and abscess
formation on imaging. 22Melamed JW, Paulson EK, Kliewer MA. Sonographic
appearance of oxidised cellulose (Surgicel): pitfall in the diagnosis of
postoperative abscess. J Ultrasound Med. 1995 Jan;14(1):27-30. PMID:
7707473. Only sporadic case reports exist where it has clinically
presented as a hypersensitivity/foreign body reaction. No case report
exists where airway compromise requiring emergency intervention was
warranted.

Herein we report a series of four patients all presenting within one
month of each other in the early post-op period with significant
complications.

\emph{Case series}

The following is an account of a 47 year old female, day 2 post right
submandibular gland excision (SMG) for suspected pleomorphic adenoma,
who was referred to the on call team with increased neck swelling and
difficulty breathing. On review, the patient had developed difficulty in
breathing in addition to dysphagia and dysphonia. There was a firm
swelling measuring 8x10cm in the right submandibular region. Fibreoptic
nasendoscopy (FNE) revealed an oedematous aryepiglottic fold and
supraglottis, causing deviation of the epiglottis with subsequent airway
compromise. Needle aspiration and opening of sutures provided minimal
relief and she was taken emergently to theatre. On exploration, minimal
clotting or frank bleeding was visualised. However, tissues around the
ORC (placed at the time of initial surgery) appeared edematous and
inflamed. The ORC was removed and minor bleeding points cauterised using
diathermy. Given the oedema initially visualised at FNE, the patient
remained intubated via a nasal tube for two days. She was discharged on
day 5 post removal of ORC.

Our second experience with ORC related morbidity was of a 56-year-old
male, day 4 post thyroglossal cyst excision, who presented to the
emergency department (ED) with pain and swelling around the surgical
site. On examination in the ED, the post-operative wound was swollen,
erythematous and tender, with discharging pus visible, appearance on
presentation can be seen in Figure 1. Needle aspiration to release the
collection yielded only 10 ml of aspirate, with minimal reduction in the
size of the collection. A CT Neck outlined a large infected haematoma
extending almost through level VI of the neck, measuring maximally
8.6cmx7cm as seen in Figure 2. The following day he was taken to theatre
for an exploration of the neck wound where copious amounts of infected
looking ORC were removed with little bleeding identified. The wound was
washed out and haemostasis achieved with bipolar diathermy. Culture of
the ORC revealed staphylococcus aureus. Recovery immediately
post-operatively was uncomplicated. However two further aspirations have
been required of the wound for post-operative seroma formation.

Our third case within this four-week period is that of a 56-year-old
female presenting with a neck swelling and fevers on day 4 post right
parotidectomy for a pleomorphic adenoma. She had undergone an
uncomplicated right parotidectomy and she was discharged 2 days later.
On review in ED the wound was clean, although a firm non-fluctuant
swelling was palpable. Labs on admission were normal. On aspiration,
3mls of haemoserous fluid was collected. She was commenced on
antibiotics and a CT neck reported an infected haematoma as seen in
Figure 3. An US neck was then performed the next day which noted that
although ``pus'' had been aspirated, the CT and sonographic features
were not consistent with an abscess and the collection was likely to be
a liquefying haematoma or a sialocele. Diagnostic intrigue remained
around the case that was not resolving clinically. Both aspirates sent
to microbiology remained sterile on culture. A further drainage attempt
was undertaken 2 days later with no further aspirate obtained. At this
point, it was thought that the swelling was likely inflammatory, so the
patient was started on Dexamethasone. She was discharged two days later.
Throughout admission, inflammatory markers were normal. Blood cultures
taken during a febrile episode were also sterile.

The fourth and final case describes a 56-year-old female who presented
to A\&E with a secondary post-tonsillectomy bleed on the fifth
post-operative day. She was taken to theatre from A\&E after
conservative measures to stop the bleeding were unsuccessful. A large
clot was found in the left tonsillar fossa with an actively bleeding
vessel in the upper pole. A small piece of ORC was placed in the
tonsillar fossa and the pillars closed. The following morning, she
complained of a foreign body sensation in her throat, with associated
nausea and vomiting. On examination, a large clot in the mid-pole of the
left tonsillar fossa was visible. She was restarted on hydrogen peroxide
gargles with regular anti-emetics. However, the foreign body sensation
worsened throughout the morning with worsening retching and agitation.
On reviewing the oral cavity, a large foreign body was partially
obstructing her oropharynx. This was removed using a Magill's forceps,
resulting in immediate relief. Further examination revealed that both
tonsillar fossae were now clear, with no clots visible. Thus, the
foreign body was in fact the ORC, which had unexpectedly expanded
significantly, bursting the sutures holding the tonsillar pillars
together leading to partial airway obstruction. On removal, the ORC
measured 7.0x1.5cm as seen in Figure 4. She remained under observation
for another 24 hours, and then discharged with oral antibiotics.

\emph{Discussion}

Intraoperative bleeding prolongs procedures and if left untended to can
result in significant morbidity and even mortality. A wide variety of
haemostatic agents exist to overcome this physiological obstacle to
surgical intervention. Oxidised Cellulose, first used in 1945, has been
adopted by surgeons worldwide and is now used in a wide variety of
surgical specialties. 11Frantz VK, Lattes R. Oxidised
cellulose-absorbable gauze (cellulosic acid). JAMA. 1945;129:798--801.

ORC provides a platform for platelet aggregation and hemostasis. Its low
pH promotes clot formation and contributes to its antibacterial
properties. Unfortunately, it can also irritate tissues causing
inflammation.22Achneck HE, Sileshi B, Jamiolkowski RM, et al.~A
comprehensive review of topical haemostathaemostatic agents: efficacy
and recommendations for use. Ann Surg.~2010;251:217--228.~ Degradation
of the product commences within 1-2 days; inflammatory granulation
tissue is seen at day 7, and complete degradation occurs between 4 and 8
weeks. 33~Frantz VK. Absorbable cotton, paper and gauze: (oxidised
cellulose)~Ann Surg.~1943;118:116--126.

Despite its use, ORC is a foreign body and has rarely caused serious
complications. Case reports in thoracic surgery have described migration
of ORC resulting in profound morbidity to the patient and even
paraplegia44Brodbelt AR, Miles JB, Foy PM, Broome JC. Intraspinal
oxidised cellulose (Surgicel) causing delayed paraplegia after
thoracotomy--a report of three cases.Ann R Coll Surg Engl. 2002 Mar;
84(2):97-9.. In gynecology and urology, ORC granulomas have been seen to
mimic tumor recurrence. 55 Radiologically, ORC has caused diagnostic
dilemmas in post-op patients especially when mimicking abscess formation
\textsuperscript{2} In two of our cases radiological imaging was not
conclusive in reaching a diagnosis.

Only three previous case-reports exist detailing complications in head
and neck surgery. One case in 2012 in Dublin, where a patient presented
30 days post-thyroidectomy with wound breakdown secondary to a delayed
hypersensitivity reaction to ORC.66\textsuperscript{8} Royds J, Kieran
S, Timon C. Oxidised cellulose (Surgicel) based reaction post
thyroidectomy mimicking an abscess: A case report. Int J Surg Case Rep.
2012;3(7):338-9. doi: 10.1016/j.ijscr.2012.03.034. PMID: 22572542. The
second in London, where delayed hypersensitivity was suspected after a
patient developed oedema and erythema over 24 to 48 hours post
thyroidectomy. 77Rubecka S, Mihaimeed F, A Rare Case of Oxidised
Cellulose Causing an Reaction Mimicking Post Thyroidectomy Abscess
Formation - A Case Report \& Review of Literature. International Journal
of Surgery and Research (IJSR) ISSN: 2379-156X Symptoms resolved on
removal of the ORC in both cases. The third case occurred in Stevenage
in 2013 where ORC was used in the management of a post tonsillectomy
bleed by placing it within sutured tonsillar pillars. This patient also
presented with partial airway obstruction due to expansion and
dislodgement of the haemostatic material. 88\textsuperscript{10}Jacques
T, Nash R, Kenway B, Vlastarakos P; Pitfalls of operative management of
secondary post-tonsillectomy haemorrhage -- a case report; B-ENT. 2013;
9(4):335-7

On discussing our particular case series with the consultants and
theatre staff involved, it was noted the ORC brands used in theatres had
recently been changed. The new brand is an absorbable haemostat not
previously used within the department, Curacel\selectlanguage{ngerman}®. We are aware that
different ORCs have different manufacturing properties, with some brands
taking longer to disintegrate. Little data exists comparing brands,
although on review of the literature no single brand had a higher
complication rate. Regardless, according to the manufacturing details of
the new brand, a significant increase in size or inflammatory response
was not expected.

\emph{Conclusion}

ORC is accepted as safe and convenient to use in all Head and Neck
surgery.

This case series highlights the need for complications of absorbable
haemostat usage to be considered in the differential diagnosis of head
and neck patients presenting with an atypical neck swelling in the acute
post-operative period. Serious consideration should also be made on
whether ORC should be used within the oral cavity due to the risk of
airway obstruction if significant expansion occurs.

\emph{Conflict of interest}

All authors have no conflict of interest

\emph{Funding}

No funding was involved in this project

\emph{Ethical approval}

Consent was sought from all four patients involved.

\emph{References}\selectlanguage{english}
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