False aneurysm complicating orthognathic surgery

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CLARK ET AL.

osteoid osteoma is not clearly defined. At present, there is apparent agreement that both conditions are probably variations of the same disease process. Clinical distinction based on size, location and symptoms have been described, indicating that osteoblastomas generally are larger, occur more often in medullary as opposed to cortical bone, are less painful and have a more diffuse radiologic patternI Vickers et a1.j4 have documented a 15-year follow-up of an untreated osteoid osteoma of the femur in which regression was noted. They cited six other cases from the literature in which spontaneous healing had been reported, and questioned the theory that the osteoid osteoma is a true neoplasm. This experience with osteoid osteoma encouraged the decision to defer surgery for our patient. To our knowledge this is the first reported long-term follow-up of an untreated benign osteoblastoma, showing spontaneous regression similar to that reported for osteoid osteoma. References I Smith RA, Hansen LJ. Resnick D. et al: Comparison of the osteoblastoma in gnathic and extrdgnathic sites. Oral Surg 54:285. 1982

J Oral Max~llofac

2. DeSouza Dias L, Frost HM: Osteoid osteoma-osteoblastoma. Cancer 33:1075. 1974 3. Dorfman HD: Case records of the Massachusetts General Hospital. Case 40- 1980. N Engl .I Med 303:866, 1980 4. Tonai M, Crawford CJ. Ahn GH, et al: Osteoblastoma: classification and report of 16 patients. Clin Orthop 167:222, 1982 5. Huvos AG: Bone Tumors. Diagnosis, Treatment and Prognosis. Philadelohia. WB Saunders. 1979. D 27 6. Seki T, Fukuda H’, I&ii Y, et al: Malignant transformation of benign osteoblastoma. A case report. J Bone Joint Surg 57A:424, 1975 7. Mirra JM. Kendrick RA, Kendrick RE: Pseudomalignant osteoblastoma versus arrested osteosarcoma. Cancer 37:2005, 1976 8. Schajowicz F. Lemos C: Malignant osteoblastoma. .I Bone Joint Surg 58B:202. 1976 9. Kenen S. Floman Y, Robins GC, et al: Aggressive osteoblastoma. Clin Orthop 195:294, 1985 10. Dorfman HD, Weiss SW: Borderline osteoblastic tumors. Problems in the differential diagnosis of aggressive osteoblastoma and low grade osteosarcoma. Sem Diagn Path01 1:215. 1984 I I. Bertoni F, Unni KK, McLeod RA. et al: Osteosarcoma resembling osteoblastoma. Cancer 55:416, 1985 12. Pieterse AS. Vernon-Roberts B, Paterson DC, et al: Osteoid osteoma transforming to aggressive (low grade malignant) osteoblastoma. Histopathology 7:789. 1983 13. Black JA, Levick RK, Sheppard WJW: Osteoid osteoma and benign osteoblastoma in childhood. Arch Dis Child 54:459. 1979 14. Vickers CW, Pugh DC, Ivins JC: Osteoid osteoma. A fifteen-year follow-up of an untreated patient. J Bone Joint Surg 41A:357. 1959

Surg

45 57-59,19&T

False Aneurysm Complicating Orthogna thic Surgery RICHARD CLARK, DDS,* DANIEL LEW, DDS,t VISHAN L. GIYANANI, AMIL GERLOCK, MD5

Aneurysms of the extracranial arterial system are rare, and most arise from either the common or internal carotid artery.‘,* The majority of the external carotid aneurysms are related to the superficial temporal artery.3-5 This is probably due to its relative vulnerability. Trauma is cited as the most common cause in this area. The most prevalent age * In pribate practice, Drexel Hill. Pennsylvania. + Chief, Oral and Maxillofacial Surgery, LSU Medical Center. Shreveport, Louisiana. $ Associate Professor, Department of Radiology. LSU Medical Center, Shreveport, Louisiana. 5 Professor, Department of Radiology. LSU Medical Center. Shreveport, Louisiana. Address correspondence and reprint requests to Dr. Lew: Department of Surgery, School of Medicine, LSU Medical Center, 1501 Kings Highway. P.O. Box 33932, Shreveport, LA 711303932. 0278-2391187

$0.00

+

.25

MD,* AND

for a traumatic aneurysm to occur is between 20 and 40 years. The other causes of aneurysms are arteriosclerosiG, which commonly occurs between 40 and 70 years of age,* syphilis, Marfan’s syndrome, cystic medial necrosis and aneurysms of congenital origin. Traumatic false aneurysms are often due to lacerations or blunt trauma from a gunshot, stab wound, or motor vehicle accident producing a breech in the continuity of the arterial wall.3,7 The result is periarterial hemorrhage that partially compresses the blood vessel wall and creates a persistent opening that is confined only by the fascia. The blood continues to be forced into the periarterial area by the arterial blood pressure during systole. The bleeding leak continues until the pressure in the periarterial zone equals the mean arterial pressure. The exuded blood then undergoes clot formation and retraction. Eventually a

58

FALSE

ANEURYSM

COMPLICATING

ORTHOGNATHIC

SURGERY

12, 1985. where, under general anesthesia administered via nasoendotracheal intubation, bilateral mandibular vertical subcondylar osteotomies were performed. During the osteotomy on the left side. severe bleeding ensued from an area anterior to the posterior border of the mandible approximately midway up the ascending ramus. An attempt to visuahze the bleeding site was unsuccessful: therefore, the area was packed. bleeding stopped, and the procedure completed. A pressure dressing was applied. The patient’s postoperative course was uneventful. He was subsequently discharged and followed as an outpatient. Nine weeks following surgery the patient presented to the emergency room with a three-day history of a 4 cm width swelling in the left preauricular region (Figs. I, 2). No bruits or thrills were present, and the patient had no complaints other than that the mass felt uncomfortable. Needle aspiration at that time was negative. The patient was admitted to the hospital and placed on intravenous antibiotics. The tentative differential diagnosis included folliculitis secondary to severe acne, an infected sebacceous cyst and acute parotitis. On hospital day three, a pulsatile sensation could be felt over the inferior pole of the lesion. In addition, the patient complained of a pounding in his left ear and slightly worsening pain. No increase in the size of the lesion could be appreciated. The Radiology Department was consulted for ultrasound and angiography of the lesion. Ultrasound discerned a cavitary lesion consistent with a pseudoaneurysm which was confirmed by arteriography (Fig. 3). Subsequently, catheter was placed into the external carotid artery and the artery feeding the aneurysm was occluded with a single 3 mm diameter Gianturco coil (Fig. 4). Discussion

FIGURE rysm.

1 (fop). Preoperative

FIGURE eurysm.

3 (horrors).

Preoperative

frontal

view

lateral

of pseudoaneu-

view of pseudoan-

cavity is formed by the liquefaction of the hematoma. This cavity endothelializes and forms a communication with the vessel of origin. As the process of liquefaction continues, the aneurysm increases in size and is walled off by an adjacent inflammatory fibrotic reaction. Report of a Case

On March 11, 1985, a 15-year-old male was admitted to the Oral and Maxillofacial Surgery service at Louisiana State University Medical Center, Shreveport, with a diagnosis of mandibular prognathism. The history and physical examination were unremarkable. Preoperative laboratory included an Astra 8, CBC, U/A, and PT and PTT, all of which were within normal limits. The ECG and chest radiograph were also normal. The patient was taken to the operating room on March

The initial absence of pulsation in the mass is not surprising since it does not occur until after liquefaction of the hematoma and is, therefore, a late phenomena.7 A bruit or a thrill are common in an aneurysm, but the bruit is generally heard only during systole and is localized. Plane radiographs may reveal a soft tissue mass with or without calcification in the wall.‘q6 Angiography is considered the procedure-of-choice for diagnosis.‘-‘,5.6: it also delineates the size of the aneurysm. In this case duplex ultrasonography was used to make the initial diagnosis, and it clearly demonstrated the process of liquefaction. Embolization was chosen as the therapeutic procedure and duplex ultrasonography was als’o used to demonstrate the internal changes which occurred in the aneurysm following embolization. Summary

A case of a pseudoaneurysm secondary to bleeding which occurred during an intraoral vertical osteotomy of the mandible is presented. The bleeding was thought to be controlled by packing,

59

CLARK ET AL.

FIGURE 3 tlefr). FIGURE 4 (ri,qhrl.

Pre-embolotherapy Post-embolotherapy

arteriogram demonstrating arteriogram demonstrating

but ultimately a pseudoaneurysm formed. Arteriography was used to diagnose the lesion and embolization to treat it. Duplex ultrasound played a complimentary role in the diagnosis, and in monitoring the therapeutic course. References I Beall AC, Crawford ES. Cooley DA, et al: Extracranial aneurysms of the carotid artery. Postgrad Med 32:93. 1962

the pseudoaneurysm

(IITYOI~,).

nonfilling of the pseudoaneurysm.

2. Johnson JN, Helsby CR. Stell PM: Aneurysm of the external carotid artery. J Cardiovasc Surg 21: 105. 1980 3. Davis JM. Zimmerman RA: Injury of the carotid and vertebra1 arteries. Neuroradiology 25:55. 1983 4. Hite SJ. Grores RA. Sharkey PC: Superficial temporal artery aneurysms. Neurology 16: 1044, 1966 5. Winslow N, Edwards M: Aneurysm of temporal artery: renort of case. Bull Sch Med Univ Marvland 19:57. 1934 6. Rittenhouse ER, Radkle HM: Carotid artery aneurysm. Review of the literature and report of a case with runture into the oropharynx. Arch S&g 105:786. 1972 1 7. Bresner M. Brekke J, Dubbit J, et al: False aneurysms of the facial region. J Oral Surg 30:307, 1972