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Life-threatening bleeding following maxillofacial trauma
Life-threatening bleeding following maxillofacial trauma* Leon Ardekian 1, N a a m a Samet ~, Yitzhak Shoshan?, Shlomo Taicher 1' 2
1Department of Oral and Maxillofacial Surgery (Head." Dr S. Taicher), The Sheba Medical Center, Tel Hashomer, 2Section of Oral and Maxillofacial Surgery (Head." Dr S. Taicher), The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Israel
S U M M A R Y. Life-threatening bleeding associated with facial trauma is considered rare, and most references on this subject do not recommend a precise treatment plan. The purpose of the present study is to review the origin of bleeding and various treatment methods, and to formulate a plan of management for these patients, emphasizing the role of the maxillofacial surgeon in the immediate intervention to control the bleeding. 222 patients with midface fractures were treated between 1985 to 1990. 10 of them had severe and life-threatening bleeding on admission. Bleeding was controlled by nasal packing (9 patients) combined with temporary fracture reduction (7 patients).
in the haematocrit (HCT) below 29 %. The situation was considered to be life-threatening when these criteria were met.
INTRODUCTION T r a u m a remains one of the principle causes of mortality and morbidity in the Western world, especially among young adults (Baker et al., 1974; Thaller and Beal, 1991). The medical literature regarding facial trauma appears to support the contention that maxillofacial injury alone is rarely life-threatening or leads to life-threatening situations unless associated with obstruction of the airway passages (Tofield, 1977; Lewis et al., 1985; Rowe, 1985; Zachariades, 1985; Thompson et al., 1987). Life-threatening bleeding associated with facial trauma is considered rare, and most references on this subject do not recommend a precise treatment plan (Buchanan and Holtmann, 1983; Solomons and Blumgart, 1988; Thaller and Beal, 1991). Recently, we observed several patients with lifethreatening bleeding following facial trauma. These cases have prompted us to review the origin of bleeding and various methods of treatment and to formulate a plan of management for such patients, emphasizing the role of the maxillofacial surgeon in the immediate intervention to control the bleeding.
RESULTS Of the 222 patients, 10 (4.5 %) had midface fractures with severe and life-threatening bleeding. The distribution of the fractures is shown in the Table. The most c o m m o n fracture was Le Fort I I I (7 patients) followed by Le Fort II fractures (3 patients). One of the latter fractures was associated with a nasoethmoidal complex fracture and 1 was in combination with a zygomatic complex fracture. It should be emphasized that in all patients no other sources of bleeding were detected. On admission, the patients' haematocrit ranged between 24 to 29 %. One patient died on the operating table from uncontrolled bleeding in the maxillofacial area. With regard to treatment, 9 patients were treated by nasal packing with gauze, and 1 with a Foley catheter.
Table Distribution of fractures and level of haematocrit on admission of the 10 patients with life-threatening bleeding
M A T E R I A L AND M E T H O D S The study group comprised 222 patients with midface fractures, treated in our department between the years 1985-1990. The criteria for severe bleeding were those recommended by Buchanan and Holtmann (1983), i.e. loss of 3 units of blood during the first 2 h and a drop * Paper presented at the llth Congress of the European Association for Cranio-Maxillo-Facial Surgery, Innsbruck September 1992. 336
Patient Typeof fracture
% Haematocrit
1 2 3 4 5 6 7 8 9 10
26 27 28 24 29 26 28 26 26 28
Le Fort Le Fort Le Fort Le Fort Le Fort Le Fort Le Fort Le Fort Le Fort Le Fort
III& mandible III III III III III III II II & nasoethmoid II & zygoma
Life-threatening bleeding following maxillofacial trauma
7 patients underwent temporary reduction in the emergency room in order to reduce the bleeding. In 1 patient, ligation of the external carotid artery was performed in combination with nasal packing and temporary reduction. Despite this treatment, the patient continued to bleed until final reduction of the fractures was performed.
DISCUSSION According to the literature, the incidence of lifethreatening bleeding following midface fractures shows a wide variation. Converse (1974) states that bleeding following maxillary fractures is fairly common, while Rowe and Killey (1970) assert that severe haemorrhage following facial fractures is relatively uncommon. Buchanan and Holtmann (1983) report that of 108 patients hospitalized for treatment of midface fractures, 11% had significant bleeding either on or after admission to hospital. Frable et al. (1974) found that of their 296 patients with midface fractures 9.4% developed severe bleeding. Thaller and Beal (1991) report that out of 400 patients with facial trauma 1.25 % suffered from severe and uncontrolled bleeding. In our study of 222 patients with midface fractures 4.5 % exhibited severe and life-threatening bleeding. The complex anatomy of the face imparts a unique status to this region in regard to its injury and management. The origin of the bleeding in midface trauma is mainly from the external carotid artery and from the internal maxillary artery and its intraosseous branches (Fig) (Mehrotra et al., 1984; Solomons and Blumgart, 1988). In addition, branches of the internal carotid artery such as the lacrimal artery, zygomatic artery and anterior and posterior ethmoidal arteries, may play a major role in the origin
337
of bleeding (Matras and Kuderna, 1980; Rowe, 1985; Solomons and Blumgart, 1988). Spontaneous epistaxis in patients under 60 years of age tends to originate from the internal carotid system (ethmoidal vessels); traumatic epistaxis usually arises from the ethmoidal vessels (Malcomson, 1963). Various methods are described in the literature for the treatment of bleeding from the maxillofacial region, including nasal packing (Olley, 1978; Rowe, 1985) arterial ligation (Hunter and Gibson, 1969; Cooke, 1985), angiography and selective embolisation (Mehrotra et al., 1984). Hunter and Gibson (1969) and Malcomson (1963) also emphasize the necessity for immediate surgical intervention in patients with severe haemorrhage caused by midface trauma. According to the protocol of our department, treatment commences in the emergency room to ensure that the airway passages are clear and to replace blood and fluids lost by the patient. Posterior nasal packing with gauze or a Foley catheter is applied, followed by an immediate temporary reduction of the fractures to stop bleeding from the intra-osseous branches close to the fracture lines. Ligation of the external carotid artery is performed if bleeding still persists, and as a last resort. Angiography and selective embolisation to detect and control traumatic maxillofacial bleeding is not favoured, except for gunshot injuries as the area contains many arterial anastomoses between the external and internal carotid systems. These connections may create a risk of embolic material crossing over from the external to the internal carotid circulation with possible central nervous system complications (Barsotti et al., 1992).
Acknowledgements The authors wish to thank Professor Amos Buehner for his helpful assistance and advice and Mrs Rita Lazar for her editorial assistance.
References
Fig - Main branches of the facial arterial pattern in relation to midface fracture lines,
Baker, S. P,, B. O'Neill, W. Haddon, W. B. Long." The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J. Trauma 14 (1974) 187-196 Barsotti, J. B., P. L. Westesson, L. M. Ketonen: Diagnostic and interventional angiographic procedures in the maxillofacial region. Oral Maxillofac. Clin. North Am. 4 (1992) 3 5 4 9 Buchanan, R. T., B. Holtmann : Severe epistaxis in facial fractures. Plast. Reconstr. Surg. 71 (1983) 768-770 Converse, J. M.: Fractures of the maxilla, In: Kazanjian and Converse's surgical treatment of facial injuries. The Williams & Wilkins Company, Baltimore 1974, 230 236 Cooke, E. T. M. : An evaluation and clinical study of severe epistaxis treated by arterial ligation. J. Laryngol. Otol. 99 (1985) 745 749 Frable, M. A., N. El-Roman, A. Lenis, J. P. Hung. Hemorrhagic complications of facial fractures. Laryngoscope 84 (1974) 2051-2057 Hunter, K., R. Gibson: Arterial ligation for severe epistaxis. J. Laryngol. Otol. 83 (1969) 1099-1103 Lewis, V. L., P. N. Manson, R. F. Morgan, L. J. Cerullo, P. R. Meyer." Facial injuries associated with cervical fractures: recognition, patterns and management. J. Trauma 25 (1985) 90-93
338 Journal of Cranio-Maxillo-Facial Surgery Malcomson, K. G. : The surgical management of massive
Thaller, S. R., S. L. Beal: Maxillofacial trauma: a potentially
epistaxis. J. Laryngol. 77 (1963) 299-314 Matras, H., H. Kuderna: Combined cranio-facial fractures. J. Maxillofac. Surg. 8 (1980) 52 59
Thompson, J. N., B. Gibson, R. L Kohut: Airway obstruction in
Mehrotra, O. N., G. E. D. Brown, IV. P. Widdowson, J. P. Wilson:
Tofield, J. J. : Pneumomediastinum following fracture of the
Arteriography and selective embolisation in the control of lifethreatening haemorrhage following facial fractures. Br. J. Plast. Surg. 37 (1984) 482485 Olley, S. F. : An aid to rapid nasal and post-nasal packing. Br. J. Oral Surg. 16 (1978) 179-182 Rowe, N. L. : Maxillofacial injuries--current trends and techniques. Injury 16 (1985) 513-525 Rowe, N. L., H. C. Killey : The preliminary care and general principles of treatment. In: Rowe and Killey: Fractures of the facial skeleton. Livingstone, Edinburgh 1970, 231-233 Solomons, N. B., R. Bhongart : Severe late-onset epistaxis following LeFort I osteotomy: angiographic localization and embolisation. J. Laryngol. Otol. 102 (1988) 26(~263
fatal injury. Ann. Plast. Surg. 27 (1991) 281-283 LeFort fractures. Laryngoscope 97 (1987) 275-279 maxillary antrum. Br. J. Plast. Surg. 30 (1977) 179-181 Zachariades, N. : Laryngeal incompetence following facial
trauma. J. Oral Maxillofac. Surg. 43 (1985) 638-639
Dr Leon Ardekian, DDS Dept of Oral and Maxillofacial Surgery The Sheba Medical Centre Tel Hashomer 52621 Israel Paper received: 8 March 1993 Accepted: 9 July 1993
1Department of Oral and Maxillofacial Surgery (Head." Dr S. Taicher), The Sheba Medical Center, Tel Hashomer, 2Section of Oral and Maxillofacial Surgery (Head." Dr S. Taicher), The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Israel
S U M M A R Y. Life-threatening bleeding associated with facial trauma is considered rare, and most references on this subject do not recommend a precise treatment plan. The purpose of the present study is to review the origin of bleeding and various treatment methods, and to formulate a plan of management for these patients, emphasizing the role of the maxillofacial surgeon in the immediate intervention to control the bleeding. 222 patients with midface fractures were treated between 1985 to 1990. 10 of them had severe and life-threatening bleeding on admission. Bleeding was controlled by nasal packing (9 patients) combined with temporary fracture reduction (7 patients).
in the haematocrit (HCT) below 29 %. The situation was considered to be life-threatening when these criteria were met.
INTRODUCTION T r a u m a remains one of the principle causes of mortality and morbidity in the Western world, especially among young adults (Baker et al., 1974; Thaller and Beal, 1991). The medical literature regarding facial trauma appears to support the contention that maxillofacial injury alone is rarely life-threatening or leads to life-threatening situations unless associated with obstruction of the airway passages (Tofield, 1977; Lewis et al., 1985; Rowe, 1985; Zachariades, 1985; Thompson et al., 1987). Life-threatening bleeding associated with facial trauma is considered rare, and most references on this subject do not recommend a precise treatment plan (Buchanan and Holtmann, 1983; Solomons and Blumgart, 1988; Thaller and Beal, 1991). Recently, we observed several patients with lifethreatening bleeding following facial trauma. These cases have prompted us to review the origin of bleeding and various methods of treatment and to formulate a plan of management for such patients, emphasizing the role of the maxillofacial surgeon in the immediate intervention to control the bleeding.
RESULTS Of the 222 patients, 10 (4.5 %) had midface fractures with severe and life-threatening bleeding. The distribution of the fractures is shown in the Table. The most c o m m o n fracture was Le Fort I I I (7 patients) followed by Le Fort II fractures (3 patients). One of the latter fractures was associated with a nasoethmoidal complex fracture and 1 was in combination with a zygomatic complex fracture. It should be emphasized that in all patients no other sources of bleeding were detected. On admission, the patients' haematocrit ranged between 24 to 29 %. One patient died on the operating table from uncontrolled bleeding in the maxillofacial area. With regard to treatment, 9 patients were treated by nasal packing with gauze, and 1 with a Foley catheter.
Table Distribution of fractures and level of haematocrit on admission of the 10 patients with life-threatening bleeding
M A T E R I A L AND M E T H O D S The study group comprised 222 patients with midface fractures, treated in our department between the years 1985-1990. The criteria for severe bleeding were those recommended by Buchanan and Holtmann (1983), i.e. loss of 3 units of blood during the first 2 h and a drop * Paper presented at the llth Congress of the European Association for Cranio-Maxillo-Facial Surgery, Innsbruck September 1992. 336
Patient Typeof fracture
% Haematocrit
1 2 3 4 5 6 7 8 9 10
26 27 28 24 29 26 28 26 26 28
Le Fort Le Fort Le Fort Le Fort Le Fort Le Fort Le Fort Le Fort Le Fort Le Fort
III& mandible III III III III III III II II & nasoethmoid II & zygoma
Life-threatening bleeding following maxillofacial trauma
7 patients underwent temporary reduction in the emergency room in order to reduce the bleeding. In 1 patient, ligation of the external carotid artery was performed in combination with nasal packing and temporary reduction. Despite this treatment, the patient continued to bleed until final reduction of the fractures was performed.
DISCUSSION According to the literature, the incidence of lifethreatening bleeding following midface fractures shows a wide variation. Converse (1974) states that bleeding following maxillary fractures is fairly common, while Rowe and Killey (1970) assert that severe haemorrhage following facial fractures is relatively uncommon. Buchanan and Holtmann (1983) report that of 108 patients hospitalized for treatment of midface fractures, 11% had significant bleeding either on or after admission to hospital. Frable et al. (1974) found that of their 296 patients with midface fractures 9.4% developed severe bleeding. Thaller and Beal (1991) report that out of 400 patients with facial trauma 1.25 % suffered from severe and uncontrolled bleeding. In our study of 222 patients with midface fractures 4.5 % exhibited severe and life-threatening bleeding. The complex anatomy of the face imparts a unique status to this region in regard to its injury and management. The origin of the bleeding in midface trauma is mainly from the external carotid artery and from the internal maxillary artery and its intraosseous branches (Fig) (Mehrotra et al., 1984; Solomons and Blumgart, 1988). In addition, branches of the internal carotid artery such as the lacrimal artery, zygomatic artery and anterior and posterior ethmoidal arteries, may play a major role in the origin
337
of bleeding (Matras and Kuderna, 1980; Rowe, 1985; Solomons and Blumgart, 1988). Spontaneous epistaxis in patients under 60 years of age tends to originate from the internal carotid system (ethmoidal vessels); traumatic epistaxis usually arises from the ethmoidal vessels (Malcomson, 1963). Various methods are described in the literature for the treatment of bleeding from the maxillofacial region, including nasal packing (Olley, 1978; Rowe, 1985) arterial ligation (Hunter and Gibson, 1969; Cooke, 1985), angiography and selective embolisation (Mehrotra et al., 1984). Hunter and Gibson (1969) and Malcomson (1963) also emphasize the necessity for immediate surgical intervention in patients with severe haemorrhage caused by midface trauma. According to the protocol of our department, treatment commences in the emergency room to ensure that the airway passages are clear and to replace blood and fluids lost by the patient. Posterior nasal packing with gauze or a Foley catheter is applied, followed by an immediate temporary reduction of the fractures to stop bleeding from the intra-osseous branches close to the fracture lines. Ligation of the external carotid artery is performed if bleeding still persists, and as a last resort. Angiography and selective embolisation to detect and control traumatic maxillofacial bleeding is not favoured, except for gunshot injuries as the area contains many arterial anastomoses between the external and internal carotid systems. These connections may create a risk of embolic material crossing over from the external to the internal carotid circulation with possible central nervous system complications (Barsotti et al., 1992).
Acknowledgements The authors wish to thank Professor Amos Buehner for his helpful assistance and advice and Mrs Rita Lazar for her editorial assistance.
References
Fig - Main branches of the facial arterial pattern in relation to midface fracture lines,
Baker, S. P,, B. O'Neill, W. Haddon, W. B. Long." The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J. Trauma 14 (1974) 187-196 Barsotti, J. B., P. L. Westesson, L. M. Ketonen: Diagnostic and interventional angiographic procedures in the maxillofacial region. Oral Maxillofac. Clin. North Am. 4 (1992) 3 5 4 9 Buchanan, R. T., B. Holtmann : Severe epistaxis in facial fractures. Plast. Reconstr. Surg. 71 (1983) 768-770 Converse, J. M.: Fractures of the maxilla, In: Kazanjian and Converse's surgical treatment of facial injuries. The Williams & Wilkins Company, Baltimore 1974, 230 236 Cooke, E. T. M. : An evaluation and clinical study of severe epistaxis treated by arterial ligation. J. Laryngol. Otol. 99 (1985) 745 749 Frable, M. A., N. El-Roman, A. Lenis, J. P. Hung. Hemorrhagic complications of facial fractures. Laryngoscope 84 (1974) 2051-2057 Hunter, K., R. Gibson: Arterial ligation for severe epistaxis. J. Laryngol. Otol. 83 (1969) 1099-1103 Lewis, V. L., P. N. Manson, R. F. Morgan, L. J. Cerullo, P. R. Meyer." Facial injuries associated with cervical fractures: recognition, patterns and management. J. Trauma 25 (1985) 90-93
338 Journal of Cranio-Maxillo-Facial Surgery Malcomson, K. G. : The surgical management of massive
Thaller, S. R., S. L. Beal: Maxillofacial trauma: a potentially
epistaxis. J. Laryngol. 77 (1963) 299-314 Matras, H., H. Kuderna: Combined cranio-facial fractures. J. Maxillofac. Surg. 8 (1980) 52 59
Thompson, J. N., B. Gibson, R. L Kohut: Airway obstruction in
Mehrotra, O. N., G. E. D. Brown, IV. P. Widdowson, J. P. Wilson:
Tofield, J. J. : Pneumomediastinum following fracture of the
Arteriography and selective embolisation in the control of lifethreatening haemorrhage following facial fractures. Br. J. Plast. Surg. 37 (1984) 482485 Olley, S. F. : An aid to rapid nasal and post-nasal packing. Br. J. Oral Surg. 16 (1978) 179-182 Rowe, N. L. : Maxillofacial injuries--current trends and techniques. Injury 16 (1985) 513-525 Rowe, N. L., H. C. Killey : The preliminary care and general principles of treatment. In: Rowe and Killey: Fractures of the facial skeleton. Livingstone, Edinburgh 1970, 231-233 Solomons, N. B., R. Bhongart : Severe late-onset epistaxis following LeFort I osteotomy: angiographic localization and embolisation. J. Laryngol. Otol. 102 (1988) 26(~263
fatal injury. Ann. Plast. Surg. 27 (1991) 281-283 LeFort fractures. Laryngoscope 97 (1987) 275-279 maxillary antrum. Br. J. Plast. Surg. 30 (1977) 179-181 Zachariades, N. : Laryngeal incompetence following facial
trauma. J. Oral Maxillofac. Surg. 43 (1985) 638-639
Dr Leon Ardekian, DDS Dept of Oral and Maxillofacial Surgery The Sheba Medical Centre Tel Hashomer 52621 Israel Paper received: 8 March 1993 Accepted: 9 July 1993