DENNIS
93
T. LANIGAN
It may be due to venous or arterial sources. Venous and some arterial bleeding may be amenable to pressure packs. Lanigan and West’ noted that if the bleeding is minor, the patient may be managed by observation. They suggested that if there was continuous hemorrhage, the patient should be taken back to the operating room to explore the surgical site. Vascular clips or packing of the suspected area can be used to treat the patient. They also stated that embolization of the internal maxillary artery and its distal branches should be considered if recurrent hemorrhage occurs during the postoperative period. What is unique about our two cases is that lifethreatening hemorrhage occurred from vessels that were too small to embolize. In the first case, a false aneurysm occurred in the descending palatine vessel several millimeters away from the posterior aspect of the maxilla. The likely cause of this injury was a fracture of the posterior wall of the maxilla or high on the pterygoid plate that lacerated the wall of the vessel. The technique used to free the maxilla involved placement of a curved osteotome in the pterygomaxillary junction. The cause of second case was puzzling. The infraorbital artery was torn 15 mm posterior to the infraorbital rim. The floor of the orbit and the rim were intact, suggesting that fracture of the floor or the canal did not occur. There were no screws in the vicinity of the canal, nor was the direction of any of the screws toward the canal. There are two possible explanations. An extraoral block was used in an attempt to achieve hemostasis before the start of the surgical procedure. The needle could have gone down the canal and lacerated the artery. Alternatively, shearing forces caused by scar tissue occurred during the second maxillary
J Oral Maxillofac 5293-94, 1997
downfracture and resulted in a tear in the vessel. The vessel was not resected because of proximity of the infraorbital nerve. Clips were placed both proximal and distal to the lesion to prevent backflow from the internal carotid system. Based on these experiences, it is recommended that when patients present with massive postoperative nasal bleeding, immediate hemorrhage control be initiated. These steps involve local anesthesia with a vasoconstrictor, nasal packing, and stabilization of the patient hemodynamically. When necessary, the patient should be taken to the operating room to ensure adequate hemostasis. Once initial hemostasis is established, angiograms should be obtained. At this point, a plan can be made as to how best to treat the patient. If the vessel is large enough to embolize, this step will be definitive. However, if the vessel is too small for successful embolization, a plan can be made to treat the injured vessel surgically. Although the most frequently injured vessel is the descending palatine artery, the second case illustrates that other vessels can be the cause of significant blood loss. References 1. Lanigan DT, West RA: Management of postoperative hemorrhage following the Le Fort I maxillary osteotomy. J Oral Maxillofac Sure 42:367. 1984 2. Newhouse RF, Schow SR, ‘Kraut RA, et al: Life-threating hemorrhage from a Le Fort I osteotomy. J Oral Maxillofac Surg 40:117, 1982 3. Li KK, Meara JG, Rubin PAD: Orbital compartment syndrome following orthognathic surgery. .I Oral Maxillofac Surg 53:964, 1995 4. Lanigan DT, Romanchuck K, Olson CK: Ophthalmic complications associated with orthognathic surgery. .I Oral Maxillofac Surg 51:480, 1993
Surg
Discussion Life-Threatening, Delayed Hemorrhage After Le Fort I Osteotomy Requiring Surgical Intervention: Report of Two Cases Dennis T. Lanigan, DMD, University
of Saskatchewan,
MD
Saskatoon,
Canada
This article is a valuable addition to the literature, because the two case reports bring out some interesting points that should be emphasized. In case 1, the bleeding was secondary to a false aneurysm of the left descending palatine artery. For technical reasons, which are not specified, the coils used for embolization were placed in the internal maxillary artery, near the junction of the descending palatine artery, rather
than used to embolize the descending palatine artery itself. Although the authors state in the discussion that this vessel was too small to embolize, a previous successful embolization with a coil of a false aneurysm of a similarly sized vessel, the sphenopalatine artery, has been reported by Hemmig et al.’ It has long been a surgical principle, based on experience with the ligation of arteries, that the source of hemorrhage should be controlled as close to the bleeding point as possible. By having to embolize the maxillary artery rather than the descending palatine artery, it allows for the potential development of collateral circulation. This collateral circulation can arise from other branches of the external carotid artery, either ipsilateral or from across the midline, or, as in this case after the second embolization, from the internal carotid artery system.
94
SPEARGUN ACCIDENTS
Despite the fact that the embolization procedure was not successful in leading to a resolution of the postoperative hemorrhage, angiography was very useful in showing the surgeons the location of the source of the hemorrhage so that the false aneurysm could be successfully resected. The value of angiography in a similar case was previously reported by Lanigan et al.’ Angiography also delineated the nature of the collateral blood flow to the region of the false aneurysm, information that would be unlikely to be ascertained from surgical exploration alone. Embolization procedures, therefore, are useful in the control of postoperative hemorrhage, but are not routinely successful in arresting bleeding, particularly if technical problems such as a spasm of the maxillary artery, or insufficient technical expertise on the part of the radiologist, do not allow for embolization at the ideal site. At times angiography may not be able to pinpoint the source of bleeding after a LeFort I osteotomy if a false aneurysm is not present, or if the patient is not actively bleeding at the time the angiogram is performed. Under these circumstances, if embolization is performed, it must be done more extensively to involve the maxillary artery and its terminal branches. The advantages of angiography plus or minus embolization over blind surgical exploration of the surgical site have been discussed previously.3 Even if the embolization is not successful, the information gained about the vascular supply from the angiograms will allow a subsequent surgical procedure to be planned and executed in a more precise and safe fashion.
J Oral Maxillofac 55:94-97, 1997
The second case is also interesting in that it is, as far as I am aware, the first reported case in which hemorrhage after a Le Fort I osteotomy was secondary to a pseudoaneurysm of the infraorbital artery. It is difficult to imagine a mechanism by which this vessel could be injured during a Le Fort I osteotomy, although it is possible that the explanations offered by the authors could apply under the particular circumstances of this case. This case is unusual in that it it a reoperation in a patient with a nonunion of a maxillary osteotomy, which is also unusual in my experience except in patients with cleft lip and palate. The increased scar tissue associated with the nonunion could perhaps increase the shearing forces transmitted to the floor of the orbit during the maxillary downfracture and have led to a partial tear of the infraorbital artery.
References 1. Hemmig S, Johnson R, Ferraro N: Management of a ruptured pseudoaneurysm of the sphenopalatine artery following a LeFort I osteotomv. J Oral Maxillofac Surg 45:533, 1987 2. Lanigan DT, Hey JH: West RA: Major vascular complications of orthognathic surgery: False aneurysms and arteriovenous fistulas following orthognathic surgery. .I Oral Maxillofac Surg 49:571, 1991 3. Lanigan DT, Hey JH, West RA: Major vascular complications of orthognathic surgery: Hemorrhage associated with LeFort I osteotomies. J Oral Maxillofac Surg 48561, 1990
Surg
Maxillofacial
Spear Gun Accident:
Report MEHMET
ALPER,
of Two Cases
MD,* SERHAT TOTAN, MDJ RUHI AND ECMEL SONGijR, MD5
Cases of penetrating injuries of the maxillofacial region caused by variety of objects have been reported.lm4Such penetrating injuries generally result from gunshots and knife stabs, but speargun injuries of the maxillofacial area are extremely rare. In this
SANKAYALI,
MD,*
report, the management of two patients with speargun injuries is discussed. Report of Cases Case 1
* Assistant Professor of Plastic and Reconstructive Surgery, Ege University School of Medicine, Izmir, Turkey. 7 Resident of Plastic and Reconstructive Surgery, Ege University School of Medicine, Izmir, Turkey. $ Plastic and Reconstructive Surgeon in Private Practice. 9 Professor of Plastic and Reconstructive Surgery, Ege University School of Medicine, Izmir, Turkey. Address correspondence and reprint requests to Dr Totan: Ege Universitesi Hastanesi, Plastik ve Rekonstruktif Cerr alv A.D., 35100 Bomova-Izmir, Turkey. 0 1997 American Association 027%2391/97/5501-0017$3.00/0
of Oral and Maxillofacial
Surgeons
A 15-year-old boy who sustained a speargun injury was admitted to the Emergency Unit. From the history, it was understood that the patient was injured accidentally by his friend with a spear having three points. On examination, the patient was conscious and oriented. All systemic findings were in the normal range and there was no neurologic deficit. The spear points were embedded in the patient with one through the nasal dorsum and two through the right infraorbital rim (Figs 1, 2). Radiographs showed the middle point of the spear to be in the sphenoid sinus, but the location of the medial and lateral points of the spear could not be determined by plain radiographs (Fig 3). Computed tomogra-