2.14 haemorrhage from the maxillary artery. a case report, j.f.lownie, b.n.shakenovsky, b.m.berez
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7/25/2019 2.14 Haemorrhage From the Maxillary Artery. a Case Report, j.f.lownie, b.n.shakenovsky, b.m.berez
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S MT DEEL 7 20 JUNIE 1987
781
emorrh ge
from the m xill ry rtery
A case report
J
F
LOWNIE
B
N
SHAKENOVSKY
B
M BEREZOWSKI
R LURIE J J LANGE NEGGER
technique
to
control haemorrhage
from the
maxillary
artery
Summary after handgun injury.
Haemorrhage f rom the maxil lary artery can be l ife-
threatening The literature related to ligation of the
externa l carotid arte ry a t var ious levels to control
such haemorrhage is reviewed and a case presented
where
a severe haemor rhage from the maxillary
artery was control led by l igat ion of the external
carot id artery dista l to the posterior auricular/ occi
pital trunk
S t r ed
J 1987; 71:
781 782.
Haemorrhage
from
the
maxillary
ar ter y ca n
be a
serious
problem in
injuries
of th e he ad
and
neck
as well as various
surgical
procedures particularly
those
carried ou t in
order
to
correct
dentofacial deformities. Th e relative inaccessibility of
this
vessel makes
it difficult
to
control haemorrhage
by
direct
ligation.
Ligation
of
th e external carotid artery
as a means of
controlling
severe
h aemo rrhage in the h ead
and neck region
has always
been
a
maller
of
controversy bu t
is s ti ll
recom-
mended by
many
authors.1.2
Th e
head
an d
neck
have
an
extensive collateral blood supply
and
this seems to offset the
benefits
of
this procedure; it has been proved experimentally
in primates and clinically in m an that this technique is
of
little
value if the vessel is l iga ted just above its
origin
in the
common carotid
artery. 3 4
In an experimental stud
y
5 on the
effect
of ligating the
external carotid a rt ery a t various levels in
controlling hae-
mor rhage fr om t he maxillary artery in the baboon i t was
found that ligating the common carot id artery proximal to its
bifurcation into the i nt er na l a nd e xt ern al c aro tid arteries
reduced blood flow from
th e
maxillary artery by 40,4 . Liga-
tion of the external carotid artery proximal
to
the linguofacial
trunk reduced maxillary artery blood flow by a mean of 72,9
whereas .ligation distal
to
the
linguofacial
trunk
reduced blood
flow by 84,6 . This increased to 99,2 when the ligation was
carried
ou t distal
to the
origin of
the
posterior auricular trunk.
Thus
exclusion
of all branches of
the
external carotid artery
is necessary in
order to
control haemorrhage from the maxillary
artery. Furthermore to control any small retrograde flow from
the collateral
system
completely
the
superficial temporal artery
should be ligated.
The
case presented below is a clinical example of using this
Division of Maxillofacial a nd Ora l
Surgery
Department of
Surgery University
of the Witwatersrand Johannesburg
J
F. LOWNIE B.D.S., H.D.DENT., M.DENT.
B
N.
SHAKENOVSKY
B.D.S., M.DENT., F.F.D. S.A.)
B M. BEREZOWSKI B.D.S., M.DENT.
R
L
URIE B.D.S., H.D.DENT., M.DENT.
J J LANGENEGGER B.D.S., M.B. CH.B. SHEFF.), M.R.C.S. ENG.),
L.R.c.P. LOND.), M.DENT.
ase report
A 37-year-old black man was
admined
to Hillbrow Hospital after
a handgun injury to his face.
The
pat ient was not shocked, the
blood pressure was 120/80
mmHg
and the pulse rate 84/min.
There was haemorrhage from both the mouth and a wound
situated just anterior to the tragus
of
the right ear. At operation it
was established that the entrance wound was on the ventral
surface
of
the anterior two-thirds
of
the tongue.
The
bullet had
then transversed the right tonsillar area, lacerating the soft palate.
A comminuted fracture
of
the r ight angle
of
the mandible and
ascending ramus was present. The exit wourid was just anterior to
the tragus of the right ear.
The th ird molar tooth in the right mandible was removed as
well
as
sharp bony fragments from the mandible. Haemostasis was
achieved by the use of diathermy and sutur ing the tongue, soft
palate and exit wound in layers.
The
mandible was immobilised
by interdental eyelet wires. A tracheostomy was performed to
ensure the airway, and
antibiotic
cover
and
analgesics were
prescribed.
On the 1st postoperative day the patient was stable but coughing
excessively to eliminate excess bronchial secretions. He was fed
through a nasogastric tube. On the 2nd postoperative day i t was
noticed that the exit wound had broken down and was discharging
small beads
of
pus and a steady ooze
of
blood. Careful suctioning
revealed some haemorrhage from the mouth wound, which slowed
spontaneously with pressure.
Further
bleeding occurred on the
3rd postoperative day.
There
was no fur ther haemorrhage unt il
the 14th postoperative day, when severe bleeding was brought on
by a coughing episode. The intermaxillary wires were removed
and haemostasis was obtained
by
pressure packs both externally
and in the
third
molar region intra-orally. The patient was taken
back to theatre and sequestra were removed from the mandible
and the inferior alveolar artery ligated. The wound was closed,
and haemorrhage once again was controlled.
On the 23rd day after admission the patient bled profusely from
the exit wound and 3 U of blood were administered. It was then
decided to explore the wound extra-orally through a pre-auricular
incision and to locate the bleeding vessel which was thought to be
the ma.xillary artery.
The
bullet tract was exposed and the superficial temporal artery
and vein were ligated. The fragment containing the condylar head,
which was ragged and displaced medially, was removed, allowing
access to the region of the maxillary artery.
The
external carotid
artery was ligated just below
the
origin
of
the maxillary artery and
haemorrhage controlled. Bismuth iodoform paste ribbon gauze
was packed lightly into
the
sof t t issue defect and was removed
gradually over 5 days.
The
patient was discharged
13
days after the last operation and
was followed up for a further 2 months. At this stage the exit
wound
had
healed completely, but mouth opening was limited.
Exercises were instituted
but
the patient failed to return for
further follow-up.
iscussion
H ae mo rr hag e f rom the
maxillary
artery
is life threatening.
Application
of pressure
and
packing
of t he are a for a
postopera
7/25/2019 2.14 Haemorrhage From the Maxillary Artery. a Case Report, j.f.lownie, b.n.shakenovsky, b.m.berez
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78 2 SAMJ VOLUME 71 20 JUNE 1987
tive period with a
suitable
material such as bismuth iodoform
paste has b een u sed in th e past to control this haemorrhage
but
there
is no doubt that ligation of the
artery
is preferable.
Th e controversy that
has
existed about ligation of the
carotid trunk at various levels has
been
discussed; the technique
described by Rosenberg er al
5
was
used
in this case
with
success should be stressed however that dislocation
of
the
mandibular condyle from
the glenoid
fossa
is
advantageous
in
locating
the
e xt er na l c arot id a rt er y i n
the
retromandibular
fossa.
In
ou r case we beli eve
that there
was
trauma to the
maxillary
artery
after the initial
injury an d
tha t t he
onset
of
sepsis
accompanied
by violent
coughing led to
maxillary
artery
rupture
Since the retromandibular fossa is familiar
territory
to
the
maxillofacial
an d
oral
surgeon ligation
of
the external carotid
dis ta l to
the origin
of the posterior
auricular
artery
combined
with
ligation of the superficial t ~ m p o r
artery at the
root of
th e zygoma may
well
be the method of choice in controlling
a
haemorrhage from the maxillary artery
REFERENCES
I
Sischer
H Du
Brul
EL Oral Anacomy St
Louis, Mo.: CV Mosby, 1975:
467-468.
2. Converse JM.
Kazanjian
and
Converse s Surgical Treacmenc of Faciallnjun·es
Baltimore: Williams
Wilkins, 1974: 225.
3. Castell i WA, Heulke
PF The
anterial system
of
the head and neck
of
the
rhesus monkey with emphasis
on
the external carotid system. m ]
Anac
1965; 116: 149-170.
4. Abraham J On EO, Aoygi M Tagashira
T
Achari AM, Meyer
JS
Regional cemetral blood flow changes after bilareral external carotid artery
ligation
in
acme experimental infection. ]
Neurosurg Psychiacry
1975; 38:
78-88.
5. Rosenherg I, Austin JC Wright PG, King RE. The effect of experimental
ligation
of
the extema carotid artery
and
the major branches
on
haemorrhage
from the
maxillary
artery. nl ]
Oral
U g 1982; ll : 251-259.
ryptococcal
infection
of the
A case
report
•
sp ne
S
GOVENDER
R
W.
CHARLES
ummary
Osseous infection due to ryptoccus
neoform ns
is
rare. A case of paraplegia due to vertebral
crypto-
coccal infection in a chi ld is reported.
S
ir ed
J 1987; 71: 782-783.
Bony involvement occurs
in
5 - 10
of reported cases of
infection
with
Cryprococcus neoformans
Spinal
involvement is
rare an d
only
5 cases have
been
reported in th e
English-
language literature
since
the introduction of amphotericin B.
I 3
se report
A 9-year-old child was admitted to King Edward VIII Hospital
with backache
and
progressive weakness
of
the lower limbs
of
4
weeks' durat ion. A week before admiss ion the patient became
incontinent of faeces and urine.
Th e
child was initially treated at a peripheral hospital as a case
of
tuberculosis
of the
spine, as
the mothe r
was
known
to have
pulmonary tuberculosis.
On
clinical assessment the child was anaemic, malnourished
and
dehydrated.
Th e upper
dorsal spine was
tender but
there was no
Department of Orthopaedic Surgery University of Natal
an d King Edward vm Hospital
Durban
S.
GOVENDER
F R CS
R.
W. CHARLES M.B. CH.B., DIP.AM.BOARD ORTH.SURG.
obvious deformity. Sensation was decreased below the nipple line
and the
lower limbs were spastic with sustained knee
and
ankle
clonus.
Laboratory investigations revealed: haemoglobin 7 g/dl; white
cell
COUDt
7,0 x
10
9
/1 (polymorphs 68 ; lymphocytes 30 );
erythrocyte sedimentation rate 82 mm/lst h (Wintrobe);
Mantoux
test positive.
Radiological evaluation revealed a paravenebral soft t issue
shadow bilaterally over the
upper
dorsal spine With destruction
of
the 4th thoracic venebra but with intac t disc space above and
below the lesion (Figs 1 and 2). A diagnosis of tuberculosis was
considered unlikely because of the intact disc space.
At
operation a left transthoracic decompression was
performed
through the third
rib.
Th e
large
paravenebral
shadow consisted
of
50
ml
of
thin whitish pus.
Th e
body
of the 4 th
thoracic
venebra
had collapsed and the posterior aspect
had
sequestrated into the
spinal canal compressing
the
spinal cord. Decompression was
effected
by
removing
the
body
of
the venebra
involved
and
a rib
graft was used to span the defect. There was evidence
of
pachy
meningitis at the level of the lesion. C neofonnans was cultured
from the pus and the bony tissue (Fig. 3).
Amphotericin B
and
flucyrosine were administered soon after
the
diagnosis was confirmed,
but the
child lapsed into a coma and
died 2 weeks after surgery.
Th e autopsy revealed extensive cryptococcal meningitis
and
associated pulmonary tuberculosis, but there was no evidence
of
spinal tuberculosis.
iscussion
Th e
chief vector for the distribution an d maintenance
of
neoformans is
the
pigeon
the organism being present in the
debris
of TOOStS
There are
essentially
two types
of
cryptococcal
disease but the manifestations depend on
host
response rather
than o n the strain
of
organism In
the normal
patient infection
following inhalation is usually
rapidly
resolved
with
minimal