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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

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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