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Haemorrhage from the maxillary artery

A case report
J. F. LOWNIE, B. N. SHAKENOVSKY,
R. LURIE, J. J. LANGE,NEGGER

B. M. BEREZOWSKI,

Summary
Haemorrhage from the maxillary artery can be lifethreatening. The literature related to ligation of the
external carotid artery at various levels to control
such haemorrhage is reviewed and a case presented
where a severe haemorrhage from the maxillary
artery was controlled by ligation of the external
carotid artery distal to the posterior auricular / occi- .
pital trunk.
S Atr Med J 1987; 71: 781-782.

Haemorrhage from the maxillary artery can be a serious

problem in injuries of the head and neck, as well as various
surgical procedures, particularly those carried out in order to
correct dentofacial deformities. The relative inaccessibility of
this vessel makes it difficult to control haemorrhage by direct
ligation. Ligation of the external carotid artery as a means of
controlling severe haemorrhage in the head and neck region
has always been a maller of controversy but is still recommended by many authors.1.2 The head and 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 man that this technique is of little
value if the vessel is ligated just above its origin in the
common carotid artery. 3,.4
In an experimental study 5 on the effect of ligating the
external carotid artery at various levels in controlling haemorrhage from the maxillary artery in the baboon, it was
found that ligating the common carotid artery proximal to its
bifurcation into the internal and external carotid arteries
reduced blood flow from the maxillary artery by 40,4%. Ligation 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 out 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 and Oral 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.

technique to control haemorrhage from the maxillary artery

after handgun injury.

Case report
A 37-year-old black man was admined to Hillbrow Hospital after
a handgun injury to his face. The patient 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 right angle of the mandible and
ascending ramus was present. The exit wourid was just anterior to
the tragus of the right ear.
The third 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 suturing 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 it 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 further haemorrhage until
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 soft tissue 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.

Discussion
Haemorrhage from the maxillary artery is life-threatening.
Application of pressure and packing of the area for a postopera-

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tive period with a suitable material such as bismuth iodoform

paste has been used in the past to control this haemorrhage
but there is no doubt that ligation of the artery is preferable.
The 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. It should be stressed, however, that dislocation of the
mandibular condyle from the glenoid fossa is advantageous in
locating the external carotid artery in the retromandibular
fossa. In our case we believe that there was trauma to the
maxillary artery after the initial injury, and that the onset of
sepsis accompanied by violent coughing led to maxillary artery
rupture.
Since the retromandibular fossa is familiar territory to the
maxillofacial and oral surgeon, ligation of the external carotid
distal to the origin of the posterior auricular artery, combined

with ligation of the superficial t~mporal artery at the root of

the 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 Faciallnjunes.
Baltimore: Williams & Wilkins, 1974: 225.

3. Castelli WA, Heulke PF. The anterial system of the head and neck of the
rhesus monkey with emphasis on the external carotid system. Am ] 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. 1nl] Oral SUTg 1982; ll: 251-259.

Cryptococcal infection of the spIne

A case report
S. GOVENDER,

R. W. CHARLES

Summary
Osseous infection due to Cryptoccus neoformans is
rare. A case of paraplegia due to vertebral cryptococcal infection in a child is reported.
S Air Med J 1987; 71: 782-783.

Bony involvement occurs in 5 - 10% of reported cases of

infection with Cryprococcus neoformans. Spinal involvement is
rare and only 5 cases have been reported in the Englishlanguage literature since the introduction of amphotericin B. I-3

Case 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' duration. A week before admission the patient became
incontinent of faeces and urine.
The child was initially treated at a peripheral hospital as a case
of tuberculosis of the spine, as the mother was known to have
pulmonary tuberculosis.
On clinical assessment the child was anaemic, malnourished and
dehydrated. The upper dorsal spine was tender but there was no

Department of Orthopaedic Surgery, University of Natal

and 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 109/1 (polymorphs 68%; lymphocytes 30%);
erythrocyte sedimentation rate 82 mm/lst h (Wintrobe); Mantoux
test positive.
Radiological evaluation revealed a paravenebral soft tissue
shadow bilaterally over the upper dorsal spine With destruction of
the 4th thoracic venebra but with intact 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. The large paravenebral shadow consisted of
50 ml of thin whitish pus. The body of the 4th 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 pachymeningitis 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.
The autopsy revealed extensive cryptococcal meningitis and
associated pulmonary tuberculosis, but there was no evidence of
spinal tuberculosis.

Discussion
The chief vector for the distribution and maintenance of C.
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 on the strain of organism. In the normal patient, infection
following inhalation is usually rapidly resolved with minimal