MORRISSETTE
J Oral Maxillofac 49:989-990,
989
AND CHEWNING
Surg
1990
Rapid Airway Compromise Following Traumatic Laceration of the Facial Artery MICHAEL P. MORRISSETTE,
DDS,* AND LEE C. CHEWNING,
Exsanguinating hemorrhage or airway compromise from bleeding vessels of the face is an unusual occurrence. ’ Traumatic aneurysm of the facial artery without airway obstruction has been infrequently reported in the literature. Blunt trauma,* penetrating injuries3 infection4 and iatrogenic surgical manipulation’ all have been implicated as possible causes of facial artery aneurysms. When blood vessels of the face are completely transected, they tend to collapse and bleeding stops spontaneously.6 Although the face is well supplied with blood vessels, they are generally small in diameter and well supplied with elastic fibers; when severed, they tend to contract and become occluded with thrombi and compressed by the enveloping hematoma.’ This is most frequently noted in penetrating wounds of the face. However, partially transected vessels have a propensity for continued hemorrhage, and when there is incomplete laceration of an artery with injury to the accompanying vein, an arteriovenous fistula may result. Partial transection of the facial artery from a penetrating stab wound to the face leading to hematoma and airway compromise was suspected in the case discussed. Report of a Case A 25year-old black man drove himself to the emergency department after being stabbed in the mouth with a butcher knife. Physical examination revealed a 4-cm through-and-through laceration of the upper lip and an actively bleeding 3-cm laceration of the right buccal vestibule. There was no evidence of respiratory distress and vital signs were as follows: blood pressure 138/90 mm Hg, pulse 98 beats per minute, and respiration 24 per minute. The intraoral laceration was closed primarily by the emergency physician to obtain hemostasis, and the oral and maxillofacial surgery service was called to evaluate and Received from Allegheny General Hospital, Pittsburgh, PA. * Formerly Chief Resident, Oral and Maxillofacial Surgerv: _ ., presently in private practice in Camarillo, CA. t Attending Staff, Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Morrissette: 608 Glowood Dr, Pittsburgh, PA 15227. 0 1990 American geons.
Association
0278-2391/90/4809-0015$3.00/O
of Oral and Maxillofacial
Sur-
DMDt
close the remaining facial laceration. A moderately indurated nonpulsatile swelling of the right buccal vestibule and submandibular region was noted. There was no audible bruit or palpable thrill. The through-and-through lip laceration was closed, and the patient was admitted for observation of the facial swelling. While waiting for bed availability, the patient began to complain of difficulty breathing, and approximately 3 hours from the time of admission the oral and maxillofacial surgery resident was resummoned to the emergency department. Examination at this time revealed a highly agitated patient who was in apparent respiratory distress. Blood gas analysis at this time showed pH 7.38, PCO, 26.0, PO, 296.1, Sao, 97.3%, HCO, 15.7, base excess -7.0. The patient was started on 100% oxygen via face mask and subsequently was successfully intubated via the nasal route and mechanical ventilation was begun. He was taken to the operating room for exploration of the stab wound and facial swelling. Using a submandibular approach, a 5-cm incision was made along the right mandibular border. The dissection was carried through the platysma muscle, where a large hematoma was noted. The hematoma had dissected along the lateral border of the mandible and superficial to the investing layer of deep cervical fascia. The platysma was incised and the hematoma was evacuated. The facial artery and vein were clamped, divided, and ligated with 3-O silk ties. Next, the surgical wound was irrigated and closed in the usual manner. At this point the patient was transferred to the trauma step-down unit where he remained intubated overnight. The next morning the left submandibular region exhibited minimal soft swelling. The patient was extubated without complication and the remainder of his hospital course was unremarkable. The patient was started on intravenous antibiotic therapy and was discharged on the seventh postoperative day.
Discussion Initially, this patient presented with uncontrolled intraoral bleeding from a small penetrating stab wound. The source of this hemorrhage could not be easily identified and a watertight intraoral closure was accomplished. Although the facial artery was suspected of being lacerated, the lack of valves in the facial vein and its branches could also permit surges of venous bleeding from the jugular system when severed.’ When initially seen by the oral and maxillofacial surgery service, the patient had a 4-cm through-and-through laceration of his upper lip, an indurated swelling of the right submandibular re-
990
MALIGNANT
gion, and an intact airway. Within a short period, the patient developed significant respiratory distress and metabolic acidosis. Had the intubation been unsuccessful, establishment of a surgical airway would have been indicated. The intraoral stab wound had penetrated the mucosa, submucosa, and buccinator muscle and had lacerated vessels in this area. A search for the exact location of the tear in the facial artery was unsuccessful as the artery and vein were ligated proximal to the level of injury. Ligation of the external carotid artery following injuries to the superficial or deep structures of the face is sometimes indicated. However, this procedure may be only partially effective in controlling bleeding because the anastomoses of right and left arteries across the midline are so numerous.7 Arteriography was considered; however, due to the location of the stab wound it was determined that the treatment of choice was surgical exploration and ligation of bleeding vessels. Summary
OF THE GINGIVA
atively short period. The patient underwent exploration of the wound with ligation of the facial artery and vein. The best method of hemorrhage control is directly at the hemorrhage site. For this reason, we recommend that all penetrating wounds to the face be surgically explored before debridement and closure. References 1. Kruger GO: Oral and Maxillofacial Surgery. St Louis, MO, Mosby, 1984 2. Schwartz SH, Blankenship 29:672, 1971
B-J, Stout RA: J Oral Surg
3. Rahmat H, Amirjamshid A, Kamalian N: Traumatic aneurysm of the facial artery caused by missile injury. J Oral Maxillofac Surg 43:992, 1985 4. DiStefano JF, Mainon W, Mandel MA: False aneurysm of the lingual artery. J Oral Surg 35:918, 1977 5. Akker HP, Lijn F: False aneurysm of the facial artery as a complication of circumferential wiring. Oral Surg 37:514, 1974 6. Bresner M, Brekhe J, et al: False aneurysms region. J Oral Surg 30:307, 1972
A patient with facial lacerations and a patent airway developed major airway compromise in a rel-
J Oral Maxillofac
HEMANGIOPERICYTOMA
7. Dubrul EL: Oral Anatomy. roAmerica, 1988
of the facial
St Louis, MO, Ishiyako Eu-
SurQ
49:990-992,199o
Malignant
Hemangiopericytoma the Gingiva:
of
Report of a Case JOSEPH J. VOGLER,
DMD,* RAO ANDAVOLU,
Hemangiopericytoma is a rare vascular neoplasm first described as an entity by Stout and Murray in 1942.’ They reported a tumor “characterized by the formation of endothelial tubes and sprouts, with a surrounding sheath of rounded and sometimes elongated cells.” These unique cells are found spiraling around the outside of blood vessels and superfiReceived from Lincoln Medical and Mental Health Center, Bronx, NY. * Former Senior Resident, Oral and Maxillofacial Surgery. t Deputy Director of Pathology. $ Chief, Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Leban: Department of Oral and Maxillofacial Surgery, Lincoln Medical and Mental Health Center, 234 E 149th St, Bronx, NY 10451. 0 1990 American geons.
Association
0278-239119014809-0018$3.00/O
of Oral and Maxillofacial
Sur-
MD,t AND STANLEY
G. LEBAN, DMDS
cially resemble leiomyoblasts. Silver connectivetissue staining techniques have demonstrated that they possess long branching processes and, although they do not contain myofibrils, they are capable of contracting, thereby regulating the caliber of the capillary lumen. Its vascular origin accounts for the ubiquitous occurrence of this tumor throughout the body.’ However, although hemangiopericytomas may occur wherever capillaries are found, there is a definite predilection for the musculoskeletal system, with the trunk being the most common site.* Others report occurrence in the brain, urinary bladder, prostate, thyroid gland, and gastrointestinal tract.3-6 Since the original publication of Stout and Murray in 1942, over 400 cases have been reported. Its incidence in the oral cavity is rare. Review of the literature by Das and Gans in t9U7 revealed 9 such
J Oral Maxillofac 49:989-990,
989
AND CHEWNING
Surg
1990
Rapid Airway Compromise Following Traumatic Laceration of the Facial Artery MICHAEL P. MORRISSETTE,
DDS,* AND LEE C. CHEWNING,
Exsanguinating hemorrhage or airway compromise from bleeding vessels of the face is an unusual occurrence. ’ Traumatic aneurysm of the facial artery without airway obstruction has been infrequently reported in the literature. Blunt trauma,* penetrating injuries3 infection4 and iatrogenic surgical manipulation’ all have been implicated as possible causes of facial artery aneurysms. When blood vessels of the face are completely transected, they tend to collapse and bleeding stops spontaneously.6 Although the face is well supplied with blood vessels, they are generally small in diameter and well supplied with elastic fibers; when severed, they tend to contract and become occluded with thrombi and compressed by the enveloping hematoma.’ This is most frequently noted in penetrating wounds of the face. However, partially transected vessels have a propensity for continued hemorrhage, and when there is incomplete laceration of an artery with injury to the accompanying vein, an arteriovenous fistula may result. Partial transection of the facial artery from a penetrating stab wound to the face leading to hematoma and airway compromise was suspected in the case discussed. Report of a Case A 25year-old black man drove himself to the emergency department after being stabbed in the mouth with a butcher knife. Physical examination revealed a 4-cm through-and-through laceration of the upper lip and an actively bleeding 3-cm laceration of the right buccal vestibule. There was no evidence of respiratory distress and vital signs were as follows: blood pressure 138/90 mm Hg, pulse 98 beats per minute, and respiration 24 per minute. The intraoral laceration was closed primarily by the emergency physician to obtain hemostasis, and the oral and maxillofacial surgery service was called to evaluate and Received from Allegheny General Hospital, Pittsburgh, PA. * Formerly Chief Resident, Oral and Maxillofacial Surgerv: _ ., presently in private practice in Camarillo, CA. t Attending Staff, Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Morrissette: 608 Glowood Dr, Pittsburgh, PA 15227. 0 1990 American geons.
Association
0278-2391/90/4809-0015$3.00/O
of Oral and Maxillofacial
Sur-
DMDt
close the remaining facial laceration. A moderately indurated nonpulsatile swelling of the right buccal vestibule and submandibular region was noted. There was no audible bruit or palpable thrill. The through-and-through lip laceration was closed, and the patient was admitted for observation of the facial swelling. While waiting for bed availability, the patient began to complain of difficulty breathing, and approximately 3 hours from the time of admission the oral and maxillofacial surgery resident was resummoned to the emergency department. Examination at this time revealed a highly agitated patient who was in apparent respiratory distress. Blood gas analysis at this time showed pH 7.38, PCO, 26.0, PO, 296.1, Sao, 97.3%, HCO, 15.7, base excess -7.0. The patient was started on 100% oxygen via face mask and subsequently was successfully intubated via the nasal route and mechanical ventilation was begun. He was taken to the operating room for exploration of the stab wound and facial swelling. Using a submandibular approach, a 5-cm incision was made along the right mandibular border. The dissection was carried through the platysma muscle, where a large hematoma was noted. The hematoma had dissected along the lateral border of the mandible and superficial to the investing layer of deep cervical fascia. The platysma was incised and the hematoma was evacuated. The facial artery and vein were clamped, divided, and ligated with 3-O silk ties. Next, the surgical wound was irrigated and closed in the usual manner. At this point the patient was transferred to the trauma step-down unit where he remained intubated overnight. The next morning the left submandibular region exhibited minimal soft swelling. The patient was extubated without complication and the remainder of his hospital course was unremarkable. The patient was started on intravenous antibiotic therapy and was discharged on the seventh postoperative day.
Discussion Initially, this patient presented with uncontrolled intraoral bleeding from a small penetrating stab wound. The source of this hemorrhage could not be easily identified and a watertight intraoral closure was accomplished. Although the facial artery was suspected of being lacerated, the lack of valves in the facial vein and its branches could also permit surges of venous bleeding from the jugular system when severed.’ When initially seen by the oral and maxillofacial surgery service, the patient had a 4-cm through-and-through laceration of his upper lip, an indurated swelling of the right submandibular re-
990
MALIGNANT
gion, and an intact airway. Within a short period, the patient developed significant respiratory distress and metabolic acidosis. Had the intubation been unsuccessful, establishment of a surgical airway would have been indicated. The intraoral stab wound had penetrated the mucosa, submucosa, and buccinator muscle and had lacerated vessels in this area. A search for the exact location of the tear in the facial artery was unsuccessful as the artery and vein were ligated proximal to the level of injury. Ligation of the external carotid artery following injuries to the superficial or deep structures of the face is sometimes indicated. However, this procedure may be only partially effective in controlling bleeding because the anastomoses of right and left arteries across the midline are so numerous.7 Arteriography was considered; however, due to the location of the stab wound it was determined that the treatment of choice was surgical exploration and ligation of bleeding vessels. Summary
OF THE GINGIVA
atively short period. The patient underwent exploration of the wound with ligation of the facial artery and vein. The best method of hemorrhage control is directly at the hemorrhage site. For this reason, we recommend that all penetrating wounds to the face be surgically explored before debridement and closure. References 1. Kruger GO: Oral and Maxillofacial Surgery. St Louis, MO, Mosby, 1984 2. Schwartz SH, Blankenship 29:672, 1971
B-J, Stout RA: J Oral Surg
3. Rahmat H, Amirjamshid A, Kamalian N: Traumatic aneurysm of the facial artery caused by missile injury. J Oral Maxillofac Surg 43:992, 1985 4. DiStefano JF, Mainon W, Mandel MA: False aneurysm of the lingual artery. J Oral Surg 35:918, 1977 5. Akker HP, Lijn F: False aneurysm of the facial artery as a complication of circumferential wiring. Oral Surg 37:514, 1974 6. Bresner M, Brekhe J, et al: False aneurysms region. J Oral Surg 30:307, 1972
A patient with facial lacerations and a patent airway developed major airway compromise in a rel-
J Oral Maxillofac
HEMANGIOPERICYTOMA
7. Dubrul EL: Oral Anatomy. roAmerica, 1988
of the facial
St Louis, MO, Ishiyako Eu-
SurQ
49:990-992,199o
Malignant
Hemangiopericytoma the Gingiva:
of
Report of a Case JOSEPH J. VOGLER,
DMD,* RAO ANDAVOLU,
Hemangiopericytoma is a rare vascular neoplasm first described as an entity by Stout and Murray in 1942.’ They reported a tumor “characterized by the formation of endothelial tubes and sprouts, with a surrounding sheath of rounded and sometimes elongated cells.” These unique cells are found spiraling around the outside of blood vessels and superfiReceived from Lincoln Medical and Mental Health Center, Bronx, NY. * Former Senior Resident, Oral and Maxillofacial Surgery. t Deputy Director of Pathology. $ Chief, Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Leban: Department of Oral and Maxillofacial Surgery, Lincoln Medical and Mental Health Center, 234 E 149th St, Bronx, NY 10451. 0 1990 American geons.
Association
0278-239119014809-0018$3.00/O
of Oral and Maxillofacial
Sur-
MD,t AND STANLEY
G. LEBAN, DMDS
cially resemble leiomyoblasts. Silver connectivetissue staining techniques have demonstrated that they possess long branching processes and, although they do not contain myofibrils, they are capable of contracting, thereby regulating the caliber of the capillary lumen. Its vascular origin accounts for the ubiquitous occurrence of this tumor throughout the body.’ However, although hemangiopericytomas may occur wherever capillaries are found, there is a definite predilection for the musculoskeletal system, with the trunk being the most common site.* Others report occurrence in the brain, urinary bladder, prostate, thyroid gland, and gastrointestinal tract.3-6 Since the original publication of Stout and Murray in 1942, over 400 cases have been reported. Its incidence in the oral cavity is rare. Review of the literature by Das and Gans in t9U7 revealed 9 such
