402
FACIAL ARTERY ANEURYSM AND AV FISTULA
nerve XI accompanying nerve X.5*9Paralysis of rightsided pharyngeal and laryngeal muscles and the vocal cord, together with the inability of the epiglottis to effectively assist in sealing off the larynx, help explain the observed aspiration. The observation of a right nerve XII palsy also helps to explain his symptoms, as this would interfere both with bolus preparation and positioning of the airway under the base of the tongue during pharyngeal swallowing. A further contributing factor to aspiration was probably mucosal anesthesia over the distribution of the affected right nerve X.9 Some preservation of the cough reflex, however, is not surprising given the intact nerve supply on the left side. In this patient, it was possible, with persistence, to elicit a gag reflex by stimulating the fauces and posterior pharyngeal wall on the affected right side. With nerve IX intact bilaterally, its sensory afferents may have activated the intact contralateral motor response from nerve X via brainstem connections5 The possibility of a partially intact right nerve X, however, remained. This patient also reported increasing “deafness” in the right ear, but without vestibular symptoms. In addition, he reported difficulty with phonation, which included a progressive “weakening” in the quality of his voice. The former may be explained by compression of the eustachian tube due to local nasopharyngeal expansion of the tumor, while the latter appeared due to a combination of a right nerve XII palsy affecting the tongue and a right vocal cord paralysis caused by the nerve X palsy. The possibility of a peripheral rather than a central lesion in this patient was strengthened by the observation that the spinal portion of nerve XI supplying the trapezius and sternocleidomastoid muscles was spared, while apparently the cranial portion running with nerve X was not; and that the right nerve IX was
J Oral Maxillofac
spared despite its initial exit through the jugular foramen with the affected nerve X. There were two prominent clinical features that, in addition to the patient’s age, aided in establishing the diagnosis. First, the patient’s racial background was significant as there is a known greater predilection for southern mainland Chinese to develop NPC than for whites. The former have an annual incidence in the range of 18 to 27 per 100,000; the latter have an incidence of 0.1 to 2.0 per 100,000.‘~2~‘oSecond, the proposition that an extracranial lesion was responsible was strengthened by the observation that only some cranial nerves (X, XI [cranial portion], and XII) arising from the posterior cranial fossa were involved, whereas others (IX and XI [spinal portion]) were not. References 1. Fedder M, Gonzalez MF: Nasophyangeal carcinoma. Brief review. Am J Med 79:365, 1985 2. Dickson RI: Nasopharyngeal carcinoma: An evaluation of 209 patients. Laryngoscope 91:333, 1981 3. Ballenger JJ: Diseases of the nose, throat and ear (ed 12). Philadelnhia. PA. Lea & Febiaer. 1977. D 323 4. Bears dH, Myers MH: Man& for St&&g of Cancer. American Joint Committee on Cancer (ed 2). Philadelphia, PA, Lipincott, 1983, p 37 5. Rontal M, Rontal E: Lesions of the vagus nerve: Diagnosis, treatment and rehabilitation. Laryngoscope 87:72, 1977 6. Rontal E, Rontal M: Lesions of the hypoglossal nerve-Diagnosis, treatment and rehabilitation. Laryngoscope 92:927, 1982 7. Lavelle CJB: Applied Oral Physiology _. (ed 2). Bristol, UK, Wright, 1988,p31 -8. Longemann JA: Swallowing physiology and pathophysiology. Otolaryngol Clin North Am 2 1:613, 1988 9. Williams PL, Warick R (eds): Gray’s Anatomy (ed 36). Edinborouah. Churchill Livinastone. 1980. DD 1047-1084. 12291239,%09-1315 ‘-10. Ning J-P, Mimi CY, Wang Q-S, et al: Consumption of salted fish and other risk factors for nasopharyngeal carcinoma (NPC) in Tianjin, a low-risk region for NPC in the People’s Republic of China. JNCI 82:291, 1990
Surg
S&402-405,1992
Traumatic Facial Artery Aneurysm and Arteriovenous Fistula: Case Report GREGORY
J. LUTCAVAGE,
* Chairman, Department of Surgery, Wayne Memorial Hospital; in private practice, Goldsboro, NC. Address correspondence and reprint requests to Dr Lutcavage: 2400 Wayne Memorial Dr, Goldsboro, NC 27534. 0 1992
American Association of Oral and Maxillofacial Surgeons
0278-2391/92/5004-0015$3.00/O
DDS*
Traumatic arterial aneurysms are rare in the facial region. When they do occur, the facial artery is one of the more frequently affected vessels owing to its anatomic location and lack of dense fascial spaces in the region. This case report illustrates the principles involved in the diagnosis and definitive management of
GREGORY J. LUTCAVAGE
403
a traumatic facial artery aneurysm associated with an arteriovenous fistula. Report of Case A 50-year-old man was evaluated in the emergency department following a motor vehicle accident. He had been extracted from his overturned car by rescue personnel and transported from the scene of the accident in full cervical and spinal immobilization. According to the emergency department physician, the patient was bleeding profusely from a 2.5-cm laceration in the left submandibular region for which he underwent immediate repair to achieve hemostasis. In addition, a right frontozygomatic laceration was repaired in the emergency department. The remainder of the patient’s injuries were primarily confined to soft-tissue lacerations of the scalp, middle face, and perioral region. He was taken to the operating room on the night of admission for definitive repair of his multiple lacerations under general anesthesia. At that time, no exploration of the repaired left submandibular laceration was undertaken. The patient was discharged from the hospital 4 days later. The patient was seen as an outpatient approximately 1 week after his discharge from the hospital. Edema had resolved completely in the regions of his multiple lacerations, but there was a palpable residual fixed mass in the left submandibular region. No bruit was auscultated and no pulsations were palpable at that time. Needle aspiration of the mass from a nondependent position produced approximately 30 mL of blood under pressure. The specimen was submitted for Gram stain as well as aerobic and anaerobic culture and sensitivity testing. A pressure dressing was placed over the aspiration site. All cultures were negative. The patient returned 10 days later. The left submandibular mass measured approximately 2 X 2 cm and had increased in size. Also, a systolic bruit was noted on auscultation. The patient was scheduled for bilateral carotid angiography, which
FIGURE 1. Selective external carotid angiogram showing the left facial artery aneurysm (A).
FIGURE 2. Subtraction angiography showing the left facial artery aneurysm (arrow).
was performed through a right femoral percutaneous approach. This study was significant for enlargement of the left facial artery, with evidence of an arteriovenous (AV) fistula. At the site of the fistula, there was an aneurysm measuring approximately 2.6 X 2.2 cm in diameter (Figs 1, 2). All contrast material flowing through the facial artery entered the aneurysm and fistula. No cross-vessel feeding from the right side was noted. In addition, a 2.0-cm length fusiform aneurysm of the left internal carotid artery was seen just beyond its origin (Fig 3). Considering that the patient’s past medical history was significant for a cerebrovascular accident (CVA) 2 years prior to his trauma, neurosurgery consultation was obtained and carotid Doppler flow studies were ordered to rule out carotid stenosis. Although some plaque formation at the bulb and bifurcation was present bilaterally, no percentage diameter reduction of arterial lumina as indicated by Doppler spectral analysis was detected and no significant stenosis was present. The patient’s prior history of CVA in conjunction with a history of alcohol and tobacco abuse placed him at significant risk for a second CVA. Thus, a dual surgical procedure was planned, involving exploration of the left internal carotid aneurysm, resection of the left facial artery aneurysm, and AV fistula. The day before surgery (37 days following injury), physical examination revealed that the fixed left submandibular mass had enlarged to approximately 3.5 X 3.0 cm in diameter (Fig 4). There was a systolic bruit on auscultation and a transmitted palpable systolic pulse. The mass was painful to palpation. No bruit was noted in association with the left internal carotid fusiform aneurysm. At the time of surgery, an anterior stemocleidomastoid incision was used for access to the lefi carotid vascular system. Vascular loops were placed about the common carotid, external carotid, internal carotid, superior thyroid, facial, and lingual arteries. Inspection of the left internal carotid aneu-
FACIAL ARTERY ANEURYSM AND AV FISTULA
Left carotid angiogram showing the left facial artery aneurysm (A)and intemaf carotid aneurysm (B). FIGURE 3.
rysm revealed it to be nontraumatic in origin and no further invasive procedures were performed in that area. The initial incision was then joined by a transverse incision anteriorly to gain access to the left submandibular triangle and left lateral facial region. The left submandibular gland was removed to facilitate access to the left facial artery aneurysm and AV fistula. The left facial artery vascular loop was tightened and the left facial artery was ligated near the aneurysmal sac. The facial artery aneurysm and AV fistula were sharply dissected from the surrounding soft tissues. Numerous collateral feeding vessels were encountered during the course of the dissection. Hemostasis was accomplished through expeditious clamping, ligation, and use of electrocautery. The aneurysmal sac and AV fistula were subsequently delivered in toto. Estimated blood loss for the procedure was 500 mL. The patient was placed in the surgical intensive care unit for observation during the first postsurgical night. He subsequently made an uneventful recovery without any neurological sequelae.
Other etiologic factors associated with true aneurysms include syphilis, mycotic infections, trauma, and congenital structural weakness. False aneurysms are usually the result of penetrating or blunt trauma, with injury to the arterial wall resulting in an incomplete transection. In penetrating injuries, a tangential laceration of the arterial wall will result in a persistent orifice secondary to partial retraction of the vessel. Extravasation of arterial blood into the surrounding tissues under pressure will then occur. When the pressure differential between the involved artery and the hematoma equalizes, further arterial flow will cease or be diminished. Over a period of days to weeks, the hematoma will subsequently liquefy with ensuing secondary hemorrhage from the previously injured artery. This can result in an increase in associated soft-tissue deformity and asymmetry. With liquefaction, a bruit and pulsation may develop. This would depend on the anatomic location of the injured artery as well as the nature of the covering tissues. Classically, a false aneurysm is associated with a systolic bruit on auscuhation and a palpable systolic pulse.‘,* However, pulsations and a bruit can be masked because of thick intervening tissue coverage.’ In cases of blunt trauma, weakening of a contused arterial wall, with subsequent erosion, can occur. This will result in the flow of arterial blood into the sur-
Discussion An aneurysm is an abnormal focal dilatation of an arterial wall. Aneurysms in the facial region are an uncommon finding. When they do occur, the faciallm5and superficial tempora16-‘0 arteries are the most frequent locations. However, other vessels can also be involved. These include the internal maxillary,’ ‘J* lingual,‘3 superior labial, I4 inferior alveolar,i4 and external carotid arteries. 15,16 Aneurysms can be classified into true and false aneurysms. True aneurysms involve all three components (intima, media, adventitia) of the arterial wall, and are most frequently associated with atherosclerosis.
FIGURE 4. Preoperative lateral view of face the day before surgery showing the submandibular mass.
405
TAKAHASHI ET AL
rounding tissues until the pressure differentials are equalized and an aneurysm will subsequently develop in the same manner as described previously. Arteriovenous fistula formation can occur when the traumatic event involves both an artery and its accompanying vein; the vein will serve as an egress point for extravasated arterial blood. An AV fistula is usually associated with a continuous bruit and thrill, which intensify during systole with wide transmission. Arteriovenous fistulae have a extensive collateral blood supply.3 In this case, there was no transmission of the bruit on clinical examination. However, an extensive collateral blood supply was noted to be associated with the AV fistula at the time of surgery, confirming the angiographic findings. In retrospect, exploration of the laceration at the time of this patient’s initial trauma surgery may indeed have prevented this vascular malformation from occurring. Acknowledgment The author would like to express his appreciation to David E. Tomaszek, MD, for his assistance in the management of this case.
References 1. Wineland PL, Topazian RG, Marble HB Jr: False aneurysm of the facial artery. J Chal Surg 34642, 1976 2. Cooperband BR, Friedel W, Bhatt GM, et al: False aneurysm of the facial artery. J Oral Maxillofac Surg 47: 1327, 1989
J Oral Maxillofac 50:405-408,
3. Schwartz SH, Blankenship BJ, Stout RA: False aneurysm of the facial artery: Report of case. J Oral Surg 29:672, 197 1 4. Cohen MA: False (traumatic) aneurysm of the facial artery caused by a foreign body. Int J Qral MaxilIofac Sung 15336, 1986 5. Akker HP van den, Lijn F van der: A false aneurysm ofthe facial artery as a complication of circumferential wiring. Oral Surg Oral Med Qral Path01 37:514. 1974 6. Jasinska M, Korzon T: A case of false aneurysm of the face. Pol Med J 6:1239, 1967 7. Dinner MI, HartwelI SW Jr, Magid AJ: Iatrogenic false aneurysm of the superficial temporal artery. Case report. Plast Reconstr Surg 60:457, 1977 8. Moses JJ, Topper DC: Arteriovenous fistula: An unusual complication associated with arthroscopic temporomandibular joint surgery. J Oral Maxillofac Surg 48: 1220, 1990 9. Matsubara J, Shionoya S, Ban I, et al: False aneurysm of the superficial temporal artery. Am J Surg 124:419, 1972 10. Vuong PN, Escourrou J, Houissa H: Faux anevrysme posttraumatique de l’artere temporale superlicielle. A propos dune observation avec revue de la litterature medicale. J Mal Vast 11:375, 1986 11. Schwartz HC, Kendrick RW, Pogorel BS: False aneurysm of the maxillary artery. An unusual complication of closed facial trauma. Arch Gtolaryngol 109:6 16, 1983 12. Miller FJ Jr. Entzminaer LB. Coleman LL. et al: Successful catheter embolization o?a false aneurysm of the internal maxillary artery. Arch Qtolaryngol 101:517, 1975 13. Distefano JF, Maimon W, Mandel MA: False aneurysm of the linaual arterv. J Oral Sum 35:918, 1977 14. Bresner M, Brekke J, Dubit i, et al: False aneurysms of the facial region. J Oral Surg 30:307, 1972 15. Kennedy JW, Kent JN: False aneurysm and a partial facial paralysis secondary to mandibular fracture: Report of case. J Oral Surg 28:854, 1970 16. Mauldin FW, Comay WJ 3d, Mahaley MS Jr, et al: Severe ep istaxis from a false aneurysm of the external carotid artery. Otolaryngol Head Neck Surg 101:588, 1989 17. Brown CB: False aneurysm of the mandible. Q Nat1 Dent Assoc 32132, 1974
Surg
1992
Pneumocephalus Associated With Carcinoma of the Maxillary Sinus KlKlJO TAKAHASHI, DDS, PHD,* HARUSACHI KANAZAWA, DDS, PHD,~ YOSHIAKI NARUKAWA, DDS, PHD,$- AND KENICHI SATO, DDS, MD, PHD§
Received from the Department of Oral Surgery, School of Medicine, Chiba University, Inohana, Chiba, Japan. * Instructor. t Lecturer. f Instructor. 4 Professor. Address correspondence and reprint requests to Dr Takahashi: Department of &al Surgery, School of Medicine, Chiba University l-8- 1, Inohana, Chiba, 280 Japan. 0 1992
American
Association
0278-2391/92/5004-0016$3.00/O
of Oral and Maxillofacial
Surgeons
Pneumocephalus is often reported as a complication of facial injuries involving the basilar skull or paranasal sinuses. It has been found less frequently with infection,lm3congenital or anatomic anomaly,4,5 radiotherapy for tumors,6,7 or surgical operation.8-‘0 The air may be epidural, subdural, subarachnoid, parenchymal, or ventricular in location, and diagnosis can be easily made by routine radiographs of the skull, especially by computerized tomography. Not infrequently the symptoms associated with pneumocephalus are severe,
FACIAL ARTERY ANEURYSM AND AV FISTULA
nerve XI accompanying nerve X.5*9Paralysis of rightsided pharyngeal and laryngeal muscles and the vocal cord, together with the inability of the epiglottis to effectively assist in sealing off the larynx, help explain the observed aspiration. The observation of a right nerve XII palsy also helps to explain his symptoms, as this would interfere both with bolus preparation and positioning of the airway under the base of the tongue during pharyngeal swallowing. A further contributing factor to aspiration was probably mucosal anesthesia over the distribution of the affected right nerve X.9 Some preservation of the cough reflex, however, is not surprising given the intact nerve supply on the left side. In this patient, it was possible, with persistence, to elicit a gag reflex by stimulating the fauces and posterior pharyngeal wall on the affected right side. With nerve IX intact bilaterally, its sensory afferents may have activated the intact contralateral motor response from nerve X via brainstem connections5 The possibility of a partially intact right nerve X, however, remained. This patient also reported increasing “deafness” in the right ear, but without vestibular symptoms. In addition, he reported difficulty with phonation, which included a progressive “weakening” in the quality of his voice. The former may be explained by compression of the eustachian tube due to local nasopharyngeal expansion of the tumor, while the latter appeared due to a combination of a right nerve XII palsy affecting the tongue and a right vocal cord paralysis caused by the nerve X palsy. The possibility of a peripheral rather than a central lesion in this patient was strengthened by the observation that the spinal portion of nerve XI supplying the trapezius and sternocleidomastoid muscles was spared, while apparently the cranial portion running with nerve X was not; and that the right nerve IX was
J Oral Maxillofac
spared despite its initial exit through the jugular foramen with the affected nerve X. There were two prominent clinical features that, in addition to the patient’s age, aided in establishing the diagnosis. First, the patient’s racial background was significant as there is a known greater predilection for southern mainland Chinese to develop NPC than for whites. The former have an annual incidence in the range of 18 to 27 per 100,000; the latter have an incidence of 0.1 to 2.0 per 100,000.‘~2~‘oSecond, the proposition that an extracranial lesion was responsible was strengthened by the observation that only some cranial nerves (X, XI [cranial portion], and XII) arising from the posterior cranial fossa were involved, whereas others (IX and XI [spinal portion]) were not. References 1. Fedder M, Gonzalez MF: Nasophyangeal carcinoma. Brief review. Am J Med 79:365, 1985 2. Dickson RI: Nasopharyngeal carcinoma: An evaluation of 209 patients. Laryngoscope 91:333, 1981 3. Ballenger JJ: Diseases of the nose, throat and ear (ed 12). Philadelnhia. PA. Lea & Febiaer. 1977. D 323 4. Bears dH, Myers MH: Man& for St&&g of Cancer. American Joint Committee on Cancer (ed 2). Philadelphia, PA, Lipincott, 1983, p 37 5. Rontal M, Rontal E: Lesions of the vagus nerve: Diagnosis, treatment and rehabilitation. Laryngoscope 87:72, 1977 6. Rontal E, Rontal M: Lesions of the hypoglossal nerve-Diagnosis, treatment and rehabilitation. Laryngoscope 92:927, 1982 7. Lavelle CJB: Applied Oral Physiology _. (ed 2). Bristol, UK, Wright, 1988,p31 -8. Longemann JA: Swallowing physiology and pathophysiology. Otolaryngol Clin North Am 2 1:613, 1988 9. Williams PL, Warick R (eds): Gray’s Anatomy (ed 36). Edinborouah. Churchill Livinastone. 1980. DD 1047-1084. 12291239,%09-1315 ‘-10. Ning J-P, Mimi CY, Wang Q-S, et al: Consumption of salted fish and other risk factors for nasopharyngeal carcinoma (NPC) in Tianjin, a low-risk region for NPC in the People’s Republic of China. JNCI 82:291, 1990
Surg
S&402-405,1992
Traumatic Facial Artery Aneurysm and Arteriovenous Fistula: Case Report GREGORY
J. LUTCAVAGE,
* Chairman, Department of Surgery, Wayne Memorial Hospital; in private practice, Goldsboro, NC. Address correspondence and reprint requests to Dr Lutcavage: 2400 Wayne Memorial Dr, Goldsboro, NC 27534. 0 1992
American Association of Oral and Maxillofacial Surgeons
0278-2391/92/5004-0015$3.00/O
DDS*
Traumatic arterial aneurysms are rare in the facial region. When they do occur, the facial artery is one of the more frequently affected vessels owing to its anatomic location and lack of dense fascial spaces in the region. This case report illustrates the principles involved in the diagnosis and definitive management of
GREGORY J. LUTCAVAGE
403
a traumatic facial artery aneurysm associated with an arteriovenous fistula. Report of Case A 50-year-old man was evaluated in the emergency department following a motor vehicle accident. He had been extracted from his overturned car by rescue personnel and transported from the scene of the accident in full cervical and spinal immobilization. According to the emergency department physician, the patient was bleeding profusely from a 2.5-cm laceration in the left submandibular region for which he underwent immediate repair to achieve hemostasis. In addition, a right frontozygomatic laceration was repaired in the emergency department. The remainder of the patient’s injuries were primarily confined to soft-tissue lacerations of the scalp, middle face, and perioral region. He was taken to the operating room on the night of admission for definitive repair of his multiple lacerations under general anesthesia. At that time, no exploration of the repaired left submandibular laceration was undertaken. The patient was discharged from the hospital 4 days later. The patient was seen as an outpatient approximately 1 week after his discharge from the hospital. Edema had resolved completely in the regions of his multiple lacerations, but there was a palpable residual fixed mass in the left submandibular region. No bruit was auscultated and no pulsations were palpable at that time. Needle aspiration of the mass from a nondependent position produced approximately 30 mL of blood under pressure. The specimen was submitted for Gram stain as well as aerobic and anaerobic culture and sensitivity testing. A pressure dressing was placed over the aspiration site. All cultures were negative. The patient returned 10 days later. The left submandibular mass measured approximately 2 X 2 cm and had increased in size. Also, a systolic bruit was noted on auscultation. The patient was scheduled for bilateral carotid angiography, which
FIGURE 1. Selective external carotid angiogram showing the left facial artery aneurysm (A).
FIGURE 2. Subtraction angiography showing the left facial artery aneurysm (arrow).
was performed through a right femoral percutaneous approach. This study was significant for enlargement of the left facial artery, with evidence of an arteriovenous (AV) fistula. At the site of the fistula, there was an aneurysm measuring approximately 2.6 X 2.2 cm in diameter (Figs 1, 2). All contrast material flowing through the facial artery entered the aneurysm and fistula. No cross-vessel feeding from the right side was noted. In addition, a 2.0-cm length fusiform aneurysm of the left internal carotid artery was seen just beyond its origin (Fig 3). Considering that the patient’s past medical history was significant for a cerebrovascular accident (CVA) 2 years prior to his trauma, neurosurgery consultation was obtained and carotid Doppler flow studies were ordered to rule out carotid stenosis. Although some plaque formation at the bulb and bifurcation was present bilaterally, no percentage diameter reduction of arterial lumina as indicated by Doppler spectral analysis was detected and no significant stenosis was present. The patient’s prior history of CVA in conjunction with a history of alcohol and tobacco abuse placed him at significant risk for a second CVA. Thus, a dual surgical procedure was planned, involving exploration of the left internal carotid aneurysm, resection of the left facial artery aneurysm, and AV fistula. The day before surgery (37 days following injury), physical examination revealed that the fixed left submandibular mass had enlarged to approximately 3.5 X 3.0 cm in diameter (Fig 4). There was a systolic bruit on auscultation and a transmitted palpable systolic pulse. The mass was painful to palpation. No bruit was noted in association with the left internal carotid fusiform aneurysm. At the time of surgery, an anterior stemocleidomastoid incision was used for access to the lefi carotid vascular system. Vascular loops were placed about the common carotid, external carotid, internal carotid, superior thyroid, facial, and lingual arteries. Inspection of the left internal carotid aneu-
FACIAL ARTERY ANEURYSM AND AV FISTULA
Left carotid angiogram showing the left facial artery aneurysm (A)and intemaf carotid aneurysm (B). FIGURE 3.
rysm revealed it to be nontraumatic in origin and no further invasive procedures were performed in that area. The initial incision was then joined by a transverse incision anteriorly to gain access to the left submandibular triangle and left lateral facial region. The left submandibular gland was removed to facilitate access to the left facial artery aneurysm and AV fistula. The left facial artery vascular loop was tightened and the left facial artery was ligated near the aneurysmal sac. The facial artery aneurysm and AV fistula were sharply dissected from the surrounding soft tissues. Numerous collateral feeding vessels were encountered during the course of the dissection. Hemostasis was accomplished through expeditious clamping, ligation, and use of electrocautery. The aneurysmal sac and AV fistula were subsequently delivered in toto. Estimated blood loss for the procedure was 500 mL. The patient was placed in the surgical intensive care unit for observation during the first postsurgical night. He subsequently made an uneventful recovery without any neurological sequelae.
Other etiologic factors associated with true aneurysms include syphilis, mycotic infections, trauma, and congenital structural weakness. False aneurysms are usually the result of penetrating or blunt trauma, with injury to the arterial wall resulting in an incomplete transection. In penetrating injuries, a tangential laceration of the arterial wall will result in a persistent orifice secondary to partial retraction of the vessel. Extravasation of arterial blood into the surrounding tissues under pressure will then occur. When the pressure differential between the involved artery and the hematoma equalizes, further arterial flow will cease or be diminished. Over a period of days to weeks, the hematoma will subsequently liquefy with ensuing secondary hemorrhage from the previously injured artery. This can result in an increase in associated soft-tissue deformity and asymmetry. With liquefaction, a bruit and pulsation may develop. This would depend on the anatomic location of the injured artery as well as the nature of the covering tissues. Classically, a false aneurysm is associated with a systolic bruit on auscuhation and a palpable systolic pulse.‘,* However, pulsations and a bruit can be masked because of thick intervening tissue coverage.’ In cases of blunt trauma, weakening of a contused arterial wall, with subsequent erosion, can occur. This will result in the flow of arterial blood into the sur-
Discussion An aneurysm is an abnormal focal dilatation of an arterial wall. Aneurysms in the facial region are an uncommon finding. When they do occur, the faciallm5and superficial tempora16-‘0 arteries are the most frequent locations. However, other vessels can also be involved. These include the internal maxillary,’ ‘J* lingual,‘3 superior labial, I4 inferior alveolar,i4 and external carotid arteries. 15,16 Aneurysms can be classified into true and false aneurysms. True aneurysms involve all three components (intima, media, adventitia) of the arterial wall, and are most frequently associated with atherosclerosis.
FIGURE 4. Preoperative lateral view of face the day before surgery showing the submandibular mass.
405
TAKAHASHI ET AL
rounding tissues until the pressure differentials are equalized and an aneurysm will subsequently develop in the same manner as described previously. Arteriovenous fistula formation can occur when the traumatic event involves both an artery and its accompanying vein; the vein will serve as an egress point for extravasated arterial blood. An AV fistula is usually associated with a continuous bruit and thrill, which intensify during systole with wide transmission. Arteriovenous fistulae have a extensive collateral blood supply.3 In this case, there was no transmission of the bruit on clinical examination. However, an extensive collateral blood supply was noted to be associated with the AV fistula at the time of surgery, confirming the angiographic findings. In retrospect, exploration of the laceration at the time of this patient’s initial trauma surgery may indeed have prevented this vascular malformation from occurring. Acknowledgment The author would like to express his appreciation to David E. Tomaszek, MD, for his assistance in the management of this case.
References 1. Wineland PL, Topazian RG, Marble HB Jr: False aneurysm of the facial artery. J Chal Surg 34642, 1976 2. Cooperband BR, Friedel W, Bhatt GM, et al: False aneurysm of the facial artery. J Oral Maxillofac Surg 47: 1327, 1989
J Oral Maxillofac 50:405-408,
3. Schwartz SH, Blankenship BJ, Stout RA: False aneurysm of the facial artery: Report of case. J Oral Surg 29:672, 197 1 4. Cohen MA: False (traumatic) aneurysm of the facial artery caused by a foreign body. Int J Qral MaxilIofac Sung 15336, 1986 5. Akker HP van den, Lijn F van der: A false aneurysm ofthe facial artery as a complication of circumferential wiring. Oral Surg Oral Med Qral Path01 37:514. 1974 6. Jasinska M, Korzon T: A case of false aneurysm of the face. Pol Med J 6:1239, 1967 7. Dinner MI, HartwelI SW Jr, Magid AJ: Iatrogenic false aneurysm of the superficial temporal artery. Case report. Plast Reconstr Surg 60:457, 1977 8. Moses JJ, Topper DC: Arteriovenous fistula: An unusual complication associated with arthroscopic temporomandibular joint surgery. J Oral Maxillofac Surg 48: 1220, 1990 9. Matsubara J, Shionoya S, Ban I, et al: False aneurysm of the superficial temporal artery. Am J Surg 124:419, 1972 10. Vuong PN, Escourrou J, Houissa H: Faux anevrysme posttraumatique de l’artere temporale superlicielle. A propos dune observation avec revue de la litterature medicale. J Mal Vast 11:375, 1986 11. Schwartz HC, Kendrick RW, Pogorel BS: False aneurysm of the maxillary artery. An unusual complication of closed facial trauma. Arch Gtolaryngol 109:6 16, 1983 12. Miller FJ Jr. Entzminaer LB. Coleman LL. et al: Successful catheter embolization o?a false aneurysm of the internal maxillary artery. Arch Qtolaryngol 101:517, 1975 13. Distefano JF, Maimon W, Mandel MA: False aneurysm of the linaual arterv. J Oral Sum 35:918, 1977 14. Bresner M, Brekke J, Dubit i, et al: False aneurysms of the facial region. J Oral Surg 30:307, 1972 15. Kennedy JW, Kent JN: False aneurysm and a partial facial paralysis secondary to mandibular fracture: Report of case. J Oral Surg 28:854, 1970 16. Mauldin FW, Comay WJ 3d, Mahaley MS Jr, et al: Severe ep istaxis from a false aneurysm of the external carotid artery. Otolaryngol Head Neck Surg 101:588, 1989 17. Brown CB: False aneurysm of the mandible. Q Nat1 Dent Assoc 32132, 1974
Surg
1992
Pneumocephalus Associated With Carcinoma of the Maxillary Sinus KlKlJO TAKAHASHI, DDS, PHD,* HARUSACHI KANAZAWA, DDS, PHD,~ YOSHIAKI NARUKAWA, DDS, PHD,$- AND KENICHI SATO, DDS, MD, PHD§
Received from the Department of Oral Surgery, School of Medicine, Chiba University, Inohana, Chiba, Japan. * Instructor. t Lecturer. f Instructor. 4 Professor. Address correspondence and reprint requests to Dr Takahashi: Department of &al Surgery, School of Medicine, Chiba University l-8- 1, Inohana, Chiba, 280 Japan. 0 1992
American
Association
0278-2391/92/5004-0016$3.00/O
of Oral and Maxillofacial
Surgeons
Pneumocephalus is often reported as a complication of facial injuries involving the basilar skull or paranasal sinuses. It has been found less frequently with infection,lm3congenital or anatomic anomaly,4,5 radiotherapy for tumors,6,7 or surgical operation.8-‘0 The air may be epidural, subdural, subarachnoid, parenchymal, or ventricular in location, and diagnosis can be easily made by routine radiographs of the skull, especially by computerized tomography. Not infrequently the symptoms associated with pneumocephalus are severe,
