grand rounds hard palate

7/29/2019 Grand Rounds Hard Palate

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Hard Palate Necrosis afterBilateral Internal Maxillary ArteryEmbolization for Epistaxis

Joel Guss, Marc Cohen, Duane Sewell, Natasha Mirza

Department of Otorhinolaryngology-Head and Neck SurgeryUniversity of Pennsylvania and

The Philadelphia VA Medical Center


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Case Report 50 year-old male admitted with severe

hypertension

History of substance abuse, mechanicalaortic valve replacement on Coumadin,renal failure on hemodialysis.

Started on a Heparin drip and developsright posterior epistaxis


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Case Report Continues to bleed despite placement of a

10 cc nasopharyngeal balloon pack and

bilateral anterior-posterior nasal tampons FFP given to correct coagulation

parameters

2 units packed red blood cells transfused

Referred to Neurointerventional Radiology bilateral internal maxillary arteriesembolization


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Case Report


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Case Report Nasal and nasopharyngeal packs removed

48 hours after embolization

No further bleeding, anticoagulationresumed

Over next week patient complains of rightsided facial and oral pain


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Case Report


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Discussion Selective embolization of external carotid

artery branches is safe and effective in

treating epistaxis refractory toconservative management

Early success rates 71-100% in controllinghemorrhage


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Discussion Neurological complications: stroke, visual

loss, cranial nerve palsy

0-4% of cases Causes: plaque disruption v. reflux of

particles v. ECAICA anastomotic vessel

Minor complications: facial

pain/numbness, trismus, headache, groinhematoma/pain


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Discussion Avoiding neurological complications:

Use of microcatheters that pass into distal

branches Avoiding forceful injection of particles

Identification of dangerous anastomoses ex:middle meningeal artery

Appropriate particle size


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Discussion Soft tissue necrosis is rare

Likely secondary to extensive collateral blood

supply in head and neck Reports of alar necrosis, nasal septal

perforation, oral mucosal and facialsloughing


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Discussion Hard palate vascular anatomy:

Major supply from descending palatine artery, branch ofIMAX

Anastomoses with sphenopalatine branches at the incisorforamen

Soft palate vasculature provides collaterals: ascendingpharyngeal and ascending palatine arteries

Facial artery branches at nasal vestibule supply maxillary

gingiva


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Discussion Gauthier, et al (Surg Radiol Anat. 2002):

Performed bilateral descending palatine artery

ligations (in setting of Le Fort osteotomies) oncadavers

Subsequent colored latex injection into thecarotid artery demonstrated perfusion of thehard palate mucosa via soft palate collaterals(ascending pharyngeal, ascending palatine)


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Discussion In our case, nasopharyngeal balloon may have

reduced flow through soft palate collaterals

Bilateral nasal packing may have decreasedsupply from the nasal cavity via the incisivecanal

Presence of packing for two days afterembolization may have allowed for sufficientischemia to cause mucosal necrosis


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Conclusions Hard palate mucosal necrosis is a rare

but serious complication of bilateral

internal maxillary artery embolization Early removal of nasopharyngeal and

nasal packing may help prevent thiscomplication

grand rounds hard palate

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