An idiopathic delayed maxillary hemorrhage after orthognathic surgery with Le Fort I osteotomy: a case report

Abstract

A Le Fort I osteotomy is a common procedure for correcting dental and facial deformities in orthognathic surgery. In rare cases, a delayed hemorrhage can occur as early as several hours or up to 12 weeks, postoperatively. The most frequently involved blood vessels in a delayed hemorrhage are the descending palatine artery, the internal maxillary artery, and the pterygoid venous plexus of veins. Intraoral bleeding accompanied by severe epistaxis in these cases makes it difficult to locate the precise bleeding focus. Eventual uncontrolled bleeding would require Merocel packing or surgical intervention. In general, a severe late postoperative hemorrhage is most effectively managed by angiography and embolization. Herein we describe a delayed hemorrhage case in which the cause was not evident on angiography. We were able to detect the bleeding point through an endoscopic nasal approach and treat it using direct cauterization.

Epistaxis in dental and maxillofacial practice: a comprehensive review

“…Primary sources of epistaxis after Le Fort I osteotomies are the anterior, posterior, or both parts of the nasal cavity, and epistaxis usually occurs within the first 10 days after surgery 15 - 19 . ( Table 2 ) Intubation and removal of the nasal mucosa from the nasal floor require special manipulation to avoid an isolated anterior 20 .…”

“…The bleeding is not very serious and usually lasts 1 to 2 days. However, recurrent epistaxis has been noted in patients 1 to 8 weeks after orthognathic surgery, in which the presence of pseudoaneurysm was suspected during orthognathic interventions 18 , 19 , 21 , wherein an incomplete injury to one or more vessel-wall layers causes hemorrhaging in the surrounding tissue, leading to hematoma formation. Subsequent expansion of a hematoma due to arterial pressure can result in increased leakage and rupture 19 , 21 .…”

“…Mehra et al 14 reported that the descending palatine artery is most likely to bleed after surgically-assisted rapid palatal expansion (SARPE) because this artery is injured by bone fractures. Primary sources of epistaxis after Le Fort I osteotomies are the anterior, posterior, or both parts of the nasal cavity, and epistaxis usually occurs within the first 10 days after surgery [15][16][17][18][19] . (Table 2) Intubation and removal of the nasal mucosa from the nasal floor require special manipulation to avoid an isolated anterior 20 .…”

“…Clinicians should distinguish an ectopic nasal tooth from foreign bodies, odontomas, rhinoliths, granulomatous infections, and tumors 28 . 4) Dental care in patients with blood disorders Milam and Copper 29 reported a case of prolonged epistaxis after dental extractions of the upper first and second molars 13 Questionnaire NM 18-23 Le Fort I osteotomy 5 18 hours to 10 days de Mol van Otterloo et al 16 Retrospective study 410 NM Le Fort I osteotomy, SARPE 3 Several days Eshghpour et al 17 Prospective study 114 18-30 Le Fort I osteotomy 2 First 24 hours Avelar et al 18 Case report 1 20 Le Fort I osteotomy 1 9 weeks Park et al 19 Case report 1 30 Le Fort I osteotomy 1 3 weeks Mehra et al 14 Case report in a 50-year-old patient with history of chronic hemodialysis. During surgery, an oroantral fistula was noted.…”

Variations in the venous supply of the floor of the oral cavity: Assessment of relative hemorrhage risk during surgery

“…Blood vessel injury during an operation can elicit a postoperative hematoma that requires reoperation. Although the causes for postoperative bleeding are unclear, venous injury could be one (Park et al, 2019). It is more difficult to identify the point of hemorrhage when veins rather than arteries are injured, leading to failure to maintain hemostasis.…”