Fungal Malignant Otitis Externa Involves a Cascade of Complications Culminating in Pseudoaneurysm of Internal Maxillary Artery: A Case Report.

BACKGROUND Pseudomonal infection is the most common cause of malignant otitis externa (MOE), which typically affects elderly diabetic patients. Fungi are a rare cause of MOE. MOE can be life-threatening if not recognized and treated promptly. It can result in a wide spectrum of complications, including skull-base osteomyelitis, cranial nerve palsy, cerebral venous thrombosis, and brain abscess. Pseudoaneurysm formation of the intracranial vessels is a life-threatening complication of MOE that is seldom reported in the literature. CASE REPORT We report the case of a 66-year-old diabetic man with MOE who was initially treated with antipseudomonal antibiotics after negative initial culture results. His MOE resulted in a cascade of complications, including facial nerve palsy, skull base osteomyelitis, and sigmoid sinus thrombosis, and culminated in left maxillary artery pseudoaneurysm formation resulting in massive epistaxis and hemodynamic instability. Endovascular embolization resulted in a successful obliteration of the pseudoaneurysm. A subsequent functional endoscopic sinus surgical (FESS) tissue biopsy confirmed Candida glabrata as the etiological agent. The patient was successfully treated with antibiotics and antifungal and anticoagulation therapy, and was discharged home in good condition. CONCLUSIONS A high index of suspicion for the diagnosis of fungal MOE, particularly in intractable cases of MOE with negative initial cultures, should be maintained. Pseudoaneurysm formation is a life-threatening complication of MOE that is seldom reported in the literature and should be suspected in any patient with MOE who presents with epistaxis or intracranial bleeding.

Maxillary Artery Pseudoaneurysm as a Complication of Maxillofacial Injuries: Report of three cases and literature review.

Traumatic maxillary artery pseudoaneurysm is an uncommonly reported complication in the field of oral and maxillofacial surgery. It is usually discovered incidentally, either early after trauma or weeks-to-months later. Quick recognition and prompt management are essential to avoid devastating consequences. In this paper, we report three uncommon cases of maxillary artery pseudoaneurysm recognised during the surgical management of maxillofacial injuries in Muscat, Oman. All cases presented as sudden brisk bleeding during the intraoperative surgical repair and were subsequently diagnosed and successfully managed by endovascular embolisation with platinum coils. This case report highlights the clinical presentation, diagnosis and management of maxillary artery pseudoaneurysm, in addition to a brief review of the literature.

Spontaneous Regression of Parapharyngeal Arteriovenous Malformation.

Arteriovenous malformations (AVMs) are fast-flow vascular malformations that mostly occur in the head and neck region. They are typically progressive and their spontaneous regression is almost never seen. We present a case with pulsatile tinnitus and a parapharyngeal AVM. It resolved completely after diagnostic catheter-based angiography alone.

Hemodynamic study with duplex ultrasonography on combined (direct/indirect) revascularization in adult moyamoya disease.

BACKGROUND: To evaluate the hemodynamic changes by duplex ultrasonography in adult moyamoya disease (MMD) patients who underwent combined direct and indirect revascularization surgery. METHODS: Seventeen adult patients underwent direct and indirect revascularization surgery in our hospital. Hemodynamic parameters, peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistance index (RI), were determined by color Doppler at the baseline, 2 weeks, and 6 months after bypass. RESULTS: Both the PSV and EDV of direct bypass were lower at 6 months after surgery compared with those at 2 weeks postoperatively. The EDV of indirect revascularization surgery of the maxillary artery (MA) at 6 months after surgery was higher and the RI of the MA lower compared with the baseline levels. Decreased PSV and EDV in the bypass vessel did not significantly correlate with increased EDV or decreased RI of the MA. CONCLUSIONS: Duplex ultrasonography is a reliable, noninvasive tool to assess hemodynamic changes and evaluate the therapeutic performance of combined bypass surgery in adult MMD.

Endosurgical repair of an iatrogenic facial arteriovenous fistula due to percutaneous trigeminal balloon rhizotomy.

A 56-year-old woman with right-sided trigeminal neuralgia (TN), who underwent technically uneventful percutaneous balloon rhizotomy, developed significant bilateral pulsatile tinnitus on the first post-operative day. Although the patient reported significantly improved neuralgia, auscultation revealed a right facial bruit. Magnetic resonance angiography (MRA) of the face and brain demonstrated prominent right facial and jugular venous vascularity. Catheter angiography confirmed the suspected facial arteriovenous fistula (AVF). A transarterial approach was used to explore the AVF which arose from a laceration of the right internal maxillary artery and which fistulized directly with the pterygoid venous plexus. Endosurgical repair utilizing three non-fibered platinum coils was done under conscious sedation at the same setting as the diagnostic angiogram. Angiographically, the fistula was obliterated, and the patient's bruit and tinnitus immediately resolved. Follow-up MRA at 3.5 months was normal, and, the patient had no clinical symptoms of recurrent AVF. In conclusion facial AVF can complicate percutaneous trigeminal rhizotomy. Iatrogenic facial AVF can be repaired via an endovascular approach.

Epistaxis: diagnosis and treatment.

Oral and maxillofacial surgeons are called on to evaluate and treat various emergencies, including acute epistaxis. Epistaxis is relatively benign in nature, but it can produce a serious, life-threatening situation. It has been estimated that up to 60% of the population has had at least 1 episode of epistaxis throughout their lifetime. Of this group, 6% seek medical care to treat epistaxis, with 1.6 in 10,000 requiring hospitalization. With fewer and fewer otorhinolaryngologists participating on hospital call schedules, it is critical for the oral and maxillofacial surgeon to be familiar with the anatomy, diagnosis, and treatment of acute epistaxis and associated medical concerns. Considerations concerning mechanism of injury, coagulopathies, and potential treatment options need to be assessed quickly and accurately to ensure the most appropriate treatment and positive outcome for the patient. The need to treat epistaxis in an emergent setting will often require the involvement of an oral and maxillofacial surgeon. By reviewing the anatomy, potential complications arising from associated medical conditions, and treatment options, patients can be accurately assessed and treated appropriately.

Estudo Comparativo das abordagens transmaxilar e retromolar à artéria maxilar, na epistaxe severa posterior / Comparative study of transmaxillar and retromolar approach on posterior severe epistaxis

Esse estudo apresenta em um caso de epistaxe severa posterior tratado por duas abordagens cirúrgicas, pelas vias bucais retromolar e transmaxilar, que em ambas as técnicas a artéria maxilar é alcançada na mesma regiäo anatômica, ou seja, na regiäo zigomática, junto à tuberosidade da maxila, o que foi corroborado por estudo complementar em dez peças anatômicas.