Ethanol embolotherapy of mandibular arteriovenous malformation-induced acute oral hemorrhage after tooth extraction.

BACKGROUND: Mandibular arteriovenous malformation (AVM) is rare. Our work aims to introduce the ethanol embolization of a patient suffering from acute oral hemorrhage induced by mandibular AVM. METHODS: A 35-year-old woman without coagulopathy underwent tooth extraction, and the acute oral bleeding occurred intraoperatively. Imaging examinations indicated the enhancement of vascular mass with bone destruction inside the mandible. Angiography finally confirmed the high blood flow nature and the diagnosis of AVM. RESULTS: During the interventional procedure, the coils were first applied into the dilated outflowing vein to slow down the blood flow rate of mandibular AVM. Absolute ethanol was injected in a multi-bolus modality to destroy the nidus of AVM. Her mandibular lesion had been stable in the 12-month re-examined angiography, no further bleeding occurred during the period. CONCLUSIONS: Ethanol embolotherapy was a less invasive, more precise, and quick-action approach managing AVM of the jaw and related emergency medicine.

Ligadura de la arteria lingual: estrategia para hemorragias por lesión de la arteria en la base de la lengua: informe de dos casos / Lingual Artery Ligation: Strategy for Bleeding from Artery Injury at the Base of the Tongue: Report of Two Cases

La hemorragia producida por lesión de la arteria lingual en la base de la lengua por cirugías o por tumores es infrecuente. La mayor frecuencia en la indicación de abordajes transorales para tratar diferentes patologías que afectan la orofaringe requiere que el equipo quirúrgico tenga experiencia en el manejo de esta complicación. La ligadura de la arteria lingual en el cuello es una técnica quirúrgica muy eficaz para solucionar la hemorragia, pero es importante conocer las posibles variantes anatómicas que puede tener la arteria en su trayecto cervical. Debido a su baja incidencia se propone como objetivo describir dos casos clínicos de pacientes que tuvieron hemorragias graves por lesión de la arteria lingual en la base de la lengua, producidas por daño quirúrgico y por erosión por tumor. [AU]

The bleeding caused by injury to the lingual artery at the base of the tongue due to surgery or tumors is infrequent. The increased frequency in the indication of transoral approaches to treat different pathologies affecting the oropharynx requires the surgical team to have experience in managing this complication. Ligation of the lingual artery in the neck is a very effective surgical technique to solve the bleeding; however, it is essential to be aware of the possible anatomical variants the artery may have in its cervical trajectory. Due to its low incidence, we propose to describe two clinical cases of patients who had severe bleeding due to a lesion of the lingual artery at the base of the tongue, produced by surgical damage and erosion due to a tumor. [AU]

Angina bullosa haemorrhagica: a systematic review and proposal for diagnostic criteria.

The aim of this study was to perform a critical review of published data on the epidemiological, aetiological, clinical, histological, biological, and therapeutic characteristics of patients with angina bullosa haemorrhagica (ABH). A literature search was conducted in the PubMed, Science Direct, Web of Science, and Cochrane Library databases. All publications fulfilling the selection criteria were included in the eligibility assessment according to the PRISMA statement. The full texts of 54 retrieved articles were screened. Forty articles published between 1985 and 2016 describing 225 cases of ABH were finally selected. The mean age of the patients was 55.4 years; the male to female ratio was 0.7. The predominant localization was the palate (66%). A third of patients had no medical history. When specified, a triggering event or promoting factor was frequently found (82%). Biological tests were normal. A biopsy was performed on 35% of the patients. Treatment was symptomatic with a favourable outcome. Recurrences were frequent (62%). In conclusion, ABH is poorly documented and only by studies of low-level evidence. This review did not allow any aetiopathogenic association to be made with a general pathology or treatment. On the basis of this systematic review of the literature, diagnostic criteria aiming to improve the care of patients presenting with ABH are proposed.

Tracheostomy Emergencies.

Tracheostomy is a common procedure for long-term airway management. Although the overall complication rate is greater than 50%, the incidence of serious complications is low. These serious complications can, however, lead to significant morbidity and mortality and it is incumbent on the emergency provider to be prepared to deal with such tracheostomy-related emergencies. The greatest life threats to the tracheostomy patient are decannulation, obstruction, and hemorrhage. Other important but lower-acuity complications include tracheoesophageal fistula formation, tracheal stenosis, infection, and tracheocutaneous fistula formation.

Interventions for treating post-extraction bleeding.

BACKGROUND: Post-extraction bleeding (PEB) is a recognised, frequently encountered complication in dental practice, which is defined as bleeding that continues beyond 8 to 12 hours after dental extraction. The incidence of post-extraction bleeding varies from 0% to 26%. If post-extraction bleeding is not managed, complications can range from soft tissue haematomas to severe blood loss. Local causes of bleeding include soft tissue and bone bleeding. Systemic causes include platelet problems, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced). There is a wide array of techniques suggested for the treatment of post-extraction bleeding, which include interventions aimed at both local and systemic causes. This is an update of a review published in June 2016. OBJECTIVES: To assess the effects of interventions for treating different types of post-extraction bleeding. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 24 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 12), MEDLINE Ovid (1946 to 24 January 2018), Embase Ovid (1 May 2015 to 24 January 2018) and CINAHL EBSCO (1937 to 24 January 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. We searched the reference lists of relevant systematic reviews. SELECTION CRITERIA: We considered randomised controlled trials (RCTs) that evaluated any intervention for treating PEB, with male or female participants of any age, regardless of type of teeth (anterior or posterior, mandibular or maxillary). Trials could compare one type of intervention with another, with placebo, or with no treatment. DATA COLLECTION AND ANALYSIS: Three pairs of review authors independently screened search records. We obtained full papers for potentially relevant trials. If data had been extracted, we would have followed the methods described in the Cochrane Handbook for Systematic Reviews of Interventions for the statistical analysis. MAIN RESULTS: We did not find any randomised controlled trial suitable for inclusion in this review. AUTHORS' CONCLUSIONS: We were unable to identify any reports of randomised controlled trials that evaluated the effects of different interventions for the treatment of post-extraction bleeding. In view of the lack of reliable evidence on this topic, clinicians must use their clinical experience to determine the most appropriate means of treating this condition, depending on patient-related factors. There is a need for well designed and appropriately conducted clinical trials on this topic, which conform to the CONSORT statement (www.consort-statement.org/).

Does Achievement of Hemostasis After Pulp Exposure Provide an Accurate Assessment of Pulp Inflammation?

PURPOSE: The purpose of this study was to determine in primary molars with carious exposures whether hemostasis at the exposure site and pulp orifice reflected inflammatory status of the pulp at the canal orifice based on cytokine levels. METHODS: Forty mandibular primary molars with deep caries were included in the study. Teeth were divided into two groups: group A had teeth where hemostasis at the exposure site was achieved within five minutes, and group B had teeth where hemostasis at the exposure site could not be achieved within five minutes. Blood samples were harvested from the exposure sites and canal orifices. Cytokine levels for IL-1ß, IL-2, IL-6, IL-8, IL-10, TNF-α, and PGE2 were measured using ELISA for all sample sites. RESULTS: The IL-6 levels at the exposure sites were found to be significantly higher in group A when compared to group B, but there was no statistically significant differences in any of the cytokine levels at the canal orifices between the two groups. CONCLUSIONS: Controlling bleeding at the exposure site or canal orifices does not provide accurate assessment of inflammation at the canal orifice and may be misleading for diagnosing vital pulp treatment in primary teeth with a carious pulp exposure.

Diagnosis of Hypofibrinogenemia After Dental Treatment Under General Anesthesia.

Congenital hypofibrinogenemia is a rare coagulation disorder characterized by a deficiency in fibrinogen protein, which is critical to the normal coagulation process. This hematological disorder can go undiagnosed until an event leads to prolonged bleeding. The purposes of this report were to describe an incidental diagnosis of congenital hypofibrinogenemia after a dental procedure, discuss the importance of recognizing coagulopathies on the delivery of dental care, examine the multi-disciplinary clinical management of prolonged bleeding after a dental procedure, and evaluate the challenges health care practitioners may encounter when obtaining a thorough medical history.

High-flow paediatric mandibular arteriovenous malformations: case reports and a review of current management.

High-flow vascular malformations in the paediatric population are potentially life-threatening and are challenging to treat. This paper describes the management of three cases of mandibular arteriovenous malformations and reviews the contemporary management options for these serious lesions.

Lupus anticoagulant hypoprothrombinemia syndrome associated with severe thrombocytopenia in a child.

Lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) comprises lupus anticoagulant, acquired hypoprothrombinemia, and often mild thrombocytopenia or normal platelets. It is usually associated with autoimmunity or postviral illness. We describe a case of a 10-year-old boy with oral bleeding and severe thrombocytopenia initially suggestive of immune thrombocytopenia. Secondary to bleeding, evaluation demonstrated prolonged coagulation tests and subsequently revealed the presence of lupus anticoagulant and hypoprothrombinemia, along with marked autoimmunity, suggestive of LAHPS. He was treated with intravenous immunoglobulin and hydroxychloroquine. This case report and discussion highlight the diagnostic and therapeutic challenges associated with LAHPS and coincident severe thrombocytopenia.

Contemporary management of carotid blowout syndrome utilizing endovascular techniques.

OBJECTIVES/HYPOTHESIS: To illustrate complex interdisciplinary decision making and the utility of modern endovascular techniques in the management of patients with carotid blowout syndrome (CBS). STUDY DESIGNS: Retrospective chart review. METHODS: Patients treated with endovascular strategies and/or surgical modalities were included. Control of hemorrhage, neurological, and survival outcomes were studied. RESULTS: Between 2004 and 2014, 33 patients had 38 hemorrhagic events related to head and neck cancer that were managed with endovascular means. Of these, 23 were localized to the external carotid artery (ECA) branches and five localized to the ECA main trunk; nine were related to the common carotid artery (CCA) or internal carotid artery (ICA), and one event was related to the innominate artery. Seven events related to the CCA/ICA or innominate artery were managed with endovascular sacrifice, whereas three cases were managed with a flow-preserving approach (covered stent). Only one patient developed permanent hemiparesis. In two of the three cases where the flow-preserving approach was used, the covered stent eventually became exposed via the overlying soft tissue defect, and definitive management using carotid revascularization or resection was employed to prevent further hemorrhage. In cases of soft tissue necrosis, vascularized tissues were used to cover the great vessels as applicable. CONCLUSIONS: The use of modern endovascular approaches for management of acute CBS yields optimal results and should be employed in a coordinated manner by the head and neck surgeon and the neurointerventionalist. LEVEL OF EVIDENCE: 4. Laryngoscope, 2016 127:383-390, 2017.

Postoperative bleeding risk for oral surgery under continued rivaroxaban anticoagulant therapy.

OBJECTIVES: The purpose of this study was to assess the risk of postoperative bleeding complications after oral procedures performed under continued mono or dual anticoagulation therapy with rivaroxaban (and aspirin). METHODS: This retrospective single-center observational study included 52 oral procedures performed under continued oral anticoagulant therapy with rivaroxaban (20 mg/day). Among them, two procedures were performed under continued dual therapy with aspirin (100 mg/day) added to the regimen. Postoperative bleeding events were compared with 285 oral procedures in patients without any anticoagulation/antiplatelet therapy. RESULTS: Postoperative bleeding complications after oral surgery occurred significantly more often in patients under continued rivaroxaban therapy (11.5 %) than in the control cases without anticoagulation/antiplatelet medication (0.7 %). All of the bleeding events were manageable: Two of them were treated with local compression, three by applying new fibrin glue with (one case) or without (two cases) secondary sutures, one occurred during a weekend and was therefore treated under inpatient conditions with suture replacement. All postoperative bleeding episodes occurred during the first postoperative week. CONCLUSIONS: According to our data, continued anticoagulation therapy with rivaroxaban significantly increases postoperative bleeding risk for oral surgical procedures, although the bleeding events were manageable. CLINICAL RELEVANCE: Oral surgeons, cardiologists, general physicians, and patients should be aware of the increased bleeding risk after oral surgical procedures. Close observation up to 1 week postoperatively is advisable to prevent excessive bleeding.

Salvage treatment of hemorrhagic arteriovenous malformations in jaws.

OBJECTIVE: To present our clinical experience on embolotherapy of arteriovenous malformations (AVMs) in jaws with acute hemorrhage. MATERIALS AND METHODS: Twelve patients with a history of hemorrhage were selected for this study. Continuous interdental sling suture, digital pressure on the extraction socket, and iodoform gauze packed into the socket and fixed with sutures to the adjacent gum were used for temporary hemostasis before embolization. Fiberoptic bronchoscopy was used in all cases to facilitate endotracheal intubation. Absolute ethanol combined with coils was used as method of embolization. RESULTS: Eight patients presented with intermittent interdental gum bleeding or controlled hemostasis before embolization. Four patients presented with torrential hemorrhage around the tooth, controlled by continuous pressure on the tooth and bilateral gum for temporary hemostasis. All patients were successfully salvaged before embolization. Ten of 12 patients were cured, and 2 had partial remission. Follow-up ranged from 12 to 26 months (mean, 16.5 months) for all patients, and there was no recurrence of the lesions. CONCLUSIONS: The treatment of hemorrhagic AVMs of the jaw requires a multidisciplinary team approach; such cases can be successfully salvaged and stably controlled by embolization with coils and absolute ethanol.

Prognostic Factors of Survival From Intractable Oronasal Bleeding After Successful Transarterial Embolization.

PURPOSE: To evaluate the prognostic factors that influence the survival of patients with traumatic intractable oronasal bleeding treated by transarterial embolization (TAE). MATERIALS AND METHODS: Patients who received TAE for intractable oronasal bleeding in the National Taiwan University Hospital from 2002 through 2013 were included in the study. Retrospective reviews were undertaken to collect relevant clinical and neuroradiologic data that might be correlated with patients' survival. The Wilcoxon rank-sum test or Fisher exact test was adopted to analyze differences between the survival group and the mortality group. Odds ratios were estimated by univariate logistic regression. RESULTS: TAE successfully controlled the bleeding in 24 of 26 patients (92.3%) who had severe craniofacial injury in the 12-year period. Of the 24 patients with successful TAE, 13 patients were discharged alive from the hospital. The overall survival rate was 50% (13 of 26). Significantly higher initial Glasgow Coma Scale (GCS) score (P = .01) and lower Injury Severity Score (ISS; P < .01) were present in the survival group than in the mortality group by the Wilcoxon rank-sum test. Moreover, patients with an ISS of at least 30, a GCS score lower than 9, initial hemoglobin level lower than 10 g/dL, and computed tomographic (CT) findings of a brain midline shift had statistically higher odds ratios predicting mortality than their counterparts as estimated by univariate logistic regression. CONCLUSIONS: The results of this study showed that the combination of diagnostic angiography and therapeutic embolization is effective treatment for intractable oronasal bleeding in patients with severe craniofacial injury. The prognosis in patients who were rescued with successful TAE was statistically correlated with the severity of trauma and concomitant brain injury. An ISS of at least 30, a GCS score lower than 9, an initial hemoglobin level lower than 10, and CT findings of a brain midline shift were strong predictors for mortality.

Conservative treatment of intraosseous hemangiomas in the mandible: case report with a 17-year follow-up period.

Intraosseous hemangiomas in the jaws are rare lesions and may lead to several complications. The authors present a case of a 12-year-old girl with a radiolucent periapical lesion between tooth 35 and 36 where nocturnal exsanguinating bleeding started to occur from periodontal sulcus during orthodontic treatment. Diagnosis of an intraosseous hemangioma in the mandible was based on positive needle aspiration for blood, computed tomography and arteriography. At first the family chose to only follow-up the lesion but episodes of nocturnal hemorrhage were becoming more frequent and a treatment was requested. Embolization and dental extraction were performed in order to treat the lesion. After a follow-up period of 17 years no more cases of hemorrhage occurred and lesion regressed.

Haemostasis. Part 1: The management of post-extraction haemorrhage.

UNLABELLED: The management of bleeding complications following a dental extraction is an essential skill for the dental practitioner. Extractions are often carried out on patients with complex medical histories and a long list of medications. This paper aims to help the clinician manage post-extraction haemorrhage. A review of the management of patients on anti-thrombotic medications will be covered in a subsequent paper. CLINICAL RELEVANCE: This article reviews the management of haemorrhage following tooth extraction; from the risk assessment of any underlying medical conditions and medications, to the clinical techniques used to control bleeding following an extraction.

[Diagnosis and therapy of bleeding in ENT]. / Blutungen im HNO-Bereich.

Bleeding in the oral cavity, nose or ear are common events in the daily routine of ENT specialists. Apart from trivial cases that often get outpatient treatment, there are numerous cases of serious bleeding that require stationary treatment and if necessary, an operative or interventional therapy. In the following section the most frequent types of bleeding, their diagnosis and therapy will be explained.