Hard Palate Necrosis after Bilateral Internal Maxillary Artery Embolization for Epistaxis

1. Hard Palate Necrosis after Bilateral Internal Maxillary Artery Embolization for Epistaxis Joel Guss, Marc Cohen, Duane Sewell, Natasha Mirza Department of Otorhinolaryngology-Head and Neck Surgery University of Pennsylvania and The Philadelphia VA Medical Center

2. Case Report • 50 year-old male admitted with severe hypertension • History of substance abuse, mechanical aortic valve replacement on Coumadin, renal failure on hemodialysis. • Started on a Heparin drip and develops right posterior epistaxis

3. 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 arteries embolization

4. Case Report

5. Case Report • Nasal and nasopharyngeal packs removed 48 hours after embolization • No further bleeding, anticoagulation resumed • Over next week patient complains of right sided facial and oral pain

6. Case Report

7. Discussion • Selective embolization of external carotid artery branches is safe and effective in treating epistaxis refractory to conservative management • Early success rates 71-100% in controlling hemorrhage

8. Discussion • Neurological complications: stroke, visual loss, cranial nerve palsy • 0-4% of cases • Causes: plaque disruption v. reflux of particles v. ECAICA anastomotic vessel • Minor complications: facial pain/numbness, trismus, headache, groin hematoma/pain

9. 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

10. 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 facial sloughing

11. Discussion • Hard palate vascular anatomy: • Major supply from descending palatine artery, branch of IMAX • Anastomoses with sphenopalatine branches at the incisor foramen • Soft palate vasculature provides collaterals: ascending pharyngeal and ascending palatine arteries • Facial artery branches at nasal vestibule supply maxillary gingiva

12. Discussion • Gauthier, et al (Surg Radiol Anat. 2002): • Performed bilateral descending palatine artery ligations (in setting of Le Fort osteotomies) on cadavers • Subsequent colored latex injection into the carotid artery demonstrated perfusion of the hard palate mucosa via soft palate collaterals (ascending pharyngeal, ascending palatine)

13. Discussion • In our case, nasopharyngeal balloon may have reduced flow through soft palate collaterals • Bilateral nasal packing may have decreased supply from the nasal cavity via the incisive canal • Presence of packing for two days after embolization may have allowed for sufficient ischemia to cause mucosal necrosis

14. 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 this complication