ZEITOUN AND DHANARAJANI
Acknowledgments
The definitive surgery in this patient was performed by Dr Nicho-
las J. Cassisi, Professor and Chairman, Department of Otolaryn-
gology, J. Hillis Miller Health Center, University of Florida.
References
1. Egbert B, Kempson R, Sagebiel R: Desmoplastic malignant mela-
noma: A clinicohistopathologic study of 25 cases. Cancer
62:2033, 1988
2. Bruijn JA, Salasche S, Sober AJ, et al: Desmoplastic melanoma:
Clinicopathologic aspects of six cases. Dermatology 185:3,
1992
J Oral Maxillofac Surg
53:203-208, 1995
Cervical Cellufitis and Mediastinitis
Caused by Odontogenic Infections:
Report of Two Cases and Review of Literature
IBRAHIM MOHAMED ZEITOUN, MB, BCH, MS, BDS, MD,*
AND P.J. DHANARAJANI, BDS, MS, MS1-
P y o g e n i c orofacial infections are most c o m m o n l y
o d o n t o g e n i c in origin. A l t h o u g h such infections are
usually self-limiting and spatially confined, purulent
material m a y o c c a s i o n a l l y b u r r o w d e e p l y into contigu-
ous fascial spaces or planes far f r o m the initial site o f
involvement. C o m p l i c a t i o n s , such as retropharyngeal
spread, suppurative mediastinal extension, airway ob-
struction, p l e u r o p u l m o n a r y suppuration, and h e m a t o g -
enous dissemination to distant organs, clearly indicate
the potentially serious nature o f these infections.
The p a t h o l o g i c process o f n e c k infections is often
not r e c o g n i z e d early b e c a u s e o f the subtle clinical
signs. I n c o m p l e t e drainage and d e b r i d e m e n t frequently
result in residual, progressive, extensive infections. 2'3
O n c e the process has e x t e n d e d to the thorax, the infec-
tion spreads with increasing speed, resulting in sepsis
Received from the Department of Oral & Maxillofacial Surgery,
Riyadh Dental Center, Riyadh, Kingdom of Saudi Arabia.
* Consultant and Head.
? Specialist.
Address correspondence and reprint requests to Dr Zeitoun: Chief
and Consultant, Department of Oral & Maxillofacial Surgery, Riyadh
Dental Center, PO Box 1584, Riyadh 11441, KSA.
© 1995 American Association of Oral and Maxillofacial Surgeons
0278-2391/95/5302-001853.00/0
203
3. Watsh NMG, Roberts JT, Orr W, et al: Desmoplastic malignant
melanoma. Arch Pathol Lab Med 112:922, 1988
4. Jain S, Allen PW: Desmoplastic malignant melanoma and its
variants: A study of 45 cases. Am J Surg Pathol 13:358, 1989
5. Bruijn JA, Mihm MC, Barnhill RL: Desmoplastic melanoma.
Histopathology 20:197, 1992
6. Skelton HG, Smith KI, Barrett TL, et al: HMB-45 staining in
benign and malignant melanocytic lesions: a reflection of
cellular activation. Am J Dermatopathol 13:543, 1991
7. Kurihara K, Sanada E, Yasuda S, et al: Desmoplastic malignant
melanoma of the gingiva. Oral Surg Oral Med Oral Pathol
74:201, 1992
8. Reiman HM, Goellner JR, Woods JE, et al: Desmoplastic mela-
noma of the head and neck. Cancer 60:2269, 1987
9. Conley J, Lattes R, Orr W: Desmoplastic malignant melanoma
(a rare variant of spindle cell melanoma). Cancer 28:914,
1971
and purulent collections that are difficult to stop. De-
scending necrotizing mediastinitis has a high mortality
rate (37% to 50%) and is frequently associated with
pleural and pericardial effusion, persistent sepsis, and
multiorgan failure. 4-6 The new i m a g i n g techniques that
permit m o r e precise localization are useful in the early
diagnosis o f cervical and thoracic c o m p l i c a t i o n s and
in planning the surgical approach. 7-1°
This article reports two cases o f deep neck infection,
one o f which had severe thoracic complications, with
septic shock and multiorgan failure.
Report of Cases
Case 1
A 37-year-old man was brought to the emergency depart-
ment of Riyadh Central Hospital. He complained of bilateral
swelling of the submandibular region, extending to the neck
and the anterior chest wall. The patient was an alcoholic and
was psychologically unstable. He gave a history of visiting
his general practitioner for toothache and being prescribed
oral penicillin and analgesics without any improvement.
At initial presentation, the patient appeared dehydrated,
toxic, and dysponic and dysphagic. His vital signs were as
follows: temperature, 39.4°C; pulse, 136 beats/min; respira-
tion, 34 breaths/min; and blood pressure, 150/90 mm Hg.
204 CERVICAL CELLULITIS AND MEDIASTINITIS

FIGURE 1. Lateral soft tissue radiograph of the neck showing

emphysema in all neck spaces.

FIGURE 3. Lateralsoft tissue radiograph of the neck showing gas

bubbles in the neck spaces and widening of the retropharyngeal
space. Notice absence of the normal cervical lordosis.

On palpation, there was emphysema of the entire neck. In-

FIGURE 2. Postoperative lateral soft tissue radiograph of the neck
showing resolution of emphysema.
traorally, there was moderate edema of the floor of the
mouth, poor oral hygiene, and multiple carious teeth.
A diagnosis of Ludwig's angina associated with cervical
cellulitis was made, and the patient was sent for a complete
blood examination and radiographs of the neck and chest
region. The blood tests showed polymorphonuclear leukocy-
tosis, and the radiographs showed involvement of the retro-
pharyngeal and parapharyngeal spaces with gas-producing
organisms, and widening of the retropharyngeal space on
the plain lateral cervical view (Fig 1). A definitive diagnosis
of Ludwig's angina involving the retropharyngeal and
parapharyngeal spaces bilaterally was established.
The patient was taken immediately to the operating room,
where drainage through a high collar incision was done under
general anesthesia. The submandibular, sublingual, pterygo-
mandibular, parapharyngeal, and retropharyngeal spaces
were explored bilaterally, and this produced a watery, fetid
discharge with air bubbles that was sent for culture and
antibiotic sensitivity testing.
The patient was kept in the intensive care unit (ICU) with
an endotracheal tube in place for 24 hours. During that time,
he was irritable and incontinent for urine and feces. The
patient was extubated, and the nasopharyngeal tube was re-
placed. He was kept on intravenous amikacin 500 mg and
metronidazole 500 mg every 8 hours. Dressings, which were
completely soaked with a watery fetid discharge, were
ZEITOUN AND DHANARAJAN1
FIGURE 4. Posteroanterior chest radiograph showing bilateral
basal opacities and obliteration of costophrenic angles. Right side
shows a large fluid collection.
changed every 8 hours. The patient showed signs of gradual
improvement, with his temperature becoming normal after 3
days. The culture and sensitivity tests showed no pathogenic
microorganisms. After complete recovery, the radiographs
of the soft tissues of the neck were repeated, and they showed
absence of air bubbles and a normal retropharyngeal space
(Fig 2). Before discharge, all of the badly carious teeth were
removed under local anesthesia. The patient's duration of
stay was 33 days.
Case 2
A 38-year-old man reported to the outpatient clinic of
Riyadh Central Hospital with a complaint of mild right sub-
mandibular swelling, dysphagia, dyspnea, and fetid dis-
charge from the mouth of 5 days' duration. He gave a history
of visiting a general dental practitioner for a toothache in the
past 2 weeks and being prescribed antibiotics and analgesics.
On examination, he was dehydrated, with a mild fever
(38°C), tachycardia, and tachypnea. There was a mild
swelling of submandibular region, more on the right side.
Intraorally, the floor of the mouth was slightly edematous,
and a fetid discharge was oozing from the lingual aspect
FIGURE 5. Posteroanteriorchest radiograph showing widening of
the mediastinum; bilateral pleural effusion, more on the left side;
and a right side intercostal tube in place.
205
FIGURE 6. Axial CT scan of the neck demonstrating gasseous
collection in the retropharyngeal and parapharyngeal spaces.
of the lower molar region; a specimen was sent for culture
and antibiotic sensitivity testing.
The patient was admitted for further investigation and
management, with a clinical diagnosis of bilateral lateral and
retropharyngeal infection. He was kept on intravenous fluid
and amikacin 500 mg and metronidazole 500 mg every 8
hours. Routine investigations showed marked leukocytosis
(26,000/#L). Arterial blood gas analysis showed diminished
partial pressure of oxygen (PO2), and oxygen was adminis-
tered by a face mask.
Radiographic examination of the neck showed involve-
ment of the retropharyngeal and parapharyngeal spaces by
gas-producing microorganisms (Fig 3). The chest radiograph
showed basal opacities on both sides, with obliteration of
the costophrenic angles (Fig 4). The patient was referred to
a chest surgeon, an internist, and an otolaryngologist for
further assessment.
The internist reported that the patient had a chest infection
and advised stopping the amikacin and starting intravenous
(IV) aqueous penicillin, 2 million units every 6 hours. The
patient was seen by the chest surgeon, who advised a new
chest radiograph. This radiograph showed bilateral pleural
effusion, greater on the right side. An intercostal drainage
tube was placed on the fight side, which evacuated 700 cc
pus. A third posteroanterior chest radiograph showed pro-
gressive fluid accumulation in the left side (Fig 5). Esopha-
gography was advised to rule out the presence of a fistulous
track associated with the esophagus; however, no esophageal
FIGURE 7. Abdominal CT scan showing a retroperitonealgas and
fluid collection.
206 CERVICAL CELLULITIS AND MEDIASTINITIS

Table 1. Summary of Patients With Mediastinitis From Odontogenic Origin

Case Age
Author/Year No. (yr)/Sex Bacteriology Outcome

1. Cogan and Martinsburg (1973) 16 1 23/M Staphylococci, streptococci, Bacteroides sp, Died
peruginosa
2. Howell et al (1976) 17 2 23/M Streptococci, Bacteroides, Pseudomonas Discharged
3 24/M Escherichia coli, anaerobes, Bacteroides, Discharged
peptostreptococci
3. McCurdy et al (1977) TM 4 63/M /3-Hemolytic streptococcus Died
4. Moncada et al (1978) 19 5 23/M Unspecified aerobes Discharged
6 44/M Not specified Discharged
7 10/M Not specified Discharged
5. Hendler and Quinn (1978) 20 8 38/M 13-Hemolytic streptococcus, gram-positive and Died
gram-negative rods
6. Baron et al (1981) 21 9 24/M Streptococci, anaerobes Died
10 23/F Streptococci Died
7. Steiner et al (1982) 22 11 41/M Streptococci, Bacteroides sp, diphtheroids Died
8. Estrera et al (1983) 5 12 20/M /3-Hemolytic streptococcus Discharged
13 25/M a-Hemolytic streptococcus, E coli, Bacteroides sp Discharged
14 22/M a-Hemolytic streptococcus, E coli, staphylococci Discharged
15 31/M Streptococci, Bacteroides sp Died
16 27/M Streptococci, staphylococci Discharged
9. Guittard et al (1984) 2~ 17 43/M /3-Hemolytic streptococci, Clostridium perfrengens, Discharged
Proteus vulgaris
10. EsGaib et al (1986) 24 18 52/M Not specified Died
19 15/M Not specified Died
ll. Levine et al (1986) 6 20 25/M Anaerobes Discharged
21 51/M /3-Hemolytic streptococci Discharged
22 19/M Anaerobes Discharged
23 24/M Not specified Died
24 44/M Aerobes and anaerobes not specified Died
12. Rubin and Grozzi (1987) 25 25 27/M /3-Hemolytic streptococci Died
13. Zachariades et al (1988) 26 26 ?/M Coagulase-negative staphylococci, Pseudomonas Discharged
14. Garatea-Creglo and Gray-Escoda 27 18/F Streptococci, staphylococci, and Bacteroides Discharged
(1991) 27 melaninogenicus
28 32/M Streptococci, Pseudomonas, and Bacteroides Discharged
melaninogenicus
29 64/M Streptococci, gram-negative bacteria Discharged
15. Colmenero Ruiz et al (1993) 28 30 32/M Not specified Discharged
31 54/M Not specified Died
32 24/M Not specified Discharged
33 48/M Not specified ?
34 17/M Not specified Died
35 39/M Not specified Discharged
36 28/M Not specified Died

leakage was encountered. Computed tomography (CT) of
the oropharynx and neck indicated the presence of air in all
the fascial spaces of the neck. (Fig 6).
After intercostal drainage, the dyspnea improved consider-
ably. Massage of the neck produced a small amount of pus
intraorally. The otolaryngologists were satisfied with the re-
suits of treatment and the general improvement. However,
on the fourth day, the patient started to complain of abdomi-
nal pain. On examination, the abdomen was tense and dis-
tended, and infrequent bowel sounds were heard.
On the fifth day, the patient went into a state of septic
shock. During this period, he was receiving penicillin and
metronidazole. He was immediately transferred to the ICU,
and a general surgeon was summoned, who requested ultra-
sonography and CT of the abdomen. The chest radiograph
done before transferring him to the ICU showed marked
effusion on the left side, which was drained by putting in an
intercostal tube. This resulted in evacuation of an enormous
amount of watery, purulent discharge. He was evaluated
under general anesthesia by an otolaryngologist, and the ret-
ropharyngeal space was drained intraorally; a very small
amount of seropurulent, fetid discharge containing air bub-
bles was obtained. A tracheostomy was done to avoid aspira-
tion and to ventilate the patient.
On the sixth day, the patient showed signs of disseminated
intravascular coagulopathy and developed epistaxis and
bleeding from the tracheal wound. Also, both intercostal
tubes drained pus mixed with blood. He had prolonged pro-
thrombin (PT) and partial thromboplastin (PTT) times (PT
17.5 seconds; control, 13 seconds; PTT, 45 seconds; control,
28 seconds). Three units of fresh frozen plasma were given.
The electrocardiogram showed elevated ST segments sug-
gestive of pericarditis. During this time, the patient was void-
ing large amounts of concentrated, amber urine.
ZEITOUN AND DHANARAJANI
The patient underwent a soft tissue radiograph of the neck.
A C T scan of the chest and abdomen showed bilateral pleural
effusion, mainly on the right side, and a collection of air in the
mediastinum and retrosternal region. Abdominal cuts showed
intra-abdominal retroperitoneal air collections, especially in the
region around the liver and the spleen (Fig 7).
On the seventh day the patient showed signs of further
deterioration, in the form of anuria, complete renal failure,
ileus, and heart failure, and went into a state of irreversible
shock and coma. He died of multiple organ failure. No au-
topsy was done.
Discussion
Odontogenic infections are usually locally confined,
self-limiting processes. However, under certain cir-
cumstances, they may break through the bony, muscu-
lar, and mucosal barriers and spread into contiguous
and distant spaces, resulting in severe fulminating in-
fections in the body cavities.
The two cases presented in this report started as simple
infections involving badly decayed teeth. Both were ini-
tially treated by general practitioners who gave the pa-
tients antibiotics empirically for some time before admis-
sion to the hospital. They shared common physical and
laboratory findings; both were nondiabetic, middle-aged
men having basically good general health and liver func-
tion. However, oral hygiene of both patients was very bad.
At the initial presentation, the infections occupied
both sides of the oral cavity, face, and neck, and were
associated with foul-smelling, grayish, watery, puru-
lent discharge mixed with air bubbles. Plain radio-
graphs showed a swollen neck with air shadows occu-
pying nearly all the intramuscular and fascial spaces.
Plain lateral cervical radiographs showed widening of
the retropharyngeal space and loss of the normal cervi-
cal lordosis. Chest radiographs of the second patient
disclosed widening of the mediastinal shadow and
obliteration of the costophrenic angle, especially on the
right side, together with bilateral basal opacification.
For the diagnosis of mediastinitis of odontogenic ori-
gin, Estrera et al 5 proposed the following criteria: 1) clini-
cal manifestations of severe infection; 2) characteristic
radiographic findings in the neck and chest of gas in the
tissues, an air-fluid level, loss of normal cervical lordo-
sis, and mediastinal widening; and 3) establishment of a
relationship between the dental infection and the develop-
ment of mediastinitis. Table 1 shows a summary of 36
cases of mediastinitis attributable to odontogenic causes
reported in the literature. It is interesting that 34 (94.5%)
were men.
Penicillin alone was used initially, but did not prove
to be useful in such fulminating gas-producing infec-
tions. Most authorities recommend the combination of
intravenous aqueous penicillin and an aminoglycoside.
Actually, penicillin remains the preferred antibiotic for
treating orofacial infections of odontogenic origin, but
207
the number of reports of penicillin-resistant organisms,
particularly Bacteroides, including B. fragilis, B. mela-
ninogenicus, B. oralis, B. clostridiformis, B. bivius, and
B. discens, has been increasing. 11'12 Of 50 specimens,
Labriola et al (1985) 13 found 21 (42%) with one or
more organisms resistant to penicillin. Seventeen of
21 organisms (80%) were anaerobes, and 30% of the
specimens containing anaerobes were resistant to peni-
cillin. Brook ]4 noted that previous use of penicillin
for treatment of oropharyngeal infections increased the
likelihood of penicillin resistance.
COMPLICATIONS
According to Alexander et al, 15 vessel erosion and
severe bleeding are not uncommon complications of
deep neck infections. The onset of abdominal pain in
patients with suppurative mediastinitis must be seri-
ously considered because this may be an indication of
retroperitoneal extension. This was the sequence of
events encountered in the second case reported.
The mortality rate for mediastinitis from odonto-
genic infection ranges from 40% to 60%. Of the 36
patients reviewed (Table 1), 16 died, a mortality rate
of 44%.
Airway obstruction may require intubation or tracheos-
tomy, especially in cases with Ludwig's angina or retro-
pharyngeal abscess. A tracheostomy is considered by
some authors as an integral part of the management of
cases with severe cervicofascial infections; the use of an
endotracheal tube is discouraged, mainly because of the
risks of reintubation. Early tracheostomy was avoided
in both cases presented because of the potential risk of
spreading the infection to the lower respiratory tract or
other neck spaces, particularly because the neck was al-
ready involved by the infection, and there was no evi-
dence of upper respiratory obstruction.
References
1. Chow, WA, Rosen SM, Brady FA: Orofacialodontogenic infec-
tions. Ann Intern Med 88:392, 1978
2. Beck HJ, Salasaa JR, McCaffery T, et al: Life threatening soft
tissue infections of the neck. Laryngoscope 94:354, 1984
3. Lalwani A, Kaplan M: Mediastinal and thoracic complications
of necrotizing fasciitis of the head and neck. Head Neck
13:531, 1991
4. Pearse HE: Mediastinitis following cervical suppuration. Ann
Surg 108:588, 1939
5. Estrera AS, Landay MI, Grisham JM: Descending necrotizing
mediastinitis. Surg Gynecol Obstet 157:545, 1983
6. Levine TM, Wurster, CF, Krepsi YP: Mediastinitis occuring
as a complication of odontogenic infections. Laryngoscopy
96:747, 1986
7. HoltFR, McManus I, NewmanRK, et al: Computedtomography
in the diagnosis of deep neck infections. Arch OtolaryngoI
108:693, 1982
8. NybergDA, JefferyRB, Brand ZawadzkiM: Computedtomogra-
phy of cervicalinfections: J ComputAssistTomogr9:288, 1985
9. Levitt GW: The surgical treatment of deep neck infections. La-
ryngoscope 81:403, 1971
208
10. Egbert GW, Simmons AK, Graham L: Toxic shock syndrome.
Oral Surg Oral Med Oral Pathol 63:167, 1987
11. Schroeder DC, Sarha ED, Hendrickson A, et al: Severe infec-
tions of the head and neck resulting from gas forming organ-
isms. JADA 114:65, 1987
12. Quinn P, Guernsey LH: The presentation and complications of
odontogenic septic shock. J Oral Surg 59:336, 1985
13. Labriola JD, Mascaro J, Alpert B: The microbiologic flora or
orofacial abscesses. J Oral Maxillofac Surg 41:711, 1983
14. Brook I: B Lactamase-producing bacteria recovered after clini-
cal failures with various penicillin therapy. Arch Otolaryngol
110:261, 1984
15. Alexander DW, Leonard JR, Trail ML: Vascular complications
of deep neck abscesses. Laryngoscope 78:361, 1968
16. Cogan M, Martinsburg WV: Necrotizing mediastinitis second-
arc to descending cervical cellulitis. Oral Surg Oral Med Oral
Pathol 36:307, 1973
17. Howell HS, Prinz RA, Pickleman JR: Anaerobic mediastinitis.
Surg Gynecol Obstet 143:353, 1976
18. McCurdy JA, McInnis EL, Hayes LL: Fatal mediastinitis after
dental infection. J Oral Surg 35:726, 1977
19. Moncada R, Warpeha R, Pickleman J, et al: Mediastinitis from
odontogenic and deep cervical infections. Chest 73:497, 1978
20. Hendler BH, Quinn PD: Fatal mediastinitis secondary to odonto-
genic infection. J Oral Surg 36:308, 1978
J Oral Maxillofac Surg
53:208-210, 1995
Embolization of Arteriovenous Fistulae of
the Maxillary Artery After
Le Fort I Osteotomy:
A Report of Two Cases
V.S. ALBERNAZ, MD,* AND T.A. TOMSICK, MD1-
D i r e c t a r t e r i o v e n o u s ( A V ) fistulae o f the e x t e r n a l
c a r o t i d artery s y s t e m are rare, 1 w h e t h e r t h e y are c o n -
g e n i t a l or a c q u i r e d . 2 M o s t a c q u i r e d c a s e s are s e c o n d a r y
to b l u n t or p e n e t r a t i n g injury or direct s u r g i c a l trauma. 1
S e v e r a l c a s e s o f A V fistulae after s u r g i c a l p r o c e d u r e s
o f the h e a d a n d n e c k , i n c l u d i n g r h i n o p l a s t y , t o o t h ex-
traction, and L e F o r t o s t e o t o m i e s h a v e b e e n r e p o r t e d
in the literature. 2"3'49 A V fistulae after o r t h o g n a t h i c sur-
* Resident in Radiology, University of North Carolina, Chapel
Hill, NC.
? Professor, Department of Radiology; Director, Division of Neu-
roradiology; Director, Interventional Neuroradiology, University of
Cincinnati Medical Center, Cincinnati, OH.
Address correspondence and reprint requests to Dr Albernaz: 131
Summerlin Dr, Chapel Hill, NC 27514.
© 1995 American Association of Oral and Maxillofacial Surgeons
0278-2391/95/5302-001953.00/0
EMBOLIZATION OF ARTERIOVENOUS FISTULAE
21. Baron D, Malinge M, Mercier J, et al: Gangrenes gazeuses a
point de depart dentaire. Rev Stomatol Chir Max Fac 82:366-
369, 1981
22. Steinern M, Grau MJ, Wilson DL, et al: Odontogenic infection
leading to cervical emphyema and fatal mediastinitis. J Oral
Maxillofac Surg 40:600, 1982
23. Guittard P, Ducase JL, Jorda MF, et al: Les mediastinitis a anaero-
bies odonto genigues. Ann Fr Anesth Reanim 3:216, 1984
24. EsGaib AS, Silva AC, Souza Meira EB: Mediastinite con-
sequente a infeccao dentaire: Relato de dois casos. Rev Paul
Med 104:283, 1986
25. Rubin MN, Grozzi GM: Fatal necrotizing mediastinitis as a
complication of odontogenic infection. J Oral Maxillofac
Surg 45:529, 1987
26. Zacchariades N, Mezitis M, Stavsinidis P, et al: Mediastinitis,
thoracic emphysema and pericarditis as complications of a
dental abscess. J Oral Maxillofac Surg 46:493, 1988
27. Garatea-Creglo J, Gray-Escoda C: Mediastinitis from odonto-
genic infection. Int J Oral Maxillofac Surg 20:65, 1991
28. Colmenero Ruiz C, Labajo AD, Yanez Vilas, et al: Thoracic
complications of deeply situated serious neck infections. J
Cranio Maxillofac Surg 21:76, 1993
29. Linder HH. The anatomy of fascial of the face and neck with
particular reference to the spread of and treatment of intra-
oral infections (Ludwig's) that have progressed into adjacent
fascial spaces. Ann Surg 204:705, 1986
g e r y u s u a l l y i n v o l v e large v e s s e l s , s u c h as the internal
carotid a r t e r y J V a s c u l a r c o m p l i c a t i o n s i n v o l v i n g
s m a l l e r v e s s e l s , like the m a x i l l a r y artery, m o s t c o m -
m o n l y o c c u r as a p s e u d o a n e u r y s m . 1 T o o u r k n o w l e d g e ,
t h e s e are the first cases o f fistulae i n v o l v i n g the m a x i l -
lary artery r e p o r t e d after o r t h o g n a t h i c surgery.
Report of Cases
Case 1
A 40-year-old woman with maxillary prognathism and
mandibular retrognathia was treated with a Le Fort I osteot-
omy and mandibular sagittal split ramus osteotomies on July
7, 1990. The medical history was unremarkable. No intraop-
erative complications were noted and estimated blood loss
was less than 500 mL. Minor intraoperative hemorrhage
from the right descending palatine artery was controlled with
hemoclips and cauterization. The left descending palatine