Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 25 (2013) 3234

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Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology

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Case report

Bloody tears after miniplate osteosynthesis for Le Fort I osteotomy

Bruno Ramos Chrcanovic a, , Fernanda Cardoso Fonseca Nunes b , Belini Freire-Maia c
a

Av. Raja Gabaglia, 1000/1209, Gutierrez, Belo Horizonte, MG 30441-070, Brazil Av. do Contorno, 4747/loja 16, Serra, Belo Horizonte, MG, CEP 30110-921, Brazil c Av. do Contorno, 4747/1010, Serra, Belo Horizonte, MG, CEP 30110-921, Brazil
b

a r t i c l e

i n f o

a b s t r a c t
Le Fort I osteotomy is usually carried out safely as an elective procedure in hospitals. However, minor complications can occur and are related to complex anatomy of the region where nerves, blood vessels and bony canals are present. One of the anatomical structures that can be damaged is the nasolacrimal duct. The patient underwent a Le Fort I osteotomy. After the surgery, blood was observed in her tears of the left eye. A lacrimal duct endoscopy was performed and computed tomography was requested and revealed an accidental perforation of the nasolacrimal duct by a screw of the miniplate osteosynthesis system. The screw (diameter: 2.0 mm; length: 7.0 mm) was then immediately removed under local anesthesia. The bleeding stopped at the rst postoperative day and left no sequelae. Surgeons should be aware of the potential risk for an accidental penetration of the nasolacrimal duct during drilling and installation of the osteosynthesis screws for the rigid internal xation of Le Fort I osteotomies. When faced with a complaint of bloody tears, the clinician should take a thorough history, then perform a careful eye examination and, when indicated, an otolaryngologic examination. Imaging of the sinuses may be useful when trauma is suspected. 2011 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.

Article history: Received 21 July 2011 Received in revised form 14 September 2011 Accepted 5 October 2011 Available online 8 November 2011 Keywords: Le Fort I osteotomy Miniplate osteosynthesis Complication Lacrimal apparatus Blood

1. Introduction Le Fort I osteotomy is a common procedure performed by oral and maxillofacial surgeons. As a result of advances in instrumentation and general anesthesia, it is usually carried out safely as an elective procedure in hospitals. Life-threatening complications are rare although the operation is performed in an area with an extensive vascular supply. However, minor complications can occur and are related to complex anatomy of the region where nerves, blood vessels and bony canals are present [1]. The authors report a case of exit of blood by the lacrimal punct after miniplate osteosynthesis for Le Fort I osteotomy. 2. Case report A 30-year-old female was referred to the Department of Oral and Maxillofacial Surgery of the Pontifcia Universidade Catlica
Asian AOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asian Society of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathology; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japanese Society of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants. Corresponding author at: Department of Oral and Maxillofacial Surgery, School of Dentistry, Pontifcia Universidade Catlica de Minas Gerais, Belo Horizonte, Brazil. Tel.: +55 31 32920997; mobile: +55 31 91625090; fax: +55 31 25151579. E-mail addresses: brunochrcanovic@hotmail.com (B.R. Chrcanovic), fernandafonsecan@gmail.com (F.C.F. Nunes), belinimaia@gmail.com (B. Freire-Maia).

de Minas Gerais, Belo Horizonte, Brazil, for assessment of her facial deformity. Her main complaint was a mild anterior open bite with poor exposure of upper incisors. A routine orthognathic work-up was performed. Cephalometric tracing revealed an increased posterior maxillary height with an anterior open bite and with a retrusive mandible. She underwent pre-surgical orthodontics including dental decompensation. The surgical plan consisted of a Le Fort I maxillary posterior impaction allowing a counterclockwise rotation of the mandible in a Class I occlusal relationship. The operation was uneventful. However, during recovery from anesthesia blood was found in the tears of her left eye (Fig. 1), which persisted even after washing with saline solution. On examination, lids, conjunctiva inclusive of fornices, palpebral part of lacrimal gland and lacrimal sac area were normal. The ocular mobility and visual acuity were preserved. The presurgical laboratory tests including platelet count, measurement of the prothrombin time, partial thromboplastin time, and bleeding times were normal. She had no hereditary tendency to bleeding. Computed tomography (CT) scans were requested, and showed evidence of screw penetration into the left nasolacrimal duct (Figs. 2 and 3), in the region just inferior to the orbital border (Fig. 4). A lacrimal duct endoscopy was performed and showed a bleeding coming from the region where the screw was. The screw (diameter: 2.0 mm; length: 7.0 mm) was then immediately removed under local anesthesia.

0915-6992/$ see front matter 2011 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ajoms.2011.10.002

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Fig. 1. Bloody tears in the left eye.

Fig. 4. Parasagittal CT. Osteosynthesis screw (OS) penetration into the left nasolacrimal duct (LND). FS, frontal sinus; SpS, sphenoidal sinus; OralC, oral cavity; OrbC, left orbital cavity; SL, superior lip; HP, hard palate.

Fig. 2. Axial CT. Osteosynthesis screw (OS) penetration into the left nasolacrimal duct (LND). RMS, right maxillary sinus; LMS, left maxillary sinus; NS, nasal septum; RNC, right nasal cavity; RND, right nasolacrimal duct.

Fig. 3. Frontal CT. Osteosynthesis screw (OS) penetration into the left nasolacrimal duct (LND). NS, nasal septum; NC, nasal cavity; HP, hard palate.

No more blood was observed at the rst postoperative day. The patient is being followed up two months after the surgery by an ophthalmologist, without signs of sequelae. 3. Discussion The nasolacrimal duct carries tears from the lacrimal sac into the nasal cavity. Excess tears ow through nasolacrimal duct which opens in the nose. Bloody tearing, or haemolacria, is an uncommon clinical phenomenon that may be caused by a wide spectrum

of abnormalities. This entity has also been described as dacryohemorrhysis, dacryohemorrhea, lacrimae cruentae, and sanguineous lacrimation [2]. This entity has been associated with conjunctival lesions including hemangiomas, bromas, inammatory granulomas, malignant melanomas [3], and hereditary hemorrhagic telangiectasis [4]. Lacrimal gland and sac tumors have also been known to cause bloody tears [2,3]. Other reported causes include corneal vascular lesions, vicarious menstruation, application of drugs such as silver nitrate, severe epistaxis with regurgitation through the lacrimal passages [2], orbital varix [5], hemophilia [6], and in patients taking anticoagulants medicaments [7]. In the emergency department they are more commonly encountered accompanying epistaxis [8]. Bloody tearing can be unnerving to patients and perplexing to physicians when it occurs and a thorough investigation yields no cause. Idiopathic bloody tearing has been described in the past [9]. Another condition that might cause spontaneous bleeding is disseminated intravascular coagulation (DIC). Until today, no single laboratory test or a combination of tests is available which is sensitive and specic enough, to allow a denitive diagnosis of DIC. However, in most cases the diagnosis can reliably be made by taking into consideration the underlying disease and a combination of laboratory ndings [10]. In routine setting, a diagnosis of DIC may be made by a combination of platelet count, measurement of global clotting times (activated partial thromboplastine time and prothrombin time), measurement of antithrombin III and/or 1 or 2 clotting factors, and a test for brin degradation products [11]. Such laboratory tests were made before the surgery in the present case and the results were considered between normal limits. The anatomical basis of the bloody tearing lies in the intimate connection of nose and eye via the lacrimal apparatus. An increase in pressure within the nasal cavity during epistaxis for example, by pinching or blowing the nose, can cause retrograde ow of blood through the system and thus lead to bloody tears emerging from the ipsilateral eye [8]. Concerning the surgical technique, Le Fort I osteotomy, alone or in combination with a mandibular osteotomy, is carried out safely in a hospital setting on a daily basis. Surgical complications are relatively rare and the common early complications include nerve injury and malocclusion. Intra operatively it is not uncommon to observe brisk haemorrhage, especially following maxillary osteotomy due to mechanical disruption of blood vessels, including greater palatine artery and pterygoid venous plexus [1]. Ophthalmic complications, such as blindness, ocular palsy and diplopia, have been reported following Le Fort I osteotomy [1214]. Atypical

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fractures of the pterygoid region propagating to the orbital apex and the base of skull have been implicated as the cause of these complications. Some complications may follow the installation of rigid internal xation using miniplates and screws. In the present case of bloody tears the use of a miniplate long in the piriform aperture region contributed to the penetration of the upper screw into the nasolacrimal duct causing bleeding and retrograde drainage into the lacrimal sac and the presence of blood in tears, which resulted in this unusual complication. It is important to observe that even screws with small lengths, such as a screw with 7.0 mm of length as presented here, can cause such problem, due to the anatomy of the region (the nasolacrimal duct lies just posterior the thin cortical bone around the superior part of the piriform aperture). When faced with a complaint of bloody tears, the clinician should take a thorough history (including a menstrual history and a family history, in a search for a hereditary tendency to bleeding), then perform a careful eye examination and, when indicated, an otolaryngologic examination. Imaging of the sinuses may be useful when trauma is suspected, and dacryocystography may aid in assessment of the nasolacrimal duct and sac [15]. If one is suspicious of the nature of the red material, microscopy and tests to detect and analyze blood are worthwhile. When these steps do not reveal the cause of the patients complaint, laboratory investigations, including a platelet count and measurement of the prothrombin time, partial thromboplastin time, and bleeding times, are necessary, as these may uncover a bleeding tendency [15]. Since all of these signs showed to be negative in conjunction with an uneventful surgery, a CT was requested in the hope of nding a possible cause. As the patient had no complications related to the lacrimal apparatus from the rst postoperative day and since then, no additional treatment was necessary, being followed up by an ophthalmologist. 4. Conclusion Surgeons should be aware of the potential risk for an accidental penetration of the nasolacrimal duct during drilling and installation of the osteosynthesis screws for the rigid internal xation of Le Fort I osteotomies.

Disclosure of interest statement The authors warrant to the journal that the article has no nancial interest and is free of conict of interest. The study was performed in compliance with authors institutions appropriate policies. References
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