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ISSN : 1225-1577(Print)
ISSN : 2384-0900(Online)
The Korean Journal of Oral and Maxillofacial Pathology Vol.44 No.4 pp.127-133

External Carotid Artery Ligation for Perioperative Bleeding Control on Maxillectomy of a Squamous Cell Carcinoma Patient

Jae-Young Yang1), Hun Jang1), Mi-Heon Ryu2), Dae-Seok Hwang1), Uk-Kyu Kim*
1)Department of Oral and Maxillofacial Surgery, School of Dentistry, Pusan National University, Beomeori, Mulgeum, Yangsan, Kyoungsangnamdo, 50612, South Korea
2)Department of Oral pathology, BK21 Plus project, School of Dentistry, Pusan National University, Yangsan, Gyeonnam, 50612, Republic of Korea
*Correspondence: Uk-Kyu Kim, Department of Oral and Maxillofacial Surgery, School of Dentistry, Pusan National University, Beomeori, Mulgeum, Yangsan, Kyoungsangnamdo 50612, South Korea Tel: +82-055-360-5100; Fax: +82-055-360-5104
May 27, 2020 May 29, 2020 August 7, 2020


To accurately determine the resection margin for maxillary cancer, it is important to closely examine the extent of tumor infiltration into the maxilla, nasal cavity, maxillary sinus, palate, and surrounding tissues. Various methods have been described for the resection of maxillary tumors, such as alveolectomy, partial maxillectomy, subtotal maxillectomy, total maxillectomy, and extended maxillectomy. The objective of this study was to introduce external carotid artery (ECA) ligation on the ipsilateral side, a perioperative bleeding control method with fewer complications. Incidence of major bleeding during maxillectomy is a rare but potentially life-threatening complication. Cases of temporary bleeding from an internal maxillary artery or other sites can be stopped, packed, and compressed. However, bleeding control is eventually achieved by ligation of the ECA or selective embolization. Herein, we report the case of a 60-year-old male with squamous cell carcinoma of the right maxilla, which was eventually treated with subtotal maxillectomy along with an elective ECA ligation for intraoperative bleeding control. The procedure produced no preoperative or postoperative bleeding. ECA ligation is a simple, effective, safe, and (at the operator’s discretion) recommended method of perioperative bleeding control during maxillectomy.

편평세포암종 환자에서 상악골 부분 절제술시 출혈 처치를 위한 외경동맥 결찰

양 재영1), 장 훈1), 유 미현2), 황 대석1), 김 욱규*
1)부산대학교 치의학전문대학원 구강악안면외과학 교실
2)부산대학교 치의학전문대학원 구강병리학 교실



    Squamous cell carcinoma (SCC) of the maxillary gingiva, maxillary sinus, and palate is rare, accounting for about 3%-5% of all head and neck cancers, and 66% of all maxillary malignancies. Compared with the SCCs in other oral regions, diagnosis of maxillary SCCs is challenging because of varied clinical presentations that often mimic benign diseases such as sinusitis, periodontal disease, inflammatory/reactive tumor-like lesions, and nonspecific granulation tissue1). Maxillary cancers can be classified according to their primary site. In the literature, maxillary cancers have been categorized into carcinomas of the oral mucosa (gingiva, alveolus, and hard palate), carcinomas of the maxillary sinus, and nasal cavity malig-nancies2-5). Recent studies have shown that the localization of gingival, alveolar, and oral SCCs is similar to that of tongue and mouth SCCs6-8).

    All SCCs with mucosal elements have a risk of lymph node metastasis. Radical neck dissection or radiotherapy, or both, are commonly performed when tumors are palpable or visible on radiological imaging at the time of initial diagnosis. Patients without any evidence of metastasis have a risk of developing delayed lymph node metastasis. Therefore, selective treatment of regional lymph nodes is widely accepted 9-11).

    Major hemorrhage during maxillectomy is an uncommon but potentially life-threatening complication. Acute bleeding must be stopped promptly, with the eventual aim of achieving bleeding control. Ligation of arteries and veins for hemostasis is a feasible treatment choice; however, it is often difficult or impossible to identify and adequately access the culprit vessels. In such cases, ligation of the external carotid artery (ECA) or selective embolization has been the conventionally used strategy for bleeding control.

    ECA ligation is rarely performed, due to the availability of interventional embolization. However, ECA ligation has a significant impact on bleeding control in patients with severe and uncontrolled bleeding. This is especially true in situations where selective embolization is infeasible. ECA ligation is the only procedure that can prevent hemorrhagic shock. However, ECA ligation can lead to complications such as bleeding, aneurysm formation, diplopia, muscles pain and facial paresis. On the contrary, ECA ligation during maxillectomy has several advantages, including controlling surgically inaccessible arterial feeders, reducing the surgical blood loss, shortening the surgical procedure time, and increasing the feasibility of total lesion resection. Hence, we present the case report of a 60-year-old man with SCC of the right maxilla that was treated with subtotal maxillectomy and ECA ligation for bleeding control. ECA ligation during maxillectomy, and at the discretion of the operator, can become a routinely performed method of perioperative bleeding control.


    A 60-year-old man visited the Department of Oral and Maxillofacial Surgery at Pusan National University Dental Hospital (Yangsan, South Korea) in November 2018 because of an ulcerative gingival lesion in the right maxillary region. The patient previously underwent examinations in other hospitals for his long-term inflammation and persistent pain. Exclusion of malignancy was difficult; therefore, biopsy was performed. The results showed a well-differentiated SCC. Upon presentation in our department, the patient displayed an ulcerative lesion in the right maxilla with delayed healing (Fig. 1). He only had hypertension in his medical history. Routine laboratory tests, positron emission tomography scan, CT and MRI were performed. Laboratory tests results showed normal values. We received written informed consent from the patient for the publication of this report and the use of his medical data. The institutional review board of Pusan National University Dental Hospital approved the study (approval number: PNUDH-2020-005).

    1. Radiographic findings

    X-ray orthopantomography images depicted bony destruction with sinusitis in the right maxillary posterior region (Fig. 2); this finding was confirmed from the results of computed tomography (CT) and magnetic resonance imaging (Fig. 3, 4). On radiological imaging, the lesion was approximately 2.3 cm in size, with soft-tissue enhancements in the right buccal space and around the maxillary alveolar process. There was no significant cervical lymphadenopathy. In addition, positron emission tomography-CT showed fluorodeoxyglucose uptake in the right maxilla, with a maximum standardized uptake value of 6.7. Hypermetabolic lesions were not observed in the scanned fields. Therefore, based on these findings, a stage IV maxillary cancer was confirmed (Fig. 5).

    2. Intraoperative and postoperative findings

    A subtotal maxillectomy and selective neck dissection was planned under general anesthesia. The subtotal maxillectomy was performed using the Weber-Ferguson incision, which is used routinely because of the advantages of excellent exposure and minimal scarring as the incision follows the natural skin crease. With an approximately 3-cm diameter resection margin, the lesion along with the right maxillary incisor was removed safely (Fig. 6A-C). The patient did not experience significant cervical lymphadenopathy, but elective neck dissection is performed when there is a risk of occult metastases. Level I and II cervical lymph nodes were dissected during selective neck dissection.

    Usually, massive hemorrhage is the most serious and im-minent complication during maxillectomy. In our case, although no hemorrhage occurred intraoperatively, ECA ligation was performed to avoid delayed bleeding postoperatively (Fig. 7A-C).

    The patient experienced convulsions and delirium, one of the complications of general anesthesia, on the evening of surgery. Thereafter, there was a risk of rebleeding due to the continuous increase in blood pressure. Although postoperative bleeding was possible, intraoperative ECA ligation was performed to prevent this complication.

    Concomitant chemoradiotherapy is generally recommended for patients with locally advanced maxillary cancer. Our patient also had advanced maxillary cancer and underwent 8 weeks of concomitant chemoradiotherapy treatment postoperatively. The surgical site healed 6 months after the lesion excision without any sequelae such as dehiscence or infection. According to the findings of a cone beam CT performed 6 months postoperatively, there was no sign of tumor recurrence, and no buccal bone regeneration was observed in the posterior right maxillary region. Six months postoperatively, a maxillary obturator prosthesis was fabricated for the preservation, support, and improvement of speech (Fig. 8A,B).

    3. Pathologic findings

    On gross examination, the mass was 3.0 x 1.9 x 1.3 cm in size. The resection margin was abutting to the inferior sur-face, and a safety margin of more than 0.3 cm was ensured for all other areas. The nuclei of the tumor cells were round or oval shaped, hyperchromatic, and malignant, with multiple atypical cell divisions. A peripheral bony invasion was observed, in addition to the oral mucosa and maxillary sinus invasions observed at low magnification (Figs. 9 and 10). The diagnosis of SCC was confirmed by the Department of Clinical Pathology at the College of Medicine, Pusan National University. The immunohistochemistry test produced negative results for p16 and p53.


    The prognosis of maxillary cancer remains poor despite aggressive treatment. For successful treatment results, complete surgical resection should be performed with adequate resection margin. However, maxillary cancer is usually diagnosed in the advanced stage, and therefore, achieving complete surgical resection is difficult because of its proximity to important organs such as the eye or cranial nerves, and owing to the risk of intra- or postoperative major hemorrhage.

    Greater palatine and maxillary arteries are often the cul-prit vessels in postoperative hemorrhage after maxillectomy. Strategies for bleeding control include packing and ligation of the ECA or maxillary artery. Control of acute bleeding is difficult. Ligation of the affected vessels is the preferred treatment choice, but limited access to the culprit vessel restricts its feasibility. In such cases, an elective intraoperative ECA ligation or embolization is usually performed. Intra- or postoperative ECA ligation is a safe procedure with comparatively fewer complications and can be done within 30 minutes. Furthermore, this procedure minimizes morbidity. Angiography systems with provisions for arterial embolization have been available for 50 years. Presently, this strategy is widely used in the management of postoperative acute bleeding. Embolization confers a selective advantage for ligation and can be performed in cases where surgery is not possible.

    The effect of ECA ligation on maxillary arterial hemorrhage was investigated in baboons. The ligation of proximal ECA reduced blood flow by 73%. Additional ligation of the superior thyroid, ascending pharyngeal, lingual, and facial arteries reduced bleeding by 85%”12-13). Complications associated with the ligation of ECA and its branches include hemiparesis, facial paresthesia, and facial pain14).

    Our patient with SCC of the right maxilla was treated with subtotal maxillectomy and intraoperative ECA ligation for bleeding control. There is a possibility of bleeding after maxillectomy, and preemptive prevention of bleeding is possible by ECA ligation. Postoperatively, the patient had a good prognosis and is presently on follow-up.

    Although performing the procedure on a patient is a limitation of our study, we plan to further investigate preventive ECA ligation and its complications, through including more patients. We suggest performing ECA ligation during maxillectomy, at the discretion of the operator, as a simple, effective, and safe method of perioperative bleeding control.


    The objective of this study was to introduce external carotid artery (ECA) ligation on the ipsilateral side, a perioperative bleeding control method with fewer complications. ECA ligation is a simple, effective, safe, and (at the operator’s discretion) recommended method of perioperative bleeding control during maxillectomy.

    List of abbreviations


    External carotid artery


    Squamous cell carcinoma


    Computed tomography



    Intraoral oral photographs at initial presentation. An ulcerative lesion with delayed healing is seen in the right maxillary region.


    Panoramic radiograph shows sinusitis with bony destruction in the right maxillary region.


    Computed tomography image shows the extent of spread of the lesion, with soft-tissue enhancements in the right buccal space and around the maxillary alveolar process.


    Facial Magnetic Resonance image shows the extent of spread of the lesion, with soft-tissue enhancement in the right buccal space and around the maxillary alveolar process.


    Abnormally increased fluorodeoxyglucose uptake was observed in the right maxilla on positron emission tomography/ computed tomography image and the maximum standardized uptake value was 6.7.


    Intraoperative photographs. A. Weber-Ferguson incision, B. Safety margin, C. Approximately 3 cm diameter of the safety margin of the resected tumor along with a maxillary tooth.


    Intraoperative photographs. A. Selective neck dissection (level I-II), B. After selective neck dissection, C. External carotid artery ligation.


    Postoperative photographs.

    A. Healing of the primary site without tumor recurrence.

    B. Placement of a maxillary obturator prosthesis


    Representative hematoxylin-eosin stained histological section of the moderately differentiated squamous cell carcinoma.

    A. Original magnification, ×40; scale bar=500 μm

    B. Original magnification, ×100; scale bar=200 μm


    Representative hematoxylin-eosin stained histological section of the invasive front of the SCC with maxillary bone invasion (original magnification, ×40; scale bar = 500 μm)



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