Abstract
False aneurysm or pseudoaneurysm is usually a result of blunt trauma causing laceration of part of the vessel wall and extravasation of blood into surrounding tissue, followed by tamponade and clot formation. The wall of the pseudoaneurysm consists of perivascular fibrous tissue. Extracranial carotid artery pseudoaneurysms are relatively rare because trauma to external carotid artery branches usually results in total transection rather then partial laceration of blood vessel. Most affected branches are the superficial temporal artery, internal maxillary artery and distal facial artery, usually where they pass over the bone (zygoma or mandible). The authors present the case of a 78-year-old male patient with facial artery pseudoaneurysm in its proximal part in the submandibular region with no known evidence of trauma. To the authors’ knowledge this is the first case in the literature of facial artery pseudoaneurysm without traumatic origin and the third case of proximal facial artery pseudoaneurysm. Although formation of pseudoaneurysm in the region of face and neck is rare, the authors consider that inclusion of pseudoaneurysm in the differential diagnosis of a neck mass is important.
True aneurysm is a dilation consisting of all three layers of blood vessel: intima, media and adventitia. False or pseudoaneurysm is usually a result of blunt trauma causing laceration of part of the vessel wall and extravasation of blood into surrounding tissue, followed by tamponade and clot formation. The wall of the pseudoaneurysm consists of perivascular fibrous tissue. The haematoma usually liquefies and communication between artery and aneurysmal sac persists. The time between the injury and clinical presentation of pseudoaneurysm can vary from days to years. Usually it manifests as a pulsatile mass with bruit, sometimes causing neurologic deficit, secondary haemorrhage or release of embolic thrombus.
Extracranial carotid artery pseudoaneurysms are relatively rare because trauma to external carotid artery branches usually results in total transection rather then partial laceration of the blood vessel. The most affected branches are the superficial temporal artery, internal maxillary artery and distal facial artery, usually where they pass over the bone (zygoma or mandible) .
The authors present a case of facial artery pseudoaneurysm in its proximal part in the submandibular region with no known evidence of trauma. To the authors’ knowledge this is the first case in the literature of facial artery pseudoaneurysm without traumatic origin and the third case of proximal facial artery pseudoaneurysm.
Case report
A 78-year-old male patient was examined in the oral surgery outpatient clinic because of an intraoral odontogenic abscess in the region of the lower right molar. Tooth 46 was extracted and an abscess was incised intraorally and drained. After 2 days of antibiotic treatment the swelling subsided and the patient was better. The oral surgeon noticed right submandibular painless swelling and referred the patient to the maxillofacial outpatient clinic. Clinical examination revealed a freely movable painless swelling in the right submandibular region measuring 50 × 50 mm ( Fig. 1 ), without skin involvement. Initially no pulsations or bruit were observed. No other swellings on the neck were noted. Intraoral examination was unremarkable.
According to the patient’s history, he had this submandibular mass for 3 years and it gradually expanded but without causing any symptoms. He denied any history of trauma. The patient was referred for a computed tomography (CT) scan of the head and neck and ultrasound guided fine needle aspiration (FNA) of the lesion, because of the suspicion that the mass might be a primary tumour of the submandibular gland or metastasis from an unknown primary. Ultrasound showed a vascular mass with blood flow inside the lesion. Carotid protocol CT angiography of the neck was carried out. There was a circumscribed nodular lesion in the right submandibular area, part of it showing intensive accumulation of the contrast and the other part filled with thrombotic masses. This lesion was in continuity with the facial artery with visible continuity of the contrast inside the vessel and inside the lesion ( Fig. 2 ). Radiomorphologically this confirmed diagnosis of facial artery (pseudo)aneurysm suspected on ultrasound. The patient underwent surgery under general anaesthesia. The lesion was approached through a lower neck crease incision, the marginal mandibular branch of the facial nerve was identified and preserved, the facial artery was ligated distally and proximally ( Fig. 3 ) of the pseudoaneurysm and the submandibular gland was extirpated as well because it was intimately adhered to the pseudoaneurysm. Suction drain was placed and the wound closed with interrupted sutures for deep layers and the skin.
