Postoperative bleeding after laser surgery in head and neck tumors

BACKGROUND: There are different reports in the literature how often postoperative hemorrhage occurs after laser resection of head-and-neck tumours. This retrospective study investigates the frequency of postoperative hemorrhage after laser surgery of head and neck tumours. Time and extent of bleeding have been considered as well as the localization of the primary tumour and possible general risk factors. METHODS AND PATIENTS: Between 1998 and 2001, microscopic laser surgery was performed in 223 patients with previously untreated squamous cell carcinomas of the oral cavity, oropharynx, supraglottic and glottic region and the hypopharynx. In case of ultrasonographic or palpable evidence of cervical lymphadenopathy surgery included subsequent neck dissection. The mean age of the patients was 59.2 year. RESULTS: Postoperative bleeding occurred in 14 out of 223 patients (6 %). It was 9 % for oral carcinoma, patients 10 % for oropharyngeal carcinoma, 5 % for supraglottic carcinoma and none for glottic and hypopharyngeal carcinoma. 5 patients were treated conservatively, 4 patients were controlled bei cautery and ligation, 1 patient was treated with ligation of the lingual artery and in 2 cases ligation of the external carotid artery was performed. 1 patient had a fatal hemorrhage. CONCLUSIONS: Laser-surgical resection of head and neck carcinomas does not lead to a higher incidence of bleeding complications compared to ordinary surgery.     

Thorium dioxide granuloma of the neck: A report of four cases

Four patients with Thorotrast granuloma are reported. The first patient had a radical neck dissection performed; however, postoperative hemorrhage and fistula occurred with a six-month delay in healing. The granuloma in this patient had totally occluded his carotid system with a greatly enlarged vertebral artery. A second patient presented with spontaneous bleeding in the neck from a granuloma followed by encephalo-malacia, hemiparesis and aphasia. The third and fourth patients presented as hoarseness with a hard mass in the neck. All four patients had Thorotrast in the liver and spleen. The latter three had laryngoscopies and in-cisional neck biopsies as their only surgical treatment. Neck malignancy from Thorotrast is very rare. Despite legal decisions suggesting removal³ and similar suggestions in the literature, the authors feel only small extravasations have had uncomplicated operations. Neck dissection is rarely indicated. Hoarseness can be improved by vocal cord injection. These patients, of course, must be followed periodically as any other tumor, checking the neck mass, liver, and carotid circulation.     

Prophylaktische und notfallmäßige Unterbindungen der Aa. carotides bei Patienten mit malignen Tumoren im Kopf-Hals-Gebiet

Life threatening hemorrhage in patients with malignant tumours of the head and neck area are often, as a result of tumour infiltration, postoperative anatomical changes, infection and radiological necrosis, difficult to control. One option for prophylaxis and treatment is the ligature of the external (ECA) or common carotid artery (CCA) and superior thyroid artery (STA). 52 patients were examined in a retrospective study to determine both the hazards and the therapeutic use of the procedure. The external carotid artery (ECA) was ligated prophylactically during the operative procedure of tumour resection and neck dissection in 25 patients. In 27 cases closure of the ECA, CCA or ECA and STA was carried out as an emergency procedure for acute hemorrhage following completed primary treatment (operation, primary or postoperative radiation or radiochemotherapy). There was no postoperative hemorrhage after prophylactic ligature of the ECA. One patient with multiple cardiovascular diseases suffered from an ipsilateral cerebral infarction 1 year after operation. In 6 of 9 patients and in all 3 patients, in whom ligature of the CCA or ECA and STA respectively was carried out as an emergency procedure, severe neurological complications up to an apallic syndrome occurred. The number of deaths due to acute hemorrhage was considerably smaller among those patients with prophylactic ligature of the ECA performed during operative procedure of tumor resection and neck dissection. In addition there were much less unfavourable courses in the sequence of prophylactic closure of the ECA than observed after ligating the CCA or ECA and STA in an emergency situation.     

Lingual artery embolization for severe and uncontrollable postoperative tonsillar bleeding

We performed emergent angiography of the external carotid artery to evaluate a patient who experienced uncontrollable oropharyngeal bleeding 3 days following an adenotonsillectomy. Angiography demonstrated a left lingual artery disruption and hemorrhage. We then performed a coil embolization of the left lingual artery, which immediately halted the hemorrhage. We conclude that coil embolization is a rapid and effective strategy for the management of massive, uncontrollable postoperative tonsillar bleeding.     

Tortuous common carotid artery encountered during neck dissection

Anomalies of the carotid artery are rare in clinical experience. To our knowledge a tortuous common carotid artery with an abnormal course encountered during neck dissection has never been reported in the available world literature. During dissection of the lower neck in a 60-year-old Korean man, a tortuous right common carotid artery was found to cross over the lower cervical trachea anteriorly and then was positioned in its usual site in the carotid sheath in the mid-neck. Received: 6 August 1997 / Accepted: 5 November 1997     

Extrusion of embolization coils through the carotid artery in a radiated neck

Extrusion of embolization coils is an exceedingly rare event. We present and discuss a unique case of coil extrusion through the carotid artery into the pharyngeal soft tissue in the setting of soft tissue radionecrosis (STRN). A 55-year-old man with previous chemoradiation therapy presented with massive transoral hemorrhage. Control of the bleeding was accomplished by coil embolization of the right carotid artery system. The patient subsequently developed spiking fevers, and an exploration of the neck revealed coil extrusion through the common carotid artery and into the neck and pharynx. Although the incidence of coil extrusion in the head and neck is remarkably low, this complication must be considered in the heavily radiated neck and a high index of suspicion should be maintained in the setting of radionecrosis and signs and symptoms of systemic infection. Appropriate management requires early recognition and removal of foreign material with wound stabilization.     

胸颈联合入路摘除加修补医源性颈总动脉假性动脉瘤1例

1 病例报告 患者,男,61岁。3年前无诱因出现视力模糊,当时诊断为糖尿病,半年前出现浮肿,劳累后明显,既往有高血压、甲状腺功能减低症、I型糖尿病、     

Transarterial carotid occlusion. Case report and review of the literature

Postoperative carotid artery rupture occurs in 3% to 4.5% of head and neck resections involving a mucosal primary and radical neck dissection. Other indications for carotid sacrifice-ligation include en bloc removal of the artery with tumor, inadvertent injury during surgery, and hemorrhage from vessel erosion by unresectable tumor. The mortality and morbidity of unilateral carotid occlusion are significantly decreased when performed electively in a hydrated and normotensive patient with a normal serum hemoglobin level. Sequelae approximate 5% when adequate collateral cerebral blood flow is present. A transarterial catheter approach to the measurement of carotid artery back pressure and permanent obstruction of flow in an awake patient is presented.     

头颈肿瘤术后并发颈动脉破裂4例报告

目的：探讨头颈部恶性肿瘤侵犯颈动脉的手术治疗方法。方法：对4例颈动脉与转移瘤粘连患者，采用从颈动脉壁上剥离切除肿瘤保留血管的术式。结果：术后1周内4例都发生了颈动脉破裂，1例经颈动脉修补术后再发血管破裂出血死亡，3例经行颈动脉结扎术后存活。结论：对于肿瘤累及颈动脉的患者术前应作好结扎切除颈动脉的准备；术中若发现肿瘤与血管壁粘连，则应结扎血管连同肿瘤一并切除；一旦术后并发颈动脉破裂，则应结扎之，而不宜行修补术。     

Carotid artery pseudoaneurysm as a rare sequela of surgery for laryngeal cancer

Formation of carotid artery pseudoaneurysm is uncommon after intensive treatment for head and neck cancer. We encountered a case of postoperative formation of pseudoaneurysm at the left carotid bifurcation in a diabetic man. The risk factors for carotid artery pseudoaneurysm in the patient included diabetes mellitus, previous radiotherapy to the neck, neck dissection, and postoperative Staphylococcus aureus infection secondary to accidental pharyngocutaneous fistula. We successfully obliterated this pseudoaneurysm using a Smart stent and detachable coils without neurological deficits. The possibility of vascular injury after treatment for head and neck cancer must be considered, especially in patients with risk factors for it due to previous treatment.     

Carotid artery pseudoaneurysm as a rare sequela of surgery for laryngeal cancer

Formation of carotid artery pseudoaneurysm is uncommon after intensive treatment for head and neck cancer. We encountered a case of postoperative formation of pseudoaneurysm at the left carotid bifurcation in a diabetic man. The risk factors for carotid artery pseudoaneurysm in the patient included diabetes mellitus, previous radiotherapy to the neck, neck dissection, and postoperative Staphylococcus aureus infection secondary to accidental pharyngocutaneous fistula. We successfully obliterated this pseudoaneurysm using a Smart stent and detachable coils without neurological deficits. The possibility of vascular injury after treatment for head and neck cancer must be considered, especially in patients with risk factors for it due to previous treatment.     

Mycotic aneurysm of the internal carotid artery

The detection of aneurysms of the internal carotid artery due to acute or chronic neck infections seems to be a rather rarely event. However, if aneurysms or pseudoaneurysms of the neck region occur, than mostly by bleeding complication or unclear significant soft tissue swelling. The case of a patient is reported, who underwent an abscess tonsillectomy. The intraoperative situation of the right tonsillar fossa was found to show suspicious pulsations under the scarred and inflamed peritonsillar tissue layer. The postoperative performed intraarterial angiography verified the diagnosis of the aneurysm of the internal carotid artery nearby the tonsillar fossa. The diagnosis mycotic aneurysm has been concluded by the long lasting tonsillitis history with one further peritonillar abscess in the past, intraoperative and histological signs of peritonsillitis and the the result of an intraarterial angiography carried through 10 years ago without any clue to aneurysm. A bleeding complication did not occur in this case. The patient went into the care of vascular surgeons with the indication to perform a stent application.     

Progressive carotid artery dissection causing tinnitus and one-sided head and neck pain

Carotid artery dissection, one of the most common causes of stroke in patients younger than 40 years of age, may develop spontaneously or after trauma. In 85% of cases, central neurological signs such as stroke, transient ischemic attack and amarozis fugax are seen, while headache and cranial nerve paralysis can be the presenting symptoms in the rest of cases. In this case report, a 35-year of age young male patient who had a progressive carotid artery dissection accompanied by complaints of left sided tinnitus and ipsilateral head and neck pain. The patient was admitted to the clinic with the diagnosis of carotid artery dissection and cerebral angiography (CA) was planned. During the CA performed the day after, three stents were placed in the dissection area. Improvement was observed in all complaints of the patient who was followed up in the clinic for 10 days. The patient was discharged in a healthy condition to return after three months for a control.     

Transoral robotic surgery for head and neck carcinomas

The objective of this study was prospectively to assess the feasibility and safety of transoral robotic surgery (TORS) in head and neck carcinomas and to report our learning curve and 2-year outcomes. Patients with oropharyngeal, hypopharyngeal and laryngeal tumors treated with TORS were prospectively included. We evaluated: the feasibility of TORS, robotic set-up time, transoral robotic surgery time, blood loss, surgical margins, tracheotomy, feeding tube, time to oral feeding and surgery-related complications. Twenty-three patients were treated for 25 carcinomas. Twenty-two patients underwent successful robotic resection for 24 carcinomas (96%). One patient required conversion to open surgery due to massive bleeding. The mean robotic set-up time was 25?min (range: 15–100?min) and mean TORS operating time was 70?min (range: 20–150?min). Positive margin of resection was observed in one patient (classified pT3) out of the 24 cancers and was managed by postoperative chemoradiation. No tracheotomy was performed. Three patients required prolonged intubation for a mean of 22?h. Two patients required a temporary gastrostomy (for 2 and 3.5?months, respectively). All other patients resumed oral feeding between the first and third postoperative day. The mean hospital stay was 6.4?days (range: 4–19?days). No postoperative complication occurred. Mean follow-up was 20?months (median: 19, range: 14–26). No death and no case of local or metastatic failure were observed. TORS is feasible and safe for the resection of selected head and neck carcinomas. The occurrence of intraoperative bleeding emphasizes the need for surgeons to be skilled in both transoral and open approaches.     

Management of infected carotid artery rupture

Carotid artery rupture (CAR) is a life-threatening complication of head and neck cancer, and infection complicates its management. The purpose of this study was to review our experience with the treatment of infected CAR and to summarize the existing literature on this topic. We retrospectively reviewed the medical records of patients treated in our department from 2000 to 2011 and re-analyzed cases reported in the literature during the same time period. We analyzed etiology, anatomic location, treatment, and rates of recurrent hemorrhage for each case. A total of 46 episodes of infected CAR occurred in the four patients in our own records and 27 patients described in the literature. Twenty-eight patients suffered from various head and neck cancers and underwent surgical resection, and 27 of them subsequently received radiotherapy or radiotherapy combined with chemotherapy (the 28th patient died before radiotherapy due to severe blood loss). The most common site of bleeding was the common carotid artery (33/46, 71.7 %). Seventeen cases (17/45, 37.8 %) were treated with surgical ligation, 20 (44.4 %) with stent placement, and 7 (15.6 %) with embolization. Surgical ligation had a lower rate of recurrent bleeding (2/17, 11.8 %) than stent placement (12/20, 60.0 %) when used for the treatment of infected CAR (P = 0.037, Chi squared test). Our results suggest that surgical ligation is an effective option in the management of infected CAR and may be the best choice to prevent recurrent hemorrhage. The complication rates, however, may be high when the common carotid or the internal carotid arteries are ligated.     

Contralateral External Carotid-Middle Cerebral Artery Bypass for Carotid Artery Resection

Resection of the common carotid or internal carotid artery is occasionally unavoidable in cases of advanced head and neck carcinoma with carotid artery involvement. To prevent the consequent decrease in cerebral perfusion, we have developed a contralateral external carotid-middle cerebral artery bypass grafting technique. From 1990 through 1995, six patients with advanced head and neck cancer involving the carotid artery underwent total tumor resection combined with vascular reconstruction using the contralateral external carotid- middle cerebral artery bypass grafting. No bypass-related complications occurred in any patient postoperatively. Cerebral hemodynamics after surgery indicated that this bypass graft worked steadily over a long term and supplied sufficient volume of blood to the cerebral cortex on the opposite side in every case.     

External carotid-external carotid crossover anastomosis for reconstruction of common carotid resection

A pilot project studying the feasibility of external carotid-external carotid cross-over anastomosis for reconstruction of common carotid artery resection is reported. Common carotid artery resection in the treatment of head and neck malignancy may be necessary when carcinoma involves the common carotid or when the common carotid artery ruptures. Ligation of the common carotid is associated with high mortality rates and high rates of neurologic complications. The vasculature to the internal carotid can be maintained by anastomosing both external carotid arteries across the midline. The diseased common carotid can then be ligated below the bifurcation. The crossover anastomosis was performed successfully in six cadaveric dissections with unilateral neck dissection and laryngectomy. Mobilizing the facial artery in conjunction with the external carotid artery provides added length. A large vessel anastomosis across the midline was performed in six sheep. Technical errors in two sheep resulted in obstruction. The remaining four anastomoses remained patent. The external carotid-external carotid crossover anastomosis may have application in the management of squamous cell carcinoma involving the common carotid or in the treatment of carotid artery blowout. Further study is warranted.     

上纵隔暴露术在颈部晚期癌手术中的应用

目的　研究累及颈根部和上纵隔区域的颈部晚期肿瘤根治性手术的方法。方法　 1992～ 1999年对 18例颈部晚期癌行不同方式的上纵隔暴露术和肿瘤根治性切除术。其中晚期气管造口复发癌 10例 ,晚期复发甲状腺癌 2例 ,晚期颈段气管癌 2例 ,锁骨上巨大转移癌 4例。根据肿瘤的部位和侵及范围行单纯胸骨柄切除 10例 ,切除一侧胸锁关节和锁骨内侧 1 2者 4例 ,切除胸骨柄和双侧锁骨内侧 1 3者 4例。其中 1例锁骨上窝肿瘤因其侵犯左侧锁骨下动脉而实行了锁骨下动脉部分节段性切除加肿瘤全切除和人工血管锁骨下动脉重建术。对 10例气管造口复发癌在肿瘤切除后以胸大肌肌皮瓣修复局部大块组织缺损 ,覆盖并保护下颈部和上纵隔大血管。结果　通过上纵隔暴露与清扫术 ,16例患者的肿瘤得以完整切除。 2例因肿瘤在上纵隔内过度向后下延伸而行大部分切除术 ,其中 1例在分离肿瘤时术中发生气胸。术后 2例发生咽瘘 ,其中 1例因伤口感染发生右侧颈总动脉假性动脉瘤 ,均经及时处理后治愈。 1例于术后 2个月发生无名动脉出血死亡。术后 1年、2年和 3年生存率分别为 72 2 % ( 13 18)、2 2 2 % ( 4 18)和 11 1% ( 2 18)。结论　上纵隔暴露术对切除累及上纵隔的颈部晚期癌是一种必要、安全和可靠的手术路径     

Temporal arterial ligation in head and neck surgery with absorbable sutures

Temporary arterial ligation is a useful concept in head and neck surgery for situations dealing with potential recurrent hemorrhage or recurrent vascular neoplasms. In this study, several absorbable sutures, including plain gut, chromic gut, and polyglycolic acid were used to ligate the common carotid artery in dogs. Arterial patency was followed by serial selective arteriograms. Only polyglycolic acid sutures proved to be a reliable material to achieve transient arterial occlusion.     

上纵隔暴露术在颈部晚期癌手术中的应用

目的 研究累及颈根部和上纵隔区域的颈部晚期肿瘤根治性手术的方法。方法 1992～1999年对18例颈部晚期癌行不同方式的上纵隔暴露术和肿瘤根治性切除术。其中晚期气管造口复发癌10例，晚期复发甲状腺癌2例，晚期颈段气管癌2例，锁骨上巨大转移癌4例。根据肿瘤的部位和侵及范围行单纯胸骨柄切除10例，切除一侧胸锁关节和锁骨内侧1／2者4例，切除胸骨柄和双侧锁骨内侧1／3者4例。其中1例锁骨上窝肿瘤因其侵犯左侧锁骨下动脉而实行了锁骨下动脉部分节段性切除加肿瘤全切除和人工血管锁骨下动脉重建术。对10例气管造口复发癌在肿瘤切除后以胸大肌肌皮瓣修复局部大块组织缺损，覆盖并保护下颈部和上纵隔大血管。结果 通过上纵隔暴露与清扫术，16例患者的肿瘤得以完整切除。2例因肿瘤在上纵隔内过度向后下延伸而行大部分切除术，其中1例在分离肿瘤时术中发生气胸。术后2例发生咽瘘，其中1例因伤口感染发生右侧颈总动脉假性动脉瘤，均经及时处理后治愈。1例于术后2个月发生无名动脉出血死亡。术后1年、2年和3年生存率分别为72．2％(13／18)、22．2％(4／18)和11．1％(2／18)。结论 上纵隔暴露术对切除累及上纵隔的颈部晚期癌是一种必要、安全和可靠的手术路径。