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Address reprint requests and correspondence: Neerav Goyal, MD, MPH, Department of Surgery, Division of Otolaryngology—Head and Neck Surgery, The Pennsylvania State University, College of Medicine, 500 University Dr, H091, Hershey, PA 17033-0850.
The otolaryngologist commonly performs several procedures in close proximity to the carotid and innominate arterial systems. In this article, we will discuss the management of catastrophic bleeding following adult tonsillectomy and tracheostomy, as well as the management of carotid blowout syndrome in head and neck cancer patients. Although the bleeding risk from tonsillectomy is considered very low, the acceptance of transoral robotic surgery as a treatment modality of oropharyngeal head and neck carcinomas makes the spectre of catastrophic oropharyngeal bleeding more real. Aggressive resection in this area can leave minimal parapharyngeal fat over the carotid artery and damage from manipulation of smaller vessels can lead to pseudoaneurysms. Tracheostomy also carries a very low but real risk of trachea-innominate artery fistula, which has devastating consequences. Finally, we will discuss how to identify head and neck cancer patients who are at risk for carotid blowout syndrome as well as appropriate interventions to manage this condition.
In this article, we will address and discuss catastrophic bleeding in the head and neck with respect to the carotid and innominate arterial systems. Specifically, we will discuss catastrophic bleeding secondary to adult tonsillectomy, tracheotomy (trachea-innominate fistula), and head and neck surgery or radiation (carotid blowout).
Tonsillectomy is one of the most common surgical procedures performed in the United States.
Although the risk of bleeding from this surgery is considered very low and the risk of catastrophic bleeding to be even less, it is important for the surgeon to realize the proximity of the surgical dissection to the major blood vessels of the head and neck. In patients without a medialized carotid artery, the distance between the peritonsillar plane and the carotid artery averages 1-2 cm.
In addition to large caliber vessels such as the internal carotid, a tonsillectomy procedure can put branching vessels off of, and including, the lingual artery and facial artery at risk, which can also lead to significant bleeding events.
With acceptance of transoral robotic surgery (TORS) of the oropharynx as a treatment modality of oropharyngeal head and neck carcinomas, the spectre of catastrophic oropharyngeal bleeding is even more real. In such surgeries for tonsillar carcinomas, the superior constrictor is often resected as the lateral margin of the specimen, sometimes leaving minimal parapharyngeal fat over the carotid artery. In some cases, resection of tumors involves reflecting the mass off of the carotid artery. Additionally, damage to the intima of smaller vessels from manipulation can lead to psuedoaneurysms.
Tracheotomy is also commonly performed by the otolaryngologist—head and neck surgeon. Similar to tonsillectomy, the procedure is done adjacent to critical structures. Depending on the patient’s anatomy, and especially in those with short necks, the distance between the proposed tracheotomy and the innominate artery can be very narrow. As such, delayed bleeding from injury to this vessel can be a very devastating complication, though extremely rare.
Additionally, as the surgical member of the head and neck cancer treatment team, otolaryngologists are aware that carotid blowout accounts for 11% of all mortality in patients with advanced head and neck disease.
Proper identification of at-risk patients and open communication with the patient, their family, and other interventional teams are paramount to obtaining the best outcomes possible in this potentially catastrophic event.
In this article, we will discuss several aspects of catastrophic bleeds from the oropharynx and neck and discuss surgical methods to address and control these bleeds.
Oropharyngeal bleeding
Posttonsillectomy hemorrhage
A relatively common yet potentially life-threatening complication of tonsillectomy is postoperative hemorrhage, with primary hemorrhage rates within 24 hours ranging from 0.3% -3.9% and secondary hemorrhage requiring admission to the hospital ranging from 2%-10.3%.
The tonsillar bed has a robust vascular supply from the following 5 major arteries: the tonsillar branch of dorsal lingual artery, tonsillar and ascending palatine branches of the facial artery, ascending pharyngeal artery, and the internal maxillary artery (Figure 1). Unlike other operative sites, there is no compression of the wound by nearby soft tissue that might aid in tamponade. Although rare, tonsillar hemorrhage can lead to hypovolemic shock, airway obstruction, and death.
Within 24 hours after tonsillectomy a fibrin clot forms over the tonsillar fossa. Bleeds occurring within 24 hours are referred to as primary hemorrhage. By postoperative day 5, the fibrin clot has proliferated and formed a thick cake. A week after tonsillectomy, the mucosa begins to grow into the wound, potentially separating the fibrin clot from the underlying tissue. The risk of secondary bleeding is highest during this period. A Cochrane review and systematic literature review showed no difference between diathermy and cold steel techniques and the risk of posttonsillectomy hemorrhage, though more recent literature suggests that coblative techniques are a risk factor.
Initial management includes evaluation of the airway and hemodynamic stability. Access should be obtained with 2 large-bore intravenous lines. The patient should be in an upright position, leaning forward, to protect the airway and prevent aspiration. Patients may present with a history of bleeding or an active bleed. Pediatric histories may include blood on the pillowcase, excessive swallowing, or episodes of hemoptysis or hematemesis although this may be blood from the operation. A history of coagulation disorders should be elicited. During initial evaluation, a calm demeanor is useful when reassuring the patient and their family members. Obtain hemoglobin and hematocrit levels to establish a baseline for future decisions.
A light source should be used to inspect the oropharynx for signs of active bleeding or clots with the aim of localizing the source to the left or right, inferior or superior pole (Figure 2). A history of repeated bleeding events should be heeded as a warning of a major bleed. A history of bleeding increases the chances of another episode 2-fold.
In the authors’ experience, bedside maneuvers to control bleeding are appropriate in carefully selected patients who are sufficiently cooperative and are not at risk for aggravating or initiating a significant bleed. This can include suctioning the clot from the fossa and applying a vasoconstrictive agent, or considering bedside cautery via electrical or chemical (silver nitrate) means. If there is no evidence of active bleeding, one can consider limited observation with discharge if no further bleeding events occur.
Figure 2Clinical view of postoperative tonsil bleed (arrow points to clot).
Uncooperative patients and those with large clots or active bleeding should be taken to the operating room (OR) for management. Specific considerations should be given to potential difficulties with intubation and also the risks of aspiration. Many of these patients, even if they have not eaten, may have ingested a significant amount of blood and pose an aspiration risk. We recommend rapid sequence induction and intubation and considering having assistive devices such as a video laryngoscope available while intubating. Details on the surgical management of posttonsillectomy bleeding are discussed elsewhere in this volume.
In our practice, after obtaining hemostasis, we let down the mouth gag for a period of time before re-evaluating, and inspect for bleeding that may have been masked by the tamponading effect of the gag. Awakening after anesthesia is a critical period of rebleeding risk due to coughing, bucking, or violent movements of the head. In practice, we do not remove any sterile equipment from the room until the patient has left the OR in the event of a rebleed during extubation. Thorough communication with the anesthesiology team before awakening will help prepare for a potential rebleed event in which airway protection should be prioritized. After management of the postoperative hemorrhage, we observe the patient overnight.
Lingual artery or facial artery pseudoaneurysm
In addition to the more common bleeding occurrences from tonsillectomy, surgeons should also be informed about the possibility of a pseudoaneurysm. Patients may present with intermittent large volume bleeds without an identifiable source on operative examination or direct visualization.
Pseudoaneurysms form following vessel injury that allows for the collection of blood between the media and adventitial layers. Otolaryngologic patients at risk for pseudoaneurysm formation include those with blunt or penetrating carotid injury (including inadvertent injury during tonsillectomy), patients who have received radiation therapy and those with tumor invasion of the internal or external carotid.
Symptomatic patients may present with arterial hemorrhage from the neck, nose, or mouth, an transient ischemic event, ipsilateral headache, Horner syndrome, neck pain, bruits, or trouble or pain on swallowing.
Patients with suspected pseudoaneurysm should undergo immediate vascular imaging with either computed tomography-angiography (CTA) or 4 vessel digital subtraction angiography (DSA).
Although DSA is currently the gold standard, as it allows for both diagnosis and intervention via endovascular techniques, several authors recommend the use of CTA followed by DSA as CTA is more readily available and rapid.
Although open ligation of the external or internal carotid artery is a viable treatment option, management of lingual and facial artery pseudoaneurysms are best addressed via endovascular occlusion.
Endovascular treatment of pseudoaneurysm as it relates to carotid blowout is discussed later in this article.
Transoral robotic surgery
Although a relatively new technology, TORS for the removal of tonsillar carcinomas has similar rates of postoperative hemorrhage when compared to tonsillectomy.
However, given the degree of resection and proximity to the great vessels, the risk of catastrophic bleeding intraoperatively is more significant.
Relevant vascular anatomy
The lingual artery originates from the external carotid artery at the level of the hyoid and continues lateral to the middle constrictor muscle until it is crossed by the hypoglossal nerve. It then passes deep to the hyoglossus muscle and runs along the superior aspect of the hyoid bone. This is where it is most likely encountered during TORS
(Figure 3). If encountered, place 3 or 4 hemoclips until the artery is protected by the musculature. Several authors have advocated the use of a staged approach involving ligation of the lingual artery during neck dissection to prevent intraoperative and postoperative bleeding although no statistical significance in postoperative bleeding has been shown.
In current clinical trials (including the cooperative Radiation Therapy Oncology Group 3311 trial) approaching the neck and ligating these vessels before the robotic oropharyngeal surgery is now mandatory.
Figure 3Surgical anatomy of the lingual artery relative to the hyoid bone.
If bleeding is encountered intraoperatively, hemostasis should be attempted via the robot with an assistant manually suctioning via a conventional suction instrument.
Large caliber vessels should be ligated with vascular clips, using either the endoscopic clip applier or the robotic clip appliers (if available). For the daVinci system (Intuitive Surgical, Inc, Sunnyvale, CA) the clip appliers are only available as 8 mm instruments, and as such, must be available during an active bleeding event.
If bleeding cannot be controlled in this manner, do not initially remove the robot. The bedside assistant should apply external pressure on the greater cornu of the hyoid, to slow the flow of blood and allow the console surgeon to identify the bleeding branch and apply hemostatic clips.
Remove the robot and pack the oropharynx to temporarily tamponade the bleed. The transcervical approach can be performed via a typical neck dissection apron incision. Care should be taken to identify all necessary landmarks including the posterior belly of the digastric and the sternocleidomastoid muscle (SCM). The carotid sheath should be approached and identified with specific attention toward identifying the common carotid and external carotid. The bifurcation is typically at the level of the hyoid bone. Key branches of the external carotid can be identified and ligated including the lingual, facial, and ascending pharyngeal arteries. Vessel ligation will significantly stem the oropharyngeal bleeding, though intraoral control may still be necessary after performing these maneuvers. If secondary or postoperative bleeds occur, the management is the same as was discussed in the first section.
Tracheoinominate fistula
Tracheoinnominate fistula (TIF) is one of the most feared complications following tracheostomy. The incidence has been reported from 0.3%-1% with 100% mortality without operative intervention.
The mechanism of injury is multifactorial with pressure necrosis being the predominating factor. Microscopic studies have shown mucosal injury in as little as 4 hours after inflation of cuffed endotracheal tubes.
As such, overinflation of the cuff (>20 mm Hg) should be avoided. Low tracheostomy tube placement below the third tracheal cartilage may result in abutment of the trachea with the innominate artery, resulting in erosion of the artery.
As such, it is important to review the patient’s anatomy and available imaging before tracheotomy and also to assess for the position of the innominate artery during the tracheotomy to ensure sufficient soft tissue between the tracheotomy tube placement and the artery. The reported incidence of TIF is less than 1% though given the rarity of this occurrence can make it difficult to get an accurate incidence.
The authors recommend using a finger to feel for pulsations inferior to the planned tracheotomy to judge the distance between where the tube will be and the innominate. Malpositioned tracheotomy tubes can place pressure on the anterior tracheal cartilage thereby increasing the risk of pressure necrosis and fistula formation.
Half of the patients will present with a “sentinel bleed,” a brief episode of bright red blood from the tracheostomy site ranging from hours to days before the massive hemorrhage event. Bleeding may stop spontaneously or from pressure from an inflated tracheal cuff. Jones et al
suggest that patients presenting with more than 10 mL of blood from the tracheostomy stoma be presumed to have a TIF until proven otherwise. Impending TIF blowout may also be preceded by a pulsating tracheotomy tube. Evaluation of the sentinel bleed can include a CT angiogram to assess the position and integrity of the major vessels.
Suspected TIF should be examined in the OR. The tracheostomy tube cuff should be overinflated and suprasternal pressure applied. The innominate artery is located anterior to the trachea, and “towing in” of the tracheotomy, with anterior angling of the inferior aspect of the tracheotomy, can help tamponade the bleed (Figure 5). If the tracheostomy cuff does not prevent blood from entering the lungs, an endotracheal tube can be advanced to below the suspected bleed and inflated to control bleeding and minimize aspiration. The patient should be crossmatched for packed red blood cells for likely transfusion and taken to the OR while continuous pressure is kept between the anterior trachea and sternum via tracheal tube or with a finger in the stoma compressing the innominate artery against the posterior sternum (Figure 5).
Figure 5Emergent tracheoinnominate artery fistula management. (A) Overinflation and “towing in” of the tracheotomy tube to apply pressure in an attempt to tamponade the bleed. Otherwise, remove the tracheotomy tube and advance an endotracheal tube from above (B) or through the tracheotomy (C). Then a finger can be placed inside the tracheostomy alongside the tube, applying pressure toward the sternum to compress the innominate artery.
Rigid bronchoscopy is performed under general anesthesia. The tracheal balloon is deflated and if no bleeding is noted, the cannula is withdrawn several centimeters and the trachea is inspected via broncoscope.
The sternotomy should extend into the third or fourth intercostal space. The innominate artery is then exposed after division of the thymus and inferior retraction of the innominate vein (Figure 6A). The innominate artery is then debrided proximally until healthy tissue is encountered and then transected (Figure 6B). There is no evidence to suggest this procedure leads to significant neurological or vascular insult.
Although arterial reconstruction has been successful historically, ligation of the innominate artery alone has had significantly better morbidity and mortality.
Figure 6Surgical management of tracheoinnominate artery fistula. (A) Exposure of innominate artery after division of the thymus and inferior retraction of the innominate vein, and (B) ligation of the innominate artery.
Rupture of the carotid artery and its branches are referred to as a carotid blowout and the clinical signs and symptoms preceding have been termed carotid blowout syndrome (CBS). Blowout can result in exsanguination, compression of the airway, stroke, and death.
As such, recognizing CBS as well as its emergent nature and knowing appropriate treatment modalities is paramount to the well-being of at-risk populations.
Risk stratification
CBS is stratified into 3 types based on mortality risk. Type 1 is characterized by threatened blowout: exposed carotid artery, radiographic evidence of vessel invasion by tumor or nonhemorrhagic pseudoaneurysm. Patients with type 2, or impending CBS, present with sentinel bleeds ranging from just before blowout to months before the event. Type 3 CBS, or acute CBS, presents with profuse exsanguination.
Risk factors for CBS include head and neck cancer, radical neck dissection, previous radiotherapy, recurrent tumors, pharyngocutaneous fistula, and pseudoanyurysms of the carotid artery.
Impaired wound healing secondary to infections, pharyngocutaneous fistulas, and 3-point junctions, lead to exposure of the carotid artery and subsequent breakdown of the arterial wall.
Patients with the aforementioned risk factors presenting with bleeding of any amount from the wound, tracheotomy site, flap, mouth, or with pulsations at the tracheotomy or wound site, should raise concern for CBS.
Initial management of suspected CBS includes control of the airway, applying pressure to the bleeding site, and fluid resuscitation via large-bore intravenous. Blood should be type and cross for possible need for transfusion. Manipulation of the neck should only involve what is required to apply pressure. For patients in which the carotid artery is exposed in an infected, fistulous, or irradiated neck wound, but without a history of bleeding, management is aimed at urgent coverage of the vessel with vascularized tissue. For patients with threatened carotid blowout in which the vessel appears unhealthy, and all patients who present with a sentinel bleed; angiography is required and patients should be transferred to a facility with interventional radiology capabilities (Figure 7). After the patient is stabilized, an angiographic study visualizes the carotid system bilaterally, identifies bleeding sites, aneurysmal dilatation, or tumor blush that may indicate bleeding, and determines the completeness of the collateral cerebral circulation. If no bleeding is identified, the venous phase should be studied, as the internal jugular vein may be the site of hemorrhage.
Figure 7Management algorithm for carotid blowout syndrome.
Although historically, management of CBS included neck exploration and ligation of affected vessels, advancement of endovascular techniques has resulted in open ligation of the common carotid artery as a last resort in the actively crashing patient.
Endovascular occlusion or endovascular stenting are both viable options for the management of CBS. Stenting is viable in cases where ligation of the internal carotid artery cannot be tolerated.
Therefore, stents should be seen as a temporary solution until bypass with subsequent occlusion or flap coverage can be performed.
In the setting of an exposed carotid artery and a threatened CBS, consider reconstruction or flap coverage of the vessel to avoid further injury and or progression of a blowout. There are many options to consider in discussing reconstruction of these wounds, and we will focus on pedicled flap options such as the supraclavicular flap and the pectoralis major flap.
For a standard pectoralis major flap, the clavicle marks the upper border, the sternum the medial border extending down to the seventh rib, and the anterior axillary fold marks the anterolateral border. Skin overlying the muscle may be used to design skin island flaps. In women, the skin island is located below the breast, in an oval shape whose long axis is parallel to the clavicle. In men, the skin island is located parasternally with the long axis of the oval oriented in the cephalocaudal axis. The dominant pedicle, the thoracoacromial artery, is located on the deep surface of the muscle at the junction of the middle and lateral third of the clavicle (Figure 8). An incision is made below the clavicle down to the muscle (a variety of locations for the incision have been described). We tend to mark an incision around the proposed skin island and extend this in a curvilinear fashion toward the axilla. Incisions for skin islands are made if necessary and the muscle is then dissected off the skin toward the clavicular incision. The muscle is then divided distally and mobilized proximally. It is unnecessary to elevate the entire muscle. At least 2 cm of muscle can be left attached to the sternum to protect the perforators from the internal thoracic artery (internal mammary artery). The thoracoacromial artery is visualized on the deep surface of the muscle and included in the flap. Complete release of the muscle around the major pedicle allows for greater arc of rotation. The muscle is then rotated toward the head and neck and passed over the clavicle and beneath the skin to reach an intraoral location, or pulled underneath the clavicle to cover the neck. The flap is then inset over the carotid artery and the donor site is closed primarily.
Figure 8Relevant anatomy for the pectoralis major flap.
Planning of the supraclavicular island flap begins with Doppler ultrasound to locate the supraclavicular artery in the triangle formed inferiorly by the clavicle, medially by the posterior border of the SCM muscle, and laterally by the external jugular vein. The artery is traced and the branch point from the transverse cervical artery is identified (Figure 9). This point will become the point of rotation for the flap and will also be the start of flap measurements. The flap is marked with a width of 6-7 cm and a length of 20-25 cm from the rotation point. The flap is raised distally in the subfascial plane, separating the skin from the deltoid muscle. Perforators from the posterior circumflex humeral artery are ligated or cauterized. The flap is then elevated to the anterior border of the trapezius. The spinal accessory nerve can be identified although it is not always necessary. The flap is raised anteriorly to the clavicle with the use of bipolar cautery after the acromion has been reached. The supraclavicular artery can then be located with Doppler ultrasound. Skeletonization of the artery in the subfascial plane may be used to improve the arc of rotation of the flap though usually unnecessary. If additional length is needed beyond the takeoff of the supraclavicular artery, the distal transverse cervical artery can be ligated and the pedicle mobilized to the thyrocervical trunk. The unneeded proximal skin paddle can be de-epithelialized before the flap is rotated into the defect. The flap can also be tunneled into the defect. The donor site is undermined and closed primarily.
Figure 9Relevant anatomy for the supraclavicular island flap.
Initial management should always include the ABCs: control of the airway, control of bleeding with pressure, and fluid resuscitation. Pressure can be applied with a gloved finger over the site of bleeding until the appropriate team can perform the ligation. In the emergent setting, an incision along the anterior border of the SCM should be considered for maximal exposure of the vessel. The SCM is then retracted posteriorly and the carotid sheath and great vessels are identified. If necessary, the omohyoid muscle can be divided or retracted. If intact, the carotid sheath is opened and the internal jugular vein is retracted laterally (Figure 10). The common carotid artery is then mobilized from the vagus nerve and ligated. In our hands, we recommend suture ligation of the vessel. After ligation, the wound should be thoroughly irrigated and the vessel should be covered with a vascularized flap.
Figure 10Surgical approach for emergent management of carotid blowout.
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