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Pathophysiology

Classification

Radiotherapy:

  • Obliteration of vaso vasorum
  • adventitial fibrosis
  • premature atherosclerosis
  • weakening of arterial wall
  • subendothelial vacuolization & oedema
  • fragmentation of the media elastic fibres

Aetiology

Epidemiology

  • Tumours
  • involvement of carotid
  • Surgery
  • neck dissection
  • salvage surgery
  • Blunt or penetrating trauma
  • Radiotherapy
  • increases risk x 7
  • total radiation dose

most imporant factor

  • >70Gy --> 14 times
  • Wound breakdown
  • Necrosis
  • Infection
  • thrombosis of v.v.
  • Pharyngocutaneous fistula
  • including salivary leak
  • tryptic enzyme activity of saliva

Other factors

  • Mobile foreign bodies
  • 4 x increase with wet gauze dressings to wound dehiscence
  • Poor nutrition (BMI <22 --> x 2 risk)
  • 10 - 15% loss of body weight
  • Diabetes mellitus
  • Prolonged corticosteroid use

Carotid Blowout Syndrome

1) Threatened Carotid Blowout

2) Impending Carotid Blowout

3) Acute Carotid Blowout

  • reported rate of 3 to 4% of patients with Head and Neck cancer
  • newer literature suggests less frequent

  • Historical data:
  • 40% mortality
  • 60% neurological morbidity

  • recent studies suggest morbidity and mortality between 0 - 8%

Type 1: Threatened rupture

Type III: Acute rupture

Type II: Impending

rupture

  • Patients with exposed carotid arteries
  • wound dehisence
  • flap necrosis/breakdown
  • infection
  • recurrence/residual tumour

Radiological Criteria

Grade 0: No evidence of vascular disruption

Grade 1: Focal weakening/irregularity of vascular wall

Grade 2: Pseudoaneurysm formation

Grade 3: Evidence of extravasation from carotid

  • Sudden rupture of vessel
  • Haemorrhage that cannot be stopped with pressure or packing
  • rapid deterioration
  • temporary/poor/no response to resuscitation
  • Mortality of 50 - 100%
  • exsanguination
  • aspiration
  • Sentinel haemorrhage
  • short, spontaneousy resolving bleed
  • usually transoral, transcervical, trans-stomal
  • through wound/fistula
  • Resolves with pressure or packing

Anatomy

Management Options

Endovascular

Surgical

Deconstruction

Vessel balloons, or coils

Advantages:

  • takes less time
  • avoids manipulation of irradiated neck
  • GA not required

Disadvantages:

  • Horner syndrome (8%)
  • Cerebral ischaemia (20%)
  • Thromboembolic events

Vessel occlusion

(deconstruction)

Vessel stent

(reconstruction)

Ligation of artery

usually done in acute setting

provides rapid securing of bleeding

less demanding than endovascular technique

Significant neurological morbidity

CVA - early or late

recurrent bleed

Vessel Stenting

Stent placement through injured area

Advantages:

  • Stops bleed with lowered risk of CVA
  • less time
  • GA not required

  • Disadvantages
  • foreign body - risk of infection
  • occlusion, re-haemorrhage
  • Temporary solution
  • until reconstruction

Definition

Vascular Anatomy

  • Uncommon complication typically of head and neck cancer patients

  • Syndrome with clinical manifestations ranging from:
  • asymptomatic exposure of artery wall
  • acute haemorrhage

Definition

"rupture of extracranial carotid arteries, or its major branches"

one of the most feared complications of head and neck cancer treatment

It's an emergency

Questions

Management

Carotid Blowout Syndrome

Open, honest approach

Decision on advanced directive

  • palliation
  • active resuscitation

Education of patient/family

  • little pain
  • very quick

Ward Care

Active resuscitation

Ensure alway G&S 4 units

Resuscitation:

  • Airway
  • Breathing
  • Circulation
  • large bore cannulas
  • volume replacement

Specific measures

  • compression on bleeding point
  • packing
  • haemostatic material
  • decision on management
  • surgical
  • endovascular

Palliation

Nursed in a single room

Equipment:

  • call bell
  • suction
  • syringes for cuff inflation
  • bowl
  • PPE: gloves/gown/eyes
  • Dark towels
  • IV access at all times
  • Syringes: morphine/midazolam

Decision for comfort care/palliation

stay with patient

call calmly for assistance

apply dark towels around the bleeding

inflate tracheostomy cuff if appropriate

gentle suctioning as required

administer midazolam IV

administer morphine for pain/breathlessness

family assistance

John Wood

ENT Registrar

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