Haemorrhage, Obstruction, Perforation, and Infection in Head and Neck Cancer

The vessels from which catastrophic haemorrhage occurs in head and neck surgery are the carotids, common and internal. Haemorrhage from these vessels is liable to be fatal not merely as a result of ex-sanguination, but because control of the bleeding by clamp or ligature, the methods likely to be required in the typical emergency situation, affects the cerebral circulation, frequently resulting in hemiplegia with a fatal outcome in a percentage of patients. The risk of haemorrhage is greatest following pharyngeal surgery and two striking aetiological factors are recognised - exposure of the vessels and damage to the vessel wall. The vessels become exposed as a result of wound breakdown or tissue necrosis. Exposure of the healthy carotid is remarkably well tolerated and it rarely if ever ruptures. It is the vessel in the neck which has previously been irradiated which is at risk (Marchetta et al. 1967). Breakdown of the neck wound is more likely and rupture of the exposed vessel becomes then a very real hazard. Exposure is most likely to be followed by rupture when the time lapse between radiotherapy and surgery exceeds 6 months (Briant 1975). Radiotherapy followed by elective surgery does not constitute the problem; it is the uncoordinated use of radiotherapy followed by salvage surgery which accounts for most carotid ruptures (Joseph and Shumrick 1973).