Cardiac Output, Venous Return, and Their Regulation
Complication neck dissection
1. Dr. SANJAY MAHARJAN
1ST YR RESIDENT, ENT-HNS,
MTH, POKHARA.
Complication of neck dissection &
its management.
2. Introduction:
Murphy’s pessimistic law, if anything can go
wrong, it will. Is a reminder that unless attempts are
made to avoid it, complications are likely to occur
Complications following head and neck surgery are
inevitable
An essential component of pre-operative counseling
and obtaining informed consent.
3. Classification:
Major and minor
Early, intermediate and late
Local and systemic
General and specific
20% will have major complications
Mortality rate 1%
4. Immediate local complication:
Bleeding:
Should be detected long before
changes in vitals
Potential sources:
o Suture lines
o Skin flaps
o Major vessels: ECA, Thyrocervical, IJV
May be due to use of small drain (12 Fr
preferred)
5. Management of bleeding:
o Diagnosis of problem
o Resuscitation (wide bore cannula, volume
replacement, bld transfusion)
o Stopping the bleed
o Treating cause
o Re-exploration (to find and ligate)
Delay chance of major vessel exposure, infection
and rupture ↑
Applying pressure dressings or packing bleeding
6. Shock:
D/to massive bld loss & insufficient volume
replacement
Shock index = HR/systolic BP
o Index 1 to 1.5 impending shock
o Index 1.5 or higher danger
Rx:
o Immediate replacement of blood with packed red blood
cell transfusion
7. Airway obstruction:
Edema d/to extensive resection of tissue
Blood, mucus or secretions plugging ET tube
Prevention:
o Elective tracheostomy
o Aphorism; “if a tracheostomy comes in ones mind
then that is the time to do it."
8. Increased intracranial pressure:
↑ 3 fold when 1 IJV is divided
↑ 5 fold when b/l IJV divided
Often returns to normal in 24hrs
Seldom cause symptoms unless Both IJV tied
simultaneously
Signs and symptoms:
o Restlessness & headache
o Slowing of pulse
o ↑ BP
9. Cyanosed lips and ears + pink & warm extremities
suggests ligation of major neck vein (NOT peripheral
caynosis)
Reducing risk of raised ICP:
o Avoiding Dressings around neck
o Restricting neck hyper-extension
o Pt. in sitting position a.s.a.p. after surgery
Mx:
o Pt. kept in sitting position
o 200 ml of 25% mannitol IV and urinary catheter
o Reversed within 10-15mins
10. Carotid sinus
syndrome:
↑ carotid arterial pressure =
↓ pulse and BP
d/to manipulation at
operation
Post operative scarring may
leave sinus in highly
sensitive state
11. Nerve injury:
Nerves that may be
involved
o Facial nerve or its
Mandibular or cervical
division
o Hypoglossal and Lingual
nerves
o Vagus, Symphathetic
trunk, Phrenic nerve or
12.
13. Immediate general complications:
Pneumothorax:
Cervical pleura may be damaged
pt. becomes restless, cyanosed or dyspnoeic after OT
Clinical features:
o Hyper-resonance to percussion
o Hyper-inflation
o Diminished breath sound
o Trachea deviated away (if under tension)
14. Air embolism:
Injury to IJV or subcalvian with dehiscent wall
May occur after removal of neck drain
Prevention:
o Pressure bandage for 1day after drain removal
o Direct digital pressure and trendelenberg position if
accidental opening of large veins before clamping
Produces precipitous fall in BP, cogwheel mumur
Rx:
o Pt. put in left lat position, air withdrawn by syringe via
16. Chylous fistula:
Occurs usu. while operating low on the left side of neck
1-2.5%
Should recognize at surgery
Pt head down and leak exaggerated by modified
valsalva instigated by anesthesist
Dramatic ↑ suction drainage volume after pt is fed
May also occur from jugular lymph duct on R. & its
communicating branches
17. Chyle duct injury may
manifest as:
o Chyloma: subcutaneous
fluid accumulation
o Chyle fistula: persistent
serous or milky secretion,
local tissue inflammation
o Chylous thorax: most
serious
Severe leak leads to
hyponatremia,
18. Small leaks (<400ml/day) : conservative Mx
NPO
Low fat enteral diet
Pressure on supra-clavicular fossa
• Major leaks (>600ml/day) :
Reopen lower part of neck, find injured duct &
oversew with silk
19. Seroma:
pocket of clear serous fluid, composed
of blood plasma and inflammatory fluid
Occur in 1st 48 hrs after removal of drain
In Supracalvicular fossa (most
dependent part)
Fossa must have dip when pt. hunch his
shoulder
Prevented by using suction drainage
Mx:
o Daily wide bore needle aspiration and
20. Skull base syndrome:
Temporary paresis and dysfunction of lower cranial
nerves
Temporary facial paresis, changes in voice or difficult
swallowing
Conservative treatment
21. Infection:
four most important factors
o 1. Contamination of surgical field.
o 2. Contamination of surgical field as operation
involves in-continuity RND and primary excision
o 3. Postoperative hematoma which then becomes
infected.
o 4. Flap necrosis and wound breakdown.
22. Failure of skin healing:
Minor wound breakdown is not uncommon
Prevented by use of
o meticulous surgical technique
o appropriate incisions
o prophylactic ab and
o post-op surgical drain
General factors related are poor nutrition, cachexia,
uncontrolled diabetes, RF and anemia
23. IJV rupture:
Multiple small bleeding episodes, aggravated by
coughing
Mx:
o Surgical exploration and ligation distant from site of
fistula
24. Carotid artery rupture:
d/to culmination of several
complications, i.e.
o Irradiated patient
o Wound break down d/to improper
incision, i.e. With vertical component
and 3 point junction
o Infections Arteries exposed
Gangrene of their walls and
thrombosis of vasa vasorum
Rupture of artery
25. Common sites of rupture:
Carotid bulb at bifurcation
CCA Just inferior to bulb
ICA, beyond bifurcation
26. Prevention:
Protected by m/s graft in irradiated pt.(dermal graft
harvested from thigh or levator scapulae flap)
Saving arteries of vaso vasorum, thyrocervical trunk
Avoiding stripping of adventitia of carotid sheath
27. Mx:
Never occurs unheralded, initial 100-200ml of brisk,
brief, self controlling bleed 24hrs. before rupture
Cuffed tracheostomy tube
4 units blood cross matched
All dead tissue excised and artery covered by frequent
moist soaks
Head down, BP and arterial CO2 tension maintained
Carotid isolated under healthy skin & tissue, and tied
with trans fixation stitch
28. Flap failure:
Flaps need to be checked
for its;
o Color
o Temperature
o Presence or absence of
capillary refill time
o texture
29. Predisposing factor for Necrosis of neck skin flap
Less than 90 angle between incision lines
Pre-operative radiotherapy
Use of monopolar cautery near skin
Constant traction by sutures anchoring skin to drapes
Drying of tissue in absence of regular saline irrigation
30. Fistula:
Causes:
o Previous radiotherapy
o Inadequate control of nutritional status, diabetes and
anemia
o Poor operative technique, like poor suturing
o Untreated seroma, hematoma or abscess
o Post-op anemia, hypoalbuminemia
Occurs when suture line gives a way or when tissue
becomes necrotic
31. Mx:
Fistula on suture line closes spontaneously
Epithelium formation along edges of tract should be
prevented and fistula covered and packed with
dressing
Established fistula, closure must be obtained both
internally & externally and gap filled in between with
vascularized tissue
32. Intermediate general complication:
Basal collapse:
u/l or b/l in 1st 48hrs
Rx:
o Vigorous physiotherapy and appropriate ab
Bronchopneumonia:
Relates to coexistent smoking related lung dzs, associated
tracheostomy and lengthy operations
Rx:
o Physiotherapy and ab
34. Prophylaxis for prevntion:
o Early mobilization
o Graduated compression stockings until fully mobile
o Peri & post-operative SC heparin until mobile
o Perioperative intermittent pneumatic compression
35. Late complications:
Primary recurrence:
m/c within 1st 2 yrs of initial treatment
Parotid gland tail hypertrophy:
Common complication
FNAC provides further reassurance
Swelling at amputated tail of parotid gland after few
weeks of RND
36. Lymphoedma:
When both IJVs are tied
d/to interruption of lymphatic drainage from head
Steps to minimize:
o Forgoing dressings
o Sitting upright
o Steroids
o Mannitol