Complications of Surgery of the Neck

Complications of Surgery of the Neck

CHAPTER 36

Wayne M. Koch

Surgery limited to the neck is less risky than more complex head and neck surgical procedures, such as composite resection, in which the upper aerodigestive tract is entered. Although still a major surgical procedure, cervical nodal dissection may seem safe for this reason, and the surgeon may minimize the potential for complications. However, the neck is located in a strategic position, encompassing all of the vital lines of communication and supply between the head and the body. Important functions including speech, deglutition, respiration, and the movement of the head and upper extremities are dependent on the cervical nerves and muscles. The intricate and compact organization of neural, vascular, muscular, and skeletal structures in the neck invoke a sense of awe for the genius and beauty of its design and a wholesome respect for the peril that awaits the unprepared surgeon who ventures therein.

rates combined with dense scarring make the preoperative assessment of viability of residual tumor bulk difficult. Performing a procedure with increased risk of complication only to find no viable tumor on the pathology report is a thorny endeavor. As a result, many clinicians are now challenging the dogma of the planned posttherapy neck dissection. Efforts to determine when a neck dissection is needed using computerized imaging, positron emission tomography scanning, ultrasonography, and fine-needle aspiration (FNA) have been used to try to determine when a residual mass with viable tumor cells is present. The accuracy of these methods to identify residual viable tumor remains limited.1 Performing a neck dissection after chemoradiation is technically challenging, particularly in the area of previous bulky disease that has received a boost of focused radiation therapy. Reports of complications as a result of planned neck dissection after chemoradiotherapy range from 0% to 17%, and chyle leak and wound breakdown are especially common.2–4

It is the surgeon’s responsibility to do all in his or her power to reduce the risk of complications. Preoperative assessment of the patient must be thorough, with the surgeon gathering information about factors that may predispose the patient to complications and allowing for precise planning of the procedure. Contingency plans can then be made for anticipated possibilities. Precise attention to anatomic detail and surgical technique helps the surgeon to avoid intraoperative mishaps and to reduce the risk of postoperative complication. A team of health-care providers with experience in the recognition and management of postoperative head and neck complications must vigilantly monitor the patient after surgery.

PROCEDURES OTHER THAN NECK DISSECTION Minor surgery of the neck may be regarded as less likely to be associated with complications. However, it is deceptive to think that a lesser procedure portends less risk. The exposure of structures is more limited, and so the definite identification of key nerves is actually more difficult. Because occasional neck surgeons may feel that small procedures (e.g., deep cervical node biopsy) are within their range of expertise, a disproportionate number of complications may occur during these procedures. The surgeon must be very familiar with the anatomy and exercise heightened alertness and caution. Nerves that are known to be near a lesion should be positively identified and protected before the excision of the lesion.

The predominant changes in the management of cervical nodal metastases during the past decade have been the result of the following: 1. The increasing frequency of primary chemoradiation for head and neck squamous cell carcinoma, even in cases with bulky nodal disease

This chapter parallels the experience of the surgeon managing a patient undergoing neck dissection. Preoperative planning and preventive considerations are discussed first. Potential pitfalls of the operative procedure are then reviewed. Technical measures designed to avoid later complications are spelled out, and a discussion of postoperative complications follows. As a result of this organization, certain topics (e.g., carotid hemorrhage) are considered at several separate points in the text.

2. Efforts to reduce surgical morbidity with the use of selective dissection Until recently, most organ-preservation protocols contained plans for scheduled postradiation neck dissection for all patients with N2 or N3 disease. In a substantial number of cases, however, there is no viable tumor detected in the resected neck specimen. Improved response 439

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PREOPERATIVE CONSIDERATIONS: PREVENTION OF COMPLICATIONS History A careful history begins any thorough surgical evaluation. The surgeon should inquire about prior surgery and tumor therapy. Previous neck surgery may have an impact on incision design and alerts the surgeon to the potential presence of iatrogenic anatomic alterations. Previous incisional biopsy of a metastatic malignant node dictates the incorporation of the old scar into the specimen to be excised to ensure the complete eradication of tumor. Radiation therapy causes subdermal fibrosis and scar, which makes surgery more difficult. Prior radiation therapy also slows healing, thus heightening the risk of postoperative complication. Current symptoms should be noted, because they may alert the surgeon to the aggressiveness of disease. For example, perineural invasion by metastatic tumor may result in cervical pain or referred otalgia. Handedness should be noted, because nerve injury on the patient’s dominant side may impair upper-extremity function and have a profound impact on the patient’s ability to perform his or her usual occupation and activities. Aspects of the general medical history may raise concerns about wound healing and overall surgical and anesthetic risk. Most head and neck cancer patients have used alcohol and tobacco excessively. These habits are associated with chronic obstructive pulmonary disease, liver dysfunction, and atherosclerosis. Questions should address the systems affected by these processes. Impaired pulmonary function will adversely affect a patient’s ability to tolerate the respiratory insult of phrenic nerve injury, chylothorax, or pneumothorax. A history of cerebrovascular accident or transient ischemic attack should alert the surgeon to the likely presence of atherosclerotic plaques in the carotid arteries. Particular care would then be warranted when working near these vessels.

dysfunction and may impair vascular perfusion, resulting in flap loss. Wound healing and recovery are closely associated with nutritional balance.6 In the severely malnourished patient with head and neck cancer, the delay of surgery for several weeks for nutritional support with nasogastric or gastrostomy tube, or parenteral feedings, is advisable. The history may disclose an underlying swallowing problem that may be further compromised by surgery. Edema of the aerodigestive tract after neck dissection or injury to the superior laryngeal nerve could render a patient with marginal swallowing tube dependent. Preoperative evaluation by a speech–language pathologist trained in swallowing rehabilitation methods is valuable in cases where difficulty with swallowing is anticipated.

Physical Examination Physical characteristics such as neck flexibility, length, and thickness affect the ease of surgical access and may influence plans for the incision and positioning. Careful study of the lesion to be excised is of great importance. Its precise location, size, firmness, and mobility with respect to surrounding structures should be noted (Figures 36-1 and 36-2). Consideration is given to important structures near the mass, and plans must be made for their preservation. Any metastatic node with a dimension of more than 3 cm is most likely a group of matted nodes. Together with decreased mobility of the mass, large size is a harbinger of spread of tumor outside of the capsule of the lymph node, which is a poor prognostic indicator.7 Magnetic resonance imaging (MRI) can also discern extracapsular spread.8 Efforts to search for distant metastatic disease in these patients should be greater and should include imaging studies of the lungs and liver. Reduced mobility of the mass may be caused by the extension of disease into the sternocleidomastoid muscle (SCM), the jugular vein, the skin, or another nearby structure.

Previous thyroid or laryngeal surgery with neck irradiation may be associated with hypothyroidism,5 and appropriate thyroid function studies should be obtained. Untreated hypothyroidism may cause delayed wound healing and postpone the return to normal activities postoperatively. Diabetes mellitus is similarly associated with impaired wound healing. Peripheral neuropathy as a result of diabetes may contribute to suboptimal results after nerve injury and repair. Patients should be encouraged to cease smoking as long before surgery as possible. Continued tobacco use during the perioperative period exacerbates pulmonary

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Figure 36-1. Measuring a lesion.

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to assess tumor vascularity, the relationship of tumor to the great vessels, and vessel patency. CT scans are able to detect cortical bone and cartilage erosion, which are important concerns when a mass approaches the base of the skull, the vertebral bodies, the laryngeal skeleton, the hyoid, or the mandible. The radiographic detection of suspicious nodes may provide the impetus for more extensive dissection than would otherwise be contemplated. Nodes that are more than 1.5 cm in diameter and that demonstrate the radiographic features of central necrosis and peripheral contrast enhancement have a high likelihood of containing metastatic tumor.10 On the basis of radiologic studies, a comprehensive ipsilateral dissection or even bilateral surgery may be indicated rather than regional nodal dissection.

Figure 36-2. Proper hand positioning for neck node palpation.

Fixation of the mass is indicative of extension into deeper structures such as the carotid artery, the skeletal structures, or the deep cervical musculature. Carotid invasion typically causes the fixation of superoinferior but not anteroposterior movement. Fixation does not mean that the carotid wall is definitely invaded, but it should raise concern and cause the surgeon to plan for that possibility. Computed tomography (CT) scanning and arteriography may or may not help to confirm such involvement when it is suspected. Inspection of the neck skin is useful. The location of surgical scars must be noted to plan incisions. The extent of ports used in radiation therapy can sometimes be discerned by observing the area of beard loss in males. Fixation of a neck mass to the skin indicates the extension of tumor into the dermis. The affected skin must be excised, and plans for flap coverage must be considered. Of course, the physical examination must include a full head and neck evaluation to assess the primary tumor and the upper airway before general anesthesia is administered. These considerations are beyond the scope of this chapter.

Radiographic Evaluation Computer-assisted imaging methods (i.e., CT, MRI, PET) are useful for the preoperative evaluation of the neck. These modalities are used for the assessment of the extent of palpable disease and the detection of clinically inapparent nodes.9 Intravenous contrast (diatrizoate meglumine and diatrizoate sodium [Hypaque] and gadolinium for CT and MRI, respectively) helps to distinguish tumor from vessels. Contrast is also useful

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When a suspicious node is detected by one of these imaging modalities but is not clinically palpable, CT scanning or ultrasound may be used to guide FNA biopsy. Radiologic guidance of FNA can also help avoid trauma to the great vessels when a node is intimately associated with them. The use of ultrasound guidance to sample the sentinel node identified by lymphoscintigraphy has recently been described as a method to gauge the need for neck dissection.11

Evaluation Before Carotid Resection If the physical examination or radiographic studies indicate possible carotid artery invasion by tumor, the surgeon may consider the option of carotid resection. Tumor invasion of deep structures is associated with a very poor prognosis. Atkinson and colleagues12 performed carotid resection on 12 patients with head and neck cancer, 7 (58%) of whom died or had recurrent disease within 1 year. Of those who were free of disease at the time of writing, most had been followed for less than 2 years. Fee and colleagues13 reported a mean survival of 15 months in a group of 29 patients with large masses attached to the carotid. These patients were treated with the debulking of tumor and radioactive seed implantation. Distant metastases were subsequently discovered in 45% of these patients, whereas 38% had recurrence in the neck. Kennedy and Krause14 presented a retrospective series of 28 patients with similar outcomes but with an even higher incidence of distant metastasis (67%). They concluded that the five patients who developed recurrent neck disease without distant spread may have benefited from a more aggressive surgical approach to the neck. In the light of the very limited survival despite aggressive therapy in this situation, the therapeutic goal may appropriately be considered to be effective palliation. If the tumor has already failed to respond to radiation, chemotherapy, or both, surgical resection is the only

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remaining therapeutic option. Surgical debulking of the mass may prevent further erosion into the carotid with hemorrhage or skin breakdown with bleeding, pain, and infection. Carotid resection is also controversial because of a risk of perioperative neurologic sequelae and death. During the first half of this century, carotid ligation carried with it a 45% risk of cerebral complication and a 30% chance of death as reported by Moore and Baker15 when reviewing a series of 88 patients. A more recent but much smaller series (N ⫽ 18) attested to the value of preoperative planning for the resection of the vessel. When carotid resection was done emergently as a result of acute hemorrhage, 7 of 11 patients (64%) died within 2 weeks of surgery. Patients undergoing elective resection fared much better, with 6 of 7 (86%) surviving the perioperative period.16 Within the past decade, Atkinson and colleagues12 reported only one perioperative death and two central nervous system (CNS) injuries in a series of 12 cancer patients undergoing elective carotid resection, owing in part to careful preoperative evaluation and case selection. CT or MRI scanning and arteriography may detect carotid encasement by tumor, but they are rarely accurate predictors of the invasion of the vessel wall. Thus arterial wall invasion may only be confirmed at surgery. When carotid involvement is suspected by physical examination and radiographic studies, further preoperative evaluation of the cerebral blood supply is indicated to decide what will be done if invasion is present. The adequacy of collateral cerebral circulation must be assessed to determine the risk of carotid ligation. In 1980, Enzmann and colleagues17 described a method using angiography with temporary balloon occlusion and the measurement of carotid back pressure. Clinical or electroencephalographic evaluation of CNS function is performed during occlusion. A later modification of the temporary balloon-occlusion test with the measurement of cerebral blood flow using stable xenon-enhanced CT was described by DeVries and colleagues.18 The method involves four-vessel angiography with pressure monitoring in the distal internal carotid artery (ICA). Occlusion of the ICA for 15 minutes is performed with continuous electroencephalographic or clinical monitoring of the patient. After this period of occlusion, the patient breathes a mixture of air and xenon while in position for a cerebral CT scan. Scans are performed first with the balloon inflated and again 20 minutes after the restoration of normal blood flow. Cerebral blood-flow measurements are determined by subtracting the values obtained during occlusion from those measured with unimpeded flow to determine the adequacy of collateral circulation. This approach attempts to identify patients who are at

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high and low risk for complications after carotid resection. Of 136 patients studied with this technique, 11 were determined to be at very high risk for stroke if the ICA was ligated, whereas 96 were predicted to have minimal risk. None of the high-risk patients underwent carotid ligation. Temporary occlusion intraoperatively in high-risk patients caused neurologic sequelae on the two occasions when it was performed. Twenty-one of the lowrisk patients had ligation or permanent balloon occlusion of the ICA with no CNS change. Patients who tolerated only short periods of occlusion of the ICA were considered to require bypass grafting at the time of carotid resection (described later in this chapter). Other studies demonstrate that balloon-occlusion test results are less-than-perfect predictors of neurologic risk.19 High-risk patients may be managed conservatively with chemotherapy and radiation or with surgical debulking, peeling tumor from the carotid, and radioactive seed implantation. Even the latter is risky in this group, because the carotid may be weakened by tumor and thus result in rupture. Among patients with marked atherosclerotic narrowing of the contralateral carotid, endarterectomy may improve cerebral blood flow, thus permitting the subsequent resection of the artery that has been invaded by tumor. Recent series of carotid resection and ligation or occlusion testing demonstrate no substantial advances as compared with decades-old studies. A risk of stroke of nearly 25% and a median survival of 12 months remain the rule when the carotid artery involved with tumor is addressed surgically. Occasional long-term survival is achieved.20–22

Fine-Needle Aspiration Biopsy When a patient presents with a neck mass without an obvious cause, the surgeon is faced with a diagnostic dilemma. A careful history and physical examination should raise suspicion of neoplasm in certain patients. To verify these suspicions, it may be necessary to obtain a specimen from the neck mass for histologic study. In 1930, Martin and Ellis23 drew attention to the danger of tumor spillage and seeding at the time of the open biopsy of neck masses. Since that time, FNA with cytopathologic evaluation has become the method of choice for initial attempts to obtain a diagnostic specimen from a neck mass. In addition to the workup of neck masses of uncertain cause, FNA may be useful for judging the need for neck dissection when physical examination or radiographic study identifies small nodes in patients with a known primary malignancy. The risk associated with FNA is low. Most series simply report no complications, but bleeding is the principal

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COMPLICATIONS OF SURGERY OF THE NECK concern. The recommended needle gauge (i.e., 22–25) is small, and bleeding is easily controlled with firm pressure (Figure 36-3). When the neck mass lies in close proximity to the great vessels or has physical characteristics that are suggestive of a vascular lesion, however, the surgeon should give careful thought before proceeding with FNA. The presence of a bruit should alert the clinician to the possible diagnosis of paraganglioma, whereas a soft, compressible mass may be a hemangioma or a lymphangioma. Radiographic analysis including CT scanning or MRI with intravenous contrast or selective angiography is useful to confirm the vascular nature of a mass and to further characterize its extent, growth pattern, and vessel of origin. The radiographic evaluation may make the diagnosis obvious and thus preclude the need for FNA. FNA of carotid body tumors is controversial. Engzell and colleagues24 have reported a death as a result of carotid thrombus and cerebral embolism after FNA of a carotid body tumor. Others report no problems after the FNA of paragangliomas.25 Still, the advice of Engzell and colleagues to reserve FNA for patients in whom the workup is not conclusive is wise. Nerve injury has not been reported after FNA in the head and neck. If FNA is performed in the immediate path of a nerve, an in-and-out movement along a single needle trajectory should be used rather than changing angles between passes. Reports of tumor seeding along the FNA track have occasionally appeared for malignancies in sites outside of the head and neck.26 Considering the vast number of neck FNA procedures performed without tumor spread, seeding is only a hypothetical consideration. It has been recommended that the needle gauge be limited to 22 or smaller and that the number of passes through normal parenchyma be kept to a minimum.27 Others advocate the excision of the aspiration tract at the time of definitive surgery.28 The latter would seem to be unnecessary given the preponderance of experience in the literature indicating the

Figure 36-3. Fine-needle aspiration.

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safety of using FNA. Batsakis and colleagues29 have raised concern regarding the effect of FNA on the ability to render an accurate tissue diagnosis of salivarygland tumors that have been studied by FNA and that later undergo resection. These adverse effects of FNA are unusual in the authors’ experience.

OPERATIVE TECHNIQUE: INTRAOPERATIVE COMPLICATIONS Preparation for Surgery The surgeon should prepare to execute a carefully constructed plan that has been designed to minimize the need for last-minute intraoperative changes. Thought must be given to patient positioning to optimize surgical exposure. Plans for intraoperative monitoring are discussed beforehand with the anesthesiologist to determine line placement and airway management. Central venous pressure (CVP) catheters should not be placed on the ipsilateral side, if possible. Even longline CVP catheters placed in the antecubital vein may enter the internal jugular (IJ) vein, thus risking surgical encounter (this is described later in this chapter). The surgeon should discuss intraoperative fluid management with the anesthesiologist before beginning the case. The injudicious replacement of fluids greatly increases postoperative edema and adds to the risk of the syndrome of inappropriate antidiuretic hormone (SIADH; also described later in this chapter). Communication between the surgeon and the anesthesiologist should be maintained throughout the case with regard to anticipated blood loss and the need for blood replacement. Careful attention to detail with regard to preparation of the skin, draping, and maintaining sterility throughout the procedure should make postoperative wound infection extremely uncommon. The value of prophylactic antibiotics for neck surgery that does not involve entry into the upper aerodigestive tract is limited. In a retrospective study of 192 patients undergoing uncontaminated neck dissection, Carrau and colleagues30 were unable to show a statistically significant impact of the use of prophylactic antibiotics for reducing the incidence of postoperative wound infection. There were 10 patients in a group of 99 (10%) that did not receive antibiotics who developed a wound infection. Of the 93 patients who did receive antibiotics, there were only 3 cases (3.3%) of wound infection. The failure of these results to reach statistical significance may be the result of the low overall incidence of infection and the relatively small number of patients studied. The use of prophylactic antibiotics (particularly a single agent or a first-generation cephalosporin) involves a low risk of complication. The benefits of prophylactic antibiotics may therefore outweigh the risks.

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Current demand for evidence-based medicine is driving a reexamination of this issue. The use of prophylactic antibiotics for surgical cases is the only criteria pertinent to surgeons included in the initial “pay-for-performance” list endorsed by the Centers for Medicare and Medicaid Services. There have been no prospective randomized trials providing level II evidence of the effectiveness of prophylactic antibiotics. Existing evidence does support limiting the use of antibiotics to the immediate perioperative period only, thus reducing the risk of selection of resistant microorganisms. Slattery and colleagues31 demonstrated in a retrospective analysis of 120 patients that 24 hours of antibiotic coverage was equally effective to longer courses. Plans should be made for all potentially important contingencies. For example, when tumor resection may necessitate carotid ligation in patients without adequate collateral circulation, arrangements must be made for vascular bypass grafting, including the availability of a vascular surgeon. If radioactive implants may be needed as a result of possible sites of unresectable invasion into deep structures, consultation with a radiation oncologist must be obtained. Vein, nerve, and skin graft or flap sites are prepared and draped if the use of such grafts is contemplated. The neck is prepared and draped so that the mastoid tip, the clavicles, and the anterior border of the trapezius are exposed at the boundaries of the dissection.

Incision The design of the incision for neck dissection has definite cosmetic and safety ramifications. Flap necrosis with tissue loss as a result of poorly designed incisions may result in wound infection, fistula, or vessel exposure and hemorrhage (Figure 36-4). Insofar as is possible, incisions should be placed in skin creases or along lines of relaxed skin tension. When a portion of an incision must violate this rule, cosmesis is enhanced by using a curved line to

prevent linear scar contracture (Figure 36-5). Scars from previous neck surgery must be taken into account when designing the incision. When an incisional biopsy of a malignant mass has been performed before neck dissection, the scar and tract should be excised with the dissected specimen. Scars from other types of procedures may be incorporated into the incision or crossed at right angles by the new incision. Skin that is fixed to tumor should be encompassed and removed with the specimen. Inadequate surgical exposure, which is a potential contributor to a host of complications, is avoided when incisions are well conceived. A long, gently curving “hockeystick” or L-shaped incision provides good exposure and excellent cosmesis in many cases (Figure 36-6, A). The horizontal portion extends anteriorly, crossing the midline to the contralateral SCM at a height of 3 cm to 5 cm above the clavicle. Exposure of the posterior triangle may be inadequate with this approach when the neck is thick, thereby necessitating a vertical limb extension. When the oral cavity or the submental region must be reached, the horizontal portion of the incision must be placed more superiorly; however, it is best kept at least two fingerbreadths below the mandibular body to avoid injury to the marginal mandibular branch of the facial nerve. Parallel horizontal (i.e., MacFee) incisions (Figure 36-6, B) are the choice of some surgeons because of superior cosmetic results. Adequate exposure can be attained with this approach, but the discontinuous view of the operative field makes it a less-than-optimal choice for the inexperienced surgeon. Alternatively, a vertical limb may be extended from a curvilinear submandibular incision (Figure 36-6, C). With a complex incision with trifurcation, the limb should be begun at right angles to the main incision to avoid compromising the vascular supply to the corners of the flaps. The trifurcation should be placed where the external jugular vein crosses the posterior border of the SCM rather than over the carotid artery. This position reduces the risk of vessel exposure should flap necrosis occur at the trifurcation. The vertical limb

Figure 36-4. Flap loss.

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Figure 36-5. Poor cosmetic results with scar hypertrophy and webbing as a result of the linear design of the perpendicular limb of the neck incision.

Elevation of Skin Flaps

A

C

B

D

Figure 36-6. Recommended incisions for neck dissection. A, “Hockey-stick” curvilinear incision. B, MacFee incision. C, Modified Schobinger incision. D, Large apron flap for bilateral neck dissection.

may form a hypertrophic scar as it crosses the concave area in the neck contour at the level of the hyoid bone. For this reason, the vertical limb describes a broad, gentle S curve to lengthen it and break up the straight line. When bilateral neck dissections are required, a large, superiorly based apron flap is a good option (Figure 36-6, D). Lengthy, complex incisions are marked with superficial crosshatch scratches or methylene blue tattoos to facilitate accurate apposition at closure. Injection along the planned incision with a vasoconstrictor such as 1:100,000 epinephrine solution reduces skin bleeding at the time of incision. To be effective, injection should be performed at least 7 to 10 minutes before the incision.

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Sensory Branches of the Cervical Plexus As the skin flaps are elevated in a subplatysmal plane, several branches of the cervical plexus are immediately encountered overlying the SCM. The division of the branches of the cervical plexus will result in a sensory deficit that extends from the pinna to the chest wall below the clavicle. Most of this sensory deficit will spontaneously resolve postoperatively over a period of months. The earlobe is one area that often remains permanently insensate. In addition, the cut nerve endings may become trigger points for postoperative pain as a result of disordered neuronal repair, scar entrapment, and neuroma formation.32 For these reasons, some have advocated the preservation of the cervical plexus in functional neck dissection.33 This adds to the complexity of the surgical dissection, particularly in the region where the nerves cross the SCM at the Erb point. It may be unwise to preserve the cutaneous branches of the cervical plexus in the setting of bulky pathologic nodes. An oncologically sound resection of the tumor is the first priority. The greater auricular nerve serves as an excellent landmark for the proper plane for elevation of the superior skin flap, because it lies lateral to the SCM. The nerve should be kept down on the SCM during flap elevation, and the decision of whether to preserve it can be made later. The preservation of the supraclavicular nerves requires dissection through the posterior triangle fat pad. Care must be exercised here, because these nerves may be confused with the spinal accessory nerve. Preservation of the great auricular nerve improves quality of life in that the earlobe receives no other sensory input, and permanent hypoesthesia here has esthetic as well as practical detrimental effects. Other branches also may be preserved, thereby reducing hypoesthesia

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from the superior chest wall to the mandible. The preservation of these branches makes the dissection of the posterior and inferior regions much more tedious. If the surgeon is unfamiliar with techniques of watching both beneath and behind the SCM, this could result in inadvertent injury to cranial nerve XI or incomplete clearance of nodal bearing tissue. In one study, the quality of life was judged to be significantly better in terms of reduced neck and shoulder pain in a group of patients in whom the cervical sensory nerves were preserved.34 If a tracheotomy is performed as a part of the procedure, however, care should be taken to avoid the connection of the elevated skin flap with the tracheotomy dissection. If such a connection occurs inadvertently, it should be closed by suturing the subcutaneous tissue of the flap to strap muscles before wound closure to avoid air leakage from the tracheotomy site to the surgical drains. Such an air leak may otherwise contribute to the risk of postoperative wound infection.

Marginal Mandibular Branch of the Facial Nerve As the superior neck flap is elevated, attention should be turned to preserving the marginal mandibular (MM) branch of the facial nerve. Injury to this nerve causes an obvious cosmetic deformity with asymmetry of the motion of the corner of the mouth (Figure 36-7). It may also contribute to drooling and difficulty with swallowing because of an inability to maintain labial closure during the oral preparatory phase. In thin patients, the MM may be easily identified, cascading from the parotid fascia over the fibrovascular tissue that connects the submandibular gland to the mandibular body (Figure 36-8). If it is not immediately visible, the nerve may be located by careful dissection. Although the nerve can usually be identified by its anatomic location, it is advisable to withhold muscle relaxants until both the MM and the spinal accessory nerves have been identified. The use of a nerve stimulator should be kept to a minimum with the power at the

Figure 36-7. Marginal nerve weakness.

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Figure 36-8. Cervical branch in fascia.

lowest (i.e., 0.5 mAmp) setting, because the repeated stimulation of the nerve can result in neurapraxia. The cervical branch of the facial nerve is located more inferiorly on the submandibular gland fascia. It may have arborizations reconnecting with the MM branch. In addition, the cervical branch innervation of the platysma contributes to the downward motion of the lip. The cervical branch may be confused with the MM branch. When both branches have been identified, it may be necessary to sacrifice the cervical branch; this may be done without permanent functional deficit. Note that, since the platysma muscle contributes to the downward movement of the lower lip, any anterolateral incision going through platysma will cause some degree of lip motion impairment. The approach to the preservation of this nerve varies depending on the presence or suspicion of pathologic lymph nodes along the external facial vein. When such nodes are likely, the nerve should be preserved by identifying it as it passes over the vein and carefully dissecting it free of the surrounding tissue that is to be included in the surgical specimen. If the nerve must be mobilized to preserve it, the technique used in dissection should avoid injury to the nerve by direct contact with instruments or lifting and stretching the nerve as much as possible. The mobilized nerve then can be protected during further dissection by the fixation of perineural tissue to the elevated superior skin flap. When concern about the presence of pathologic facial lymph nodes is low, the MM branch of the facial nerve can be preserved by incising the fascia of the submandibular gland low on the gland and elevating this fascia with the superior neck flap (Figure 36-9). The external facial vein is also ligated inferiorly as it emerges from the fatty tissue in the submandibular triangle, and the superior stump of the vein is retracted with the skin flap. The MM branch is thus rolled up with the elevated skin and kept away from further surgical dissection. If the MM branch is inadvertently cut during dissection,

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Figure 36-9. Submandibular fascia elevation.

immediate neurorrhaphy should be performed. This can be done with magnification using 8-0 to 10-0 monofilament nylon suture placed in the epineurium.

Lingual Nerve The lingual branch of the trigeminal nerve (cranial nerve VIII) is located under the deep cervical fascia beneath the submandibular gland. Level I neck dissection incorporating submandibular gland excision puts this nerve at risk for injury. The lingual and hypoglossal nerves should be visualized beneath the gland before sharp dissection in this region. The anterior retraction of the mylohyoid muscle facilitates the needed exposure. The lingual nerve traces a downward loop as it gives off its branch to the submandibular ganglion. The main body of the nerve must be appreciated before the dissection and division of the branch to the ganglion. Control of the nerve branch and its accompanying vessels before dividing this structure prevents the need to cauterize near the main trunk of the nerve. Failure to protect the lingual nerve leads to annoying hypoesthesia or paresthesias of the hemitongue with resultant difficulty with speech and deglutition. Spinal Accessory Nerve Pain and weakness of the shoulder are among the most common postoperative complications of neck dissection. Sacrifice of or damage to the spinal accessory nerve (cranial nerve XI) is a major contributing factor to complaints related to the shoulder. Many surgeons routinely modify the standard radical neck dissection by isolating and preserving this nerve in an effort to prevent shoulder dysfunction. Alternatively, the posterior triangle may be left untouched in a selective or regional neck dissection (e.g., supraomohyoid dissection).35 The primary concern of the surgeon caring for a cancer patient must be the complete extirpation of malignancy. A growing number of reports in the literature advocate the routine use of selective anterior neck dissection because of the rarity of posterior triangle nodal involvement by metastatic disease.36–38

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Schuller and colleagues39 point out that cranial nerve XI is much more likely to be close to pathologic nodes along its course in the upper jugular region (i.e., level II) than in the posterior triangle. Of 50 neck specimens from patients with a variety of primary sites, 21 had nodes along this nerve, and 19 of these (90.5%) had involvement only in the superior portion of the nerve’s path. With this in mind, Eisele and colleagues40 advocate the examination of the anterosuperior portion of cranial nerve XI early during the procedure. They dissect under the anterior edge of the SCM to identify the nerve overlying the jugular vein high in the neck, inspecting for suspicious nodes. If nodal disease is encountered intimately related to the nerve, cranial nerve XI preservation is abandoned, thereby saving further time and effort. In the authors’ experience, however, cranial nerve XI can be preserved in many cases, even when it is surrounded by suspicious nodes. Often an escape route between nodes can be identified, sometimes posterior and deep to the nerve, where blunt dissection can free the nerve without directly violating nodal tissue. No careful prospective randomized study of survival or recurrence exists comparing the results of nervesparing and radical neck dissection. Retrospective series that report the outcomes of nerve-sparing procedures as being equal to or better than radical surgery are subject to criticism about bias introduced by the criteria used to select one type of surgery rather than another. These reports at least serve to demonstrate that sparing cranial nerve XI can be accomplished without greatly compromising the oncologic result, even in the face of clinically involved nodes.41–43 Whether the preservation of cranial nerve XI substantially improves shoulder function continues to be debated. The degree of trauma to the nerve likely depends on how much of its length is exposed (i.e., proximal, intra, and distal to SCM) and how it is handled. Wide variabilities in outcome from both radical and nervesparing surgeries are reported in studies that cite subjective assessment of pain and functionality by patients. Questionnaires used by several investigators failed to demonstrate a statistically significant benefit of nervesparing surgery.44,45 Indeed, in one study, 40% of radical neck dissection patients reported no significant postoperative shoulder pain or dysfunction.46 Other reports indicate a higher incidence of shoulder complaints among patients who have undergone radical surgery.47 It is likely the case that, the more carefully one investigates shoulder dysfunction, the more evidence one finds. Muscle strength testing and electromyography consistently show a greater level of function among patients in whom cranial nerve XI has been spared.44,45,48,49 The contribution of the cervical plexus to trapezius innervation has been invoked as a factor in the variability of shoulder function after the sacrifice of cranial nerve XI

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and as a rationale for sparing these fibers during neck dissection (Figure 36-10). Weitz and colleagues50 claim good shoulder function results among 12 patients in whom the C2 through C4 roots were spared and proximal cranial nerve XI was cut as it entered the SCM. They do not state how shoulder function was assessed, however. Alternatively, when cranial nerve XI is left intact, the sacrifice of the cervical contribution does not seem to have a significant negative impact on shoulder function, according to Soo and colleagues.51 Their electromyography findings, however, serve as evidence for minor motor input from the cervical plexus to cranial nerve XI, especially going to the lower two thirds of the trapezius. This is in contrast with Weisberger’s52 conclusions from a study of the stimulation of the ventral rami of the cervical spinal nerves in cats and humans. He states that there is rarely any evidence of motor input from the cervical plexus. According to Weisberger, motor potentials recorded in the trapezius instead are caused by the spread of current to contiguous tissues. Still, the temporary but significant shoulder dysfunction noted by Remmler and colleagues49 may be caused in part by the sacrifice of the cervical roots as well as by the neurapraxia caused by the surgical stretching and irritation of cranial nerve XI. Not surprisingly, patients

Figure 36-10. Contribution of the cervical plexus to the spinal accessory nerve (arrow). The presence of motor-nerve contributions to the spinal accessory nerve is controversial.

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undergoing supraomohyoid dissection have shoulder function that is superior to those who have had a full dissection sparing cranial nerve XI, probably because of the complete lack of surgical manipulation of the posterior triangle in the selective procedure.45 If the decision has been made to preserve the spinal accessory nerve, then the surgeon must identify it carefully in each region along its course. In some individuals, the nerve is very superficial in the posterior triangle, and it can be inadvertently injured during flap elevation. The platysma, which is a reliable landmark for depth of flap elevation in the anterior neck, splays out and eventually ends in the posterior triangle. Experienced surgeons note a virtual plane extrapolated from the level of the platysma posteriorly in which no substantial vessels are encountered. Care must be taken to not perforate the skin during this portion of flap elevation. Considerable individual variation exists with regard to the amount of fibrofatty tissue surrounding the nerve, thus adding to the difficulty of finding and preserving it. The spinal accessory nerve follows a reasonably constant path through the posterior triangle. It extends from a point one fingerbreadth (i.e., 2 cm) above the Erb point (where the cervical plexus branches cross the posterior border of the SCM) and courses inferiorly and posteriorly, disappearing under the trapezius muscle at a point approximately two fingerbreadths above the clavicle. Occasionally there may be difficulty distinguishing cranial nerve XI from the supraclavicular sensory branches of the cervical plexus. Tracing the candidate nerve superiorly under the SCM and toward the jugular vein confirms its identity as the spinal accessory nerve. If necessary, a single low-amperage impulse by a nerve stimulator can be used to confirm the identity of the nerve, but this type of stimulation should be kept to a minimum. As dissection continues superiorly, the surgeon must be aware that the nerve can course through the body of the SCM or merely send branches to that muscle as it passes beneath it. The location of the nerve as it courses away from the muscle adjacent to the internal jugular vein toward the jugular foramen should be confirmed before further dissection in the superior jugular region (Figure 36-11). Once again, gentle handling of the nerve to avoid stretching and repeated stimulation by the instrumentation is important to minimize postsurgical neurapraxia. When cranial nerve XI is injured or must be sacrificed because of tumor along its course, some authors have reported good success with cable grafting of the nerve from the skull base to the distal stump.47,53 Objective postoperative assessment of shoulder function after cable grafting has demonstrated a level of function that is intermediate between that seen with sacrifice or preservation of the nerve.53

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and desirability of permanent cord medialization can be discussed with the patient later.57 If the possible need to sacrifice the vagus nerve has been anticipated (e.g., schwannoma or paraganglioma of the vagus nerve in the parapharyngeal space), vocal-cord augmentation may be included in the operative consent. If not, vocal-cord injection can easily be done postoperatively, after the situation has been explained to the patient.

Figure 36-11. Cranial nerve XI’s superior course.

Dissection of the Inferior Neck Vagus Nerve Whether the surgeon plans to sacrifice or preserve the IJ vein, it is necessary to first identify all of the structures in the carotid sheath. Inadvertent injury to the vagus nerve may occur during the process of ligating the vein. Particularly treacherous is the large IJ vein. One may see cranial nerve X on one side of the IJ vein and then include it in isolated tissue destined for clamping while working from the other side. The surgeon and his or her assistant must make a positive identification of the nerve from both anterior and posterior approaches before setting the clamps or ties. Injury to the vagus nerve at this location will result in ipsilateral laryngeal and pharyngeal paralysis and a loss of sensation in the larynx at the level of the true vocal cord and below. A breathy voice, an inefficient cough, and a subjective sense of dyspnea result. Dysphagia may also occur as a result of inefficient pharyngeal peristalsis together with a tendency for laryngeal penetration during swallowing, especially of thin liquids. The loss of more distal vagal innervation has little clinical effect. Immediate neurorrhaphy of the transected vagus nerve is generally not considered to be useful. Experimental evidence from canine studies indicates good recovery of the neuronal count and of the diameter of recurrent laryngeal nerves repaired immediately after transection. However, neither abduction nor adduction of the vocal cords was restored in these animals.54 Still, immediate neurorrhaphy may allow for the preservation of some muscle tone with the prevention of atrophy despite misdirected reinnervation and synkinesis.55 Techniques such as nerve-muscle pedicle grafting56 remain controversial and are not recommended for use at the time of intraoperative vagal injury. Consideration may be given to immediate intraoperative vocal-cord augmentation. Micronized AlloDerm (Cymetra) injection provides temporary vocal-cord medialization that lasts for more than 12 months. The need

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Venous Injury The IJ vein often has small, thin-walled branches, and rough dissection can result in hemorrhage with significant blood loss and the obfuscation of important structures. Dissection around the vein should be performed with a blunt clamp making spreading motions perpendicular to the wall of the vein to avoid injury to these branches. Alternatively, sharp-knife dissection and feathering over the edge of the vein exposes the branches. Injury to the venous system low in the neck may also occur because of an unusually high position of the subclavian vein. When hemorrhage from the inferior IJ or the subclavian vein cannot be controlled from the cervical exposure, it may be necessary to resect the head of the clavicle to obtain exposure and control of the injured vessel. The necessary bone instruments for this emergency must be available during every neck dissection. If the subclavian vein is crossclamped and ligated, swelling of the upper extremity will complicate the postoperative course. Any uncontrolled rent in a vein located above the level of the heart carries a risk for venous air embolism. Air embolism is a potentially fatal (albeit uncommon) occurrence. It must be suspected whenever cardiovascular collapse occurs during neck dissection, especially when it is temporally related to dissection near the internal or external jugular, subclavian, and transverse cervical veins. After air enters the vein, it travels to the heart and mixes with blood to form foam that is compressed during systole and that expands during diastole. This prevents adequate output from the right ventricle. The anesthesiologist will hear a loud churning sound on auscultation that is caused by the heart beating against the air–blood mixture as the pulmonary arterial pressure rises. Right heart failure ensues with increased CVP. Decreased filling pressure for the left heart results in systemic circulatory collapse with diminished cardiac output, cyanosis, arrhythmias, and tachycardia.58 When massive venous air embolism is suspected, the patient must immediately be placed in a left lateral decubitus position with the head tilted down (i.e., Trendelenburg). This causes the air bubbles to shift away from the outflow tract of the right ventricle, thereby allowing for the resumption of adequate cardiac output. Cardiac resuscitative measures including closed-heart massage, vasopressors, and 100% oxygen ventilation under positive pressure are continued until circulation is restored.

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Nitrous oxide should be discontinued, because it increases the size of air bubbles within the circulatory system. Positive-pressure ventilation is used, because the gradients that cause air-bubble entry into the venous system are increased by the fall in thoracic pressure that occurs with active inspiration. Resuscitation may be successful without the aspiration of air from the right ventricle in most cases.59 If cardiac collapse persists, however, aspiration of the air may be required. This may be possible via the CVP line if there is one present, and it can be passed into the right ventricle. If not, percutaneous needle aspiration can be performed.60 Ericsson and colleages59 reported 68 fatalities (73%) in 93 cases of venous air embolism. Six of these occurred during head and neck operations.61 In one case report,62 as little as 100 ml of air was shown to be lethal. Smaller air emboli may proceed to the small pulmonary arterioles and capillaries. Here microthrombi form as a result of platelet activation at the bubble–blood interface. Subsequently inflammatory vasoactive mediators are released, resulting in pulmonary vasoconstriction, increased lung flow resistance, decreased compliance, and areas of ventilation– perfusion mismatch. Air may also pass to the left heart either through a probe-patent foramen ovale in the septum or through the pulmonary microcirculation. Gas bubbles then proceed to the cerebral circulation, where they can cause cerebral ischemia and edema with neurologic sequelae. These neurologic problems may appear postoperatively with a progressive decline in the level of consciousness. If this occurs, hyperbaric oxygen therapy should be administered immediately.63 Venous air embolism may be prevented by avoiding operative positioning with the head elevated and by the careful dissection and ligation of veins during neck surgery. The negative pressure within the venous system that predisposes a patient to air embolus increases when the patient is positioned with the head elevated. If vascular control is lost, the vein should be immediately digitally compressed below the site of injury while repair or ligation is accomplished. The surgical and anesthesia team must be alert to the possibility and signs of air embolism and prepared to take the emergency measures previously outlined. When the IJ vein is ligated, a misdirected longline CVP catheter may be found within the vein’s lumen (Figure 36-12). Although the antecubital vein site is an easy, safe route of CVP insertion that is out of the field of neck dissection, proper threading of the catheter into the superior vena cava is difficult from this position. The incidence of placement of the CVP tip into the IJ vein is about 15%.64 If the misplacement is not detected and corrected when the vein is ligated, it can result in catheter-tip embolism, thrombophlebitis, and septicemia. When positioning or constraints on venous access dictate that the ipsilateral antecubital or femoral vein be used for CVP placement, the

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Figure 36-12. A central venous pressure line visible within the internal jugular vein at the time of neck dissection.

surgeon should palpate the IJ vein before cross-clamping. If the catheter is malpositioned, it can be withdrawn and rethreaded by the anesthesiologist. If the catheter is inadvertently divided with the vein, it is important to retrieve the distal tip. Usually this is possible by allowing for the free flow of blood for a few seconds or by grasping the catheter with a clamp to remove or secure it until the distal vein is ligated.

Posterior Triangle Floor When the posterior triangle is to be dissected, the floor of the triangle must be identified inferiorly. The phrenic nerve and brachial plexus are located beneath the deep cervical fascia. The transverse cervical artery and vein course through the posterior triangle parallel to the clavicle. In a functional neck dissection, these vessels may be isolated and preserved. This allows for their potential use as recipient vessels for vascularized free-tissue transfer or for an inferior trapezius flap at some time in the future. The apex of the pleura may be encountered in the root of the neck. It is located deep to the deep cervical fascia and need not be exposed. If it is violated, pneumothorax may result. An abrupt change in oxygenation and a lack of breath sounds on auscultation should alert the anesthesiologist to this problem. An intraoperative chest radiograph may confirm the need for a chest tube. Repair of the pleural rent is also required.

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Lymphatic Ducts The cervical lymphatic ducts and, on the left side, the thoracic duct are located inferomedially in the neck. As with many complications, the best way to manage a lymphatic leak is to prevent it from occurring. The intraoperative identification of all lymphatic ducts followed by gentle and effective ligation with nonabsorbable suture is the best way to prevent a leak. The thoracic duct usually emerges in the left neck, bringing chyle from the abdomen and the thorax. It arches deep to the great vessels but superficial to the thyrocervical trunk, the vertebral artery, the phrenic nerve, and the anterior scalene muscle, looping from medial to lateral and then back to the IJ vein.65 Before entering the venous system, it is joined by the left cervical lymphatic vessels. The right neck also has a lymphatic duct that drains the right head, neck, lung, and upper extremity and the convex surface of the liver. The cervical lymphatic ducts are formed by the confluence of jugular, subclavian, and bronchomediastinal trunks. The ducts enter the great veins of the neck near the junction of the IJ and the subclavian veins. The pattern and location of entry is widely variable and possibly multiple, although entry into the distal IJ vein is the usual course66 (Figure 36-13). Because of the multiple branches, the ligation of one structure does not guarantee the control of all potential sites of leakage. It is classically taught that the thoracic duct is a rightsided structure in fewer than 5% of individuals.67 In Crumley and Smith’s65 series, 25% of lymphatic drainage occurred in the right neck. Profuse lymphatic fluid often collects after neck dissection in cases with bulky and diffuse metastatic disease. Thus a vigilant search

Int jugular v. Ext jugular v.

Subclavian v. Lt. innominate v.

Thoracic duct Sup. vena cava

Figure 36-13. Anatomy of the thoracic duct. In most individuals, the duct enters the internal jugular vein (solid lines), but a number of possible anatomic variations exist (dashed lines).

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for lymphatic structures is warranted when dissecting either side. One effective approach to the floor of the posterior triangle is to score the superficial cervical fascia with a knife or scissors just superior to the clavicle in a horizontal fashion beginning several centimeters lateral to the carotid sheath after the contents of the sheath have been identified. Firm blunt dissection sweeping the fibrofatty tissue superiorly and using bipolar cautery or clamps to control small vessels found in this region allows for the precise identification of the important structures in the floor of the posterior triangle. The thoracic duct is sometimes located immediately, but at times the lymphatic structures are very small or inapparent. As the surgeon moves medially from the phrenic nerve and laterally from the vagus, all lymphatic vascular structures should be doubly clamped and ligated. Every effort should be made to avoid tearing these thin-walled structures. In the left neck, the entrance of the cervical lymphatics into the thoracic duct from above and the site of emergence of the duct from behind the carotid artery several centimeters above the clavicle are often forgotten sites of potential lymphatic leakage. Chyle leakage is usually easily recognized intraoperatively by the pooling of characteristically milky fluid in the inferomedial corner of the neck. Flow can be increased by having the anesthesiologist hyperinflate the lungs to identify the site of ductal injury. Efforts to identify and ligate the lymphatics must be made cautiously, avoiding inadvertent injury to the vagus nerve or the phrenic nerve. When a single point of leakage cannot be identified, figure-of-8 ligatures in the region of greatest lymphatic collection may be effective. For situations in which there is a persistent but very slow rate of chyle flow despite exhaustive efforts to ligate the duct, a local pedicle of fibromuscular tissue may be rotated over the site and mattressed to surrounding tissue. A layer of fibrin glue may be useful as a sealant over the repair.68,69 The area should be inspected again just before the wound is closed. As the patient emerges from deep levels of anesthesia, the intrathoracic pressure increases, and chyle may appear. In Crumley and Smith’s65 series, 75% of postoperative chylous leaks had first been noted during surgery. Under no circumstances should the neck be closed while chylous drainage persists.

Brachial Plexus Lateral to the phrenic nerve beneath the fascial floor of the posterior triangle is the brachial plexus, which is wedged between the scalenus muscles. This structure, like the phrenic nerve, is deep to the deep cervical fascia, and it should be easily preserved when gentle blunt dissection of the fat overlying the fascia is performed. Occasionally the upper trunk of the brachial plexus or

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the anterior division of the cervical nerves (i.e., C5 and C6) that form it may lie within a sheath of fat and could be mistakenly included in the dissection in an effort to thoroughly clean the posterior triangle.70 In addition, the presence of supraclavicular sensory nerves that may be safely sacrificed can make dissection in this area somewhat confusing. Injury to the upper trunk affects the function of the supraspinatus, the infraspinatus, the biceps muscles, and the triceps muscles as a result of the complex pattern of nerve branching and anastomosis in the trunks and cords of the brachial plexus. Any fat that does not come away from the floor of the posterior triangle with gentle blunt dissection must be cautiously examined to be certain that there is no nerve running within. If a nerve is present, the surgeon must decide whether to dissect it free of the surrounding fat or to leave the fat at the floor of the dissection; this will depend on the presence of bulky level V nodal disease.

nerve is formed by the anterior division branches of C3 through C5. These cervical nerves also contribute to the sensory nerves that proceed from behind the SCM at the Erb point. Because the sensory branches are encountered running up in the reflected specimen, care must be taken to cut them high on the specimen and to sweep the proximal stump downward to the muscle floor. This avoids injury to the phrenic contributions, which may tent upward with traction on the surgical specimen.

Cervical Plexus Contributions to the Phrenic Nerve As elevation of the contents of the posterior triangle proceeds from the trapezius toward the carotid sheath, the cervical plexus contributions to the phrenic nerve or to a loop of the phrenic nerve itself may be injured. Although not life-threatening, phrenic injury results in the paralysis of the ipsilateral diaphragm, and it may contribute to postoperative pulmonary complications. The ability to compensate for aspiration, atelectasis, pneumothorax, chylothorax, or other pulmonary insult may be seriously compromised by the loss of innervation to the diaphragm, thus prolonging the need for ventilatory support. Fluoroscopic examination postoperatively confirms the diagnosis of phrenic injury with the paralysis of the injured diaphragm (Figure 36-14). The phrenic

Jugular Vein Dissection It is important to clear the upper jugular nodes thoroughly, because they are common sites for tumor recurrence (Figure 36-15). Cranial nerve XI, if it is being preserved, must be cleared of surrounding fibrofatty tissue and kept in view during this procedure. Exposure of the digastric muscle and the upward elevation of it allows for the thorough removal of underlying lymphatic tissue. If the IJ vein is to be ligated, it should first be thoroughly exposed, with the position of the vagus and hypoglossal nerves being noted. A loss of control of the upper jugular stump is managed by packing the skull base with microfibrillar collagen hemostat (i.e., Avitene), oxidized regenerated cellulose (i.e., Surgicel), or fat. A flap of levator scapulae or splenius cervicis muscle can be rotated into the site, if necessary. In functional neck surgery, the ansa cervicalis and hypoglossi may be preserved as dissection proceeds over the IJ vein, taking the superficial carotid fascia. Maintenance of the functional integrity of the innervation to the strap muscles assists with deglutition. The loss of this muscle function may contribute to multifactorial postoperative dysphagia. The IJ vein has several large tributaries that enter it anterosuperiorly. If it is to be spared, care must be taken to ligate these branches well away from the wall

Figure 36-14. Elevation of the right hemidiaphragm as a result of phrenic nerve injury in the neck.

Figure 36-15. Recurrence of tumor at the mastoid tip 6 months after radical neck dissection.

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COMPLICATIONS OF SURGERY OF THE NECK of the preserved vein. Narrowing of the vein probably contributes to the postoperative thrombosis and occlusion that are reported to occur in 15% of preserved jugular veins.71 Facial edema, increased intracranial pressure (ICP), and the sequelae of radical neck surgery follow.

Sympathetic Trunk As the dissection of the carotid sheath is completed, a transition must be made between the deep cervical (i.e., prevertebral) fascia and the fascia of the carotid sheath. Failure to recognize and accomplish this may result in injury to the cervical sympathetic chain that lies deep to the carotid artery. There is rarely any reason to enter this area during tumor removal, but, when tumor is adherent to the deep cervical musculature posterior to the artery, the surgeon may stray as a cuff of muscle is taken in an effort to remove all of the tumor. The fusiform superior cervical ganglion located from the level of the atlas to C2 and C3 must not be mistaken for a retropharyngeal lymph node. Unlike these nodes, the ganglion should be deep to the deep cervical fascia. The neurologic deficit caused by injury to the cervical sympathetic nerves depends on the site of injury. A full Horner syndrome consists of the following ipsilateral conditions (Figure 36-16): 1. Miosis (pupillary constriction as a result of unopposed constrictor input from cranial nerve III when sympathetic input to the dilator pupillae muscle is lost) 2. Ptosis (as a result of the paralysis of the smooth muscle of Horner) 3. Transient blush (the loss of vasoconstrictor tone that returns in a matter of days)

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4. Anhidrosis (the loss of the sympathetic innervation of the sweat glands) 5. Nasal congestion No Horner syndrome will result from an injury below the stellate ganglion located behind the vertebral artery in the root of the neck. If preganglionic fibers at the C8 through T1 level are injured, pupillociliary signs without anhidrosis are seen. Injury to the intracranial ICA or the cavernous sinus may also produce a partial Horner syndrome without anhidrosis, because sweat fibers leave the oculopupillary fibers after synapsing in the superior cervical ganglion. Anhidrosis alone may result from a lesion below the first thoracic ganglion.72

Carotid Artery Injury and Resection Tumor invasion of the carotid artery is a relatively uncommon event of advanced aggressive disease or revision surgery for a recurrent neck mass. Even large neck masses with decreased mobility can often be carefully dissected free of the vessel. However, this may thin the vessel wall and raise the chances for carotid rupture, particularly in the setting of prior neck irradiation. Thus, when tumor does not approach the carotid sheath, the adventitia should not be violated. When tumor cannot be cleared from the carotid, the surgeon must make a difficult choice. The procedure can be aborted, leaving bulk disease in the neck. Alternatively, the tumor can be shaved from the carotid, or the vessel can be resected. If the carotid is resected, a decision about bypass grafting must also be made. Ideally the potential for tumor invading the carotid will have been foreseen preoperatively and a contingency plan made ready. It is unlikely that carotid involvement will be found intraoperatively when physical and radiographic warnings are absent. More likely is that the finding of carotid invasion, which

Figure 36-16. Left-sided Horner syndrome as a result of the injury of the cervical sympathetic trunk, resulting in ptosis, miosis, and anhidrosis.

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was present in 5.5% of neck dissections in one series, will merely confirm preoperative suspicions.14 Moore and Baker15 reported an 11.4% mortality rate and a 31.4% incidence of cerebral complication in the latter half of their series of carotid ligation in patients who had no preoperative assessment of collateral flow. This indicates that proceeding with carotid resection when vessel invasion has not been suspected and worked up carries a risk that is inordinately high. This is particularly true given the small potential benefit to patients with that extent of disease who have poor longterm prognoses. If faced with unanticipated carotid artery invasion, the intraoperative estimation of a patient’s ability to withstand ligation is possible by measuring carotid stump pressure.73 After the vessel is exposed, a 22-gauge needle attached to a pressure transducer is inserted into the artery distal to an occluding clamp. Stump pressures of 50 mm Hg to 70 mm Hg are reported to be indicative of adequate collateral flow, thus allowing for ligation without reconstruction. However, intraoperative stump pressures may be unreliable. A more conservative recommendation by Hibbert74 is to resect without reconstruction when stump pressures exceed 70 mm Hg, to resect with reconstruction for pressures from 55 mm Hg to 70 mm Hg, and to not only replace the vessel but to use a temporary shunt intraoperatively for pressures below 55 mm Hg. The use of systematic anticoagulants (i.e., heparin 5000 U subcutaneously) among patients who undergo carotid ligation may be beneficial. The rationale for this practice is the prevention of delayed neurologic sequelae as a result of thrombosis in the vessel stump with subsequent clot embolism. For the same reason, it is usually recommended that the internal carotid be tied off as close to the skull base as possible. Doing so prevents the formation of a pouch where a clot can propagate. Autopsies of patients in the series reported by Moore and Baker15 do not support an important role of thromboembolic events in the fatalities of patients after carotid ligation. Instead, abnormalities in the brain were usually the result of low perfusion and subsequent infarction. A major contributing factor to mortality associated with carotid ligation is transient hypotension. Moore and Baker15 attribute the improved results in the later part of their series to the anticipation of the transient hypotensive episode that follows vessel cross-clamping and the aggressive maintenance of blood pressure during that time. Care must be taken to ensure the secure ligation of the vessel. The walls of an atherosclerotic carotid artery may tear easily. The site of ligation must be distant from tissue weakened by tumor, dissection, infection, or radiation.

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Reconstruction of a resected carotid artery can be achieved with an autogenous vein (saphenous) or a GoreTex or Dacron graft. Alloplastic graft material is not recommended by some as a result of the contaminated, irradiated nature of many of these cases.66 Alternatively, scarring and fibrosis may occlude vein grafts, which has led others to advocate the use of prosthetic grafts.75 An alternative to carotid resection is to debulk the tumor, peeling it from the vessel and separating the adventitia from the tunica media. External-beam therapy or radioactive 125iodine implants (i.e., brachytherapy) can be used in an effort to control residual cancer. This approach was reported by Fee and colleagues13 to have good early results. The risk of the delayed rupture of the carotid may be reduced by ensuring good coverage of the weakened vessel. If the skin has been resected over the carotid, a myocutaneous flap is recommended. The muscle pedicle can be sutured to tissue around the carotid to ensure that muscle will adhere to the vessel wall. The use of dermal grafts and rotated muscle pedicle flaps (e.g., levator scapulae) has been advocated for high-risk cases.76 However, the value of these tissues to cover the carotid has been questioned. The use of dermal grafts is associated with a 7% incidence of minor complications. At the same time, they have not been shown to reduce the rate of carotid catastrophe. They are no substitute for tight mucosal closure and coverage achieved with healthy tissue, particularly a healthy myocutaneous flap. Even when tumor is not adherent to the vessel wall, dissection around the carotid can be hazardous. Atherosclerotic plaque may be dislodged and cause embolic damage if a diseased carotid is handled roughly. Bradyarrhythmia and hypotension are commonly seen during the manipulation of the carotid. Undue pressure on the carotid sinus may result in ventricular fibrillation, particularly when a patient is digitalized. The instillation of 1% xylocaine without epinephrine into the subadventitial tissue with a 25- or 27-gauge needle blunts the carotid sinus reflex temporarily as dissection continues. Intravenous atropine is also effective. If bradycardia occurs, the surgical team should stop the manipulation of the vessel until preventive measures take effect.

Anterior Dissection The hypoglossal (cranial nerve XII) and superior laryngeal nerves lie on the floor of the anterior dissection and should be preserved whenever possible. The hypoglossal is more superficial, but it lies beneath a layer of fascia, usually accompanied by complex venae comitantes. Injury to these veins should be avoided. The

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Figure 36-17. Cranial nerve XII dissection.

area just anterior and superior to the carotid bifurcation is a common site of soft-tissue invasion by metastatic tumor with extracapsular spread. The external carotid artery can be sacrificed without significant sequelae, but cranial nerve XII should be preserved when possible or repaired with cable graft, if necessary (Figure 36-17). The internal branch of the superior laryngeal nerve passes under the carotid, coursing over the pharyngeal constrictor muscle to enter the thyrohyoid membrane and provide sensory innervation to the supraglottic larynx. Injury to the superior laryngeal nerve contributes to the risk of postoperative aspiration. Unless it is involved with tumor, the fascia encasing the visceral neck structures should not be violated, with the superior laryngeal nerve kept out of harm’s way. The ansa hypoglossi descends from cranial nerve XII as it turns superiorly, running just anterior to the IJ and the common carotid artery immediately superficial to the superior thyroid artery and the superior laryngeal nerve. Dissection beneath the plane of the ansa is rarely needed.

Concomitant Bilateral Neck Dissections Bilateral neck dissections may be indicated when clinical disease is present bilaterally or when a large midline primary tumor (i.e., the base of the tongue, the supraglottis, the floor of the mouth) is present with an associated high incidence of bilateral occult metastases. Bilateral radical neck dissection has been considered ill advised because of an increase in postoperative complications related to the interruption of venous return, including facial edema, blindness, increased ICP, and even death.77 A number of alternatives to simultaneous bilateral radical neck dissection exist, including the use of postoperative radiotherapy for stage N0 or N1 necks, staged surgery delaying the ligation of the IJ vein on the less-involved side by 6 to 8 weeks, and simultaneous surgery that spares the IJ vein on at least one side. If the last option is chosen, the possibility of postoperative thrombosis and the occlusion of the preserved IJ vein must be considered.71 With

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careful intraoperative fluid management and postoperative vigilance for signs of increased ICP, bilateral radical neck dissection is well tolerated in selected cases. General physical disability, prior radiation, and the need for extensive surgery to extricate the primary tumor are concurrent risk factors that must be weighed against the decision to perform bilateral radical neck dissections.

POSTOPERATIVE MANAGEMENT: IMMEDIATE AND DELAYED POSTOPERATIVE COMPLICATIONS A trend in neck dissection over the past decade has been a tendency to release patients after a short stay or even to do the procedure as an outpatient surgery. Patients with stable home environments can be taught to maintain suction drain catheters and bulbs and to measure and record output. The drain can be removed when the output falls to a target volume during a certain time interval (i.e., 25 cc in 24 hours). The author and colleagues recently reported the clinical course of 23 patients at their institution who were discharged after an overnight hospital stay after neck dissection. There were no unusual complications or problems encountered with this practice. Two patients developed seromas at a later time after drain removal, but this was not felt to be related to early discharge.78

IMMEDIATE COMPLICATIONS Air Leakage Suction drains are placed beneath the flaps at the time of closure to evacuate any persistent drainage that distends the flaps and that serves as a medium for wound infection. Skin closure must be airtight for the drains to function properly. As previously discussed, a tracheotomy site is one potential source of air leak, so it must be kept separate or sealed off from the rest of the wound. The patient should not be awakened until drains are functioning well with no

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evidence of air leakage. Leakage noted in the recovery room may sometimes be corrected with one or two additional stitches placed at the bedside or with the placement of ointment or tissue glue. Failing this, the patient may be returned to the operating room to revise the closure. If the surgery involved oral or pharyngeal entry, the problem is compounded. Air leak may be the result of incomplete mucosal closure. Revision is required to prevent the development of an orocutaneous fistula. Such a fistula is exacerbated by active suction from the drains pulling air and saliva through the dehiscence.

Hemorrhage As the patient emerges from anesthesia, maintaining firm pressure over the dissected neck may help reduce the likelihood of hemorrhage, because the elevated venous pressure that occurs during coughing or struggling may open a sealed vessel. Suction drains are capable of evacuating small amounts of persistent bleeding and of preventing hematoma and related flap necrosis, wound infection, or airway compromise. When the drain system malfunctions or is overwhelmed by a high rate of bleeding, the neck flaps become distended and eventually ecchymotic. At times, the manipulation of the drains may correct the problem if it is relatively minor and detected early. Large amounts of bleeding necessitate wound reexploration, clot evacuation, irrigation, the identification and ligation of uncontrolled vessels, and the placement of new drains. Small arteries (e.g., facial, thyroid, thyrocervical trunk, transverse cervical) or veins are often the cause of bleeding that is sufficient to require surgical control. The undersurface of the SCM, if it is spared, should be inspected, and the provision of the Valsalva maneuver should be requested of the anesthesiologist. However, the identification of a specific bleeding vessel is not always successfully accomplished at reexploration. Still, reexploration may shorten the hospital stay and improve the course recovery simply through the removal of clot and the replacement of functioning drains.79

DELAYED COMPLICATIONS Problems Associated With Interrupted Venous and Lymphatic Return Facial edema is common after neck dissection. Although this is most marked with bilateral surgery (Figure 36-18), it may occur with unilateral and even with vein-sparing procedures. High volumes of fluid replacement intraoperatively can exacerbate the problem. The fibrosis of collateral lymphatics results in a greater degree of postoperative edema after surgery in a previously irradiated neck. Massive edema with further venous congestion may contribute to flap necrosis. Chemosis may also accompany severe facial edema. Of greater concern is increased ICP with various accompanying problems. CVP increases after IJ vein ligation, thus impairing the rate of cerebrospinal fluid absorption. Headache and nausea may herald impaired neurologic function with visual changes and eventual coma. SIADH is a rare sequela of radical neck dissection, but it is more common in the setting of bilateral surgery or prior radiation therapy. In the small series of cases of SIADH after unilateral neck dissection presented by Wenig and Heller,80 two thirds (4 of 6) of the patients had had radiation during the past, and one had had the contralateral neck operated on previously. SIADH is manifested by a low serum sodium level and a urine osmolality that is more than the serum osmolality.

Pulmonary Complications A chest radiograph is obtained in the recovery room during the immediate postoperative period. Problems with focal atelectasis and fluid overload are common after lengthy surgical procedures. Diuretics and aggressive pulmonary physiotherapy should be initiated as indicated. Pneumothorax is an unusual complication of head and neck surgery, but it may result from CVP line placement or the dissection in the root of the neck. Small pneumothoraces (i.e., ⬍20%) with no evidence of respiratory insufficiency may be managed expectantly with repeated chest radiographs to confirm resolution. More extreme collapse requires the placement of a chest tube.

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Figure 36-18. Patient with severe facial edema after left radical and right modified neck dissection.

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Renal function is normal. Hyponatremia may result in further neurologic sequelae, including weakness, lethargy, mental confusion, convulsion, and coma. Wenig and Heller80 stress stringent intraoperative fluid management for high-risk patients to prevent postoperative SIADH. SIADH is managed by restricting the amount of free water that is administered to less than I L per day until serum sodium levels return to normal. More severe cases may require infusions of intravenous saline and the use of furosemide. Blindness has been reported after bilateral neck dissection. In one case, Balm and colleagues81 noted bilateral papilledema, distention of the superior orbital veins, and elevated cerebrospinal fluid pressure, thus linking the blindness with elevated ICP. Although most discussions of severe complications caused by increased ICP focus on bilateral neck surgery, such problems can follow unilateral neck dissection, particularly among patients with anomalous intracranial venous drainage.82 Head and neck patients are usually positioned with the head of the bed elevated during the immediate postoperative period. If renal function and nutritional status are good, there should be prompt mobilization and the cessation of fluids given intraoperatively. When headache, visual disturbance, or other evidence of increased ICP is noted, diuretics, carbonic anhydrase inhibitors (i.e., acetazolamide), and steroids may be helpful. Continuous lumbar drainage or serial lumbar puncture has been advocated, as has optic nerve decompression in the event of the loss of vision.81,82

Excessive Drainage and Chylous Fistula Within 2 to 3 days postoperatively, the fluid evacuated from a neck dissection wound should become serous, and the volume should decline dramatically. When drainage volume instead begins to increase, the source of the problem must be determined. Chyle may be clear during the postoperative period, when the patient has not yet been fed, and it may be indistinguishable from lymphatic fluid or saliva. When the tail of the parotid gland has been amputated during dissection, a large volume of saliva may collect in the drains. The measurement of the triglycerides and amylase in the fluid will identify its source. If the fluid is saliva (i.e., with a high amylase level and a low triglyceride content), drains may be taken off of wall suction but maintained as a closed system as long as necessary until drainage eventually stops. Chyle in the suction drains presents a more difficult problem. When the patient begins to eat, the volume increases, and the characteristic milky appearance makes the diagnosis unmistakable (Figure 36-19). A chyle leak may cause physiologic problems in addition

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Figure 36-19. Chyle in suction drain bulbs from a patient with postoperative chyle leak.

to problems with wound healing and infection. Chyle is made up of lymph and emulsified fat absorbed in the intestine. It has a high protein content (2%–4%) with electrolytes that are similar to those found in plasma. Seventy percent of ingested fat passes through the thoracic duct, giving chyle a fat content of 1% to 3%.65 Because chyle flow rates may exceed 2 L per day and because volumes exceeding 500 ml per day are common, severe imbalances of electrolytes, protein, fat, and fat-soluble vitamins and the loss of circulating lymphocytes may occur. The electrolyte and nutritional problems are proportional to the rate of leakage. The incidence of chylous fistula after radical neck dissection has been reported to be 1% to 2%.65,83 Prior radiation therapy may be a contributing factor to the development of a postoperative leak. The leak is suspected because of increased wound drainage on the second or third postoperative day in the majority of cases. However, chyle leak can occur later. A case of delayed lymphocele appearing 3 weeks postoperatively has been reported.84 The initial management strategy of chyle leak is usually conservative. Nutritional support is modified to minimize the volume of chyle produced, and mechanical means are employed to halt the extravasation. The patient is kept on bed rest with the head elevated. Drains are taken off suction but left in place to allow for the passive egress of fluid, and a pressure dressing is applied. Adequate fluid and electrolyte replacement are directed by strict records of intake and output. The replacement of losses from chyle leakage must be added to maintenance fluids. Parenteral nutrition or enteral feeding with medium-chain triglycerides is begun. Long-chain triglycerides found in fatty meals are broken down into fatty acids that are incorporated into chyle, thus increasing the flow in the thoracic duct. Mediumchain triglycerides are absorbed directly into the portal system, bypassing the thoracic duct.83 When drainage

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falls to less than 20 ml per day, drains are removed. The subsequent reaccumulation of a small amount of chyle can be managed by repeated aspiration. Conservative management can be safely maintained for prolonged periods of time. The expense of prolonged hospitalization and specialized nutritional support, the increased risk of further complications such as wound infection or flap loss, and the need to begin radiation therapy in a timely fashion make it desirable to move on to the surgical management of the leak when conservative therapy is unlikely to succeed. In the series by Spiro and colleagues,83 conservative management succeeded in 4 of 16 cases, all of which involved a leakage rate of less than 600 ml per day. Six other patients were treated by opening the wound and packing. In these cases, the leak resolved after 11 to 28 days. Crumley and Smith65 recommended surgical intervention when leakage exceeds 500 ml per day for 4 or 5 consecutive days. Patients with a very high flow rate (i.e., several liters per day) should undergo surgical exploration as soon as possible. Patients undergoing reexploration are given 4 oz to 6 oz of cream 3 to 24 hours before surgery. Local anesthesia is sufficient in most cases. Patients are placed in the Trendelenburg position, and the wound is opened and filled with saline. Creamy chyle rising from the site of the leak is easily identified in the saline pool, especially when the patient performs a Valsalva maneuver. If necessary, an operating microscope is used to identify the leak. The defect is suture ligated with nonabsorbable material. Fibrin glue,68,69 Gelfoam, or Surgicel is applied, and the wound is closed over a Penrose drain. Pressure dressings are applied for several days. The success of reexploration is generally excellent.65,83 Resultant soft-tissue defects may later be filled with an axial muscle or a myocutaneous flap. Two patients in the series of Spiro and colleagues83 had chyle leaks that presented with a pleural effusion without significant drainage via neck drains. Chylothorax is a rare event after neck dissection. The site of injury to the thoracic duct in these cases is unclear. The duct has a complex system of branches within the posterior mediastinum.85 It is theorized that back pressure after the ligation of the main duct may cause the nontraumatic extravasation of chyle in the chest.86 The amount of chyle leakage may be much greater (i.e., 4500 ml/day in one case) in patients with chylothorax as compared with those with cervical chyle leak. Massive pleural effusion may cause cardiorespiratory compromise as a result of mechanical compression on the lung and the great vessels. Treatment initially may be by repeated thoracentesis or closed thoracostomy drainage. Effusion resolved in one of the cases of Spiro and colleages83 when the neck wound was opened and packed;

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the other patient required thoracotomy with ligation of the thoracic duct and subtotal pleurectomy.

Wound Infection and Flap Loss As previously discussed, the incidence of wound infection after surgery of the neck without entry into the aerodigestive tract should be very low. Prophylactic antibiotics may be continued during the first 24 to 72 postoperative hours. Constant suction should be maintained on the drains and sterile technique used when disconnecting and emptying the bulb. Erythema and induration appear before wound dehiscence and the release of purulent drainage. If these early signs are present when the output has abated, thus allowing for drain removal, the tips of the drain from under the flap may be sent for bacterial culture when removed. Wound infection is a contributing factor to dehiscence and flap skin loss. Others include poor nutrition, prior radiation therapy with damage to small dermal blood vessels, poor incision and flap design producing inferiorly based skin flaps with acutely angled tips, and continued smoking during the perioperative period. Flap elevation superficial to the platysma adds to the problem of skin loss. Leakage from a mucosal closure suture line markedly increases the risk of skin wound breakdown and fistula. Skin flap loss may be treated conservatively with wetto-dry sterile dressings changed two to three times daily if the great vessels are not exposed in the wound. Granulation tissue will form given time and nutritional support. Hyperbaric oxygen therapy may speed wound healing, especially among patients who have been heavily irradiated.87 When a good bed of granulation tissue has formed, the defect can be repaired easily using a split-thickness skin graft or a myocutaneous flap. Topical negative-pressure devices (e.g., vacuumassisted wound closure [wound VAC]) may be useful, particularly in complicated wounds with pharyngeal fistulas. The hypothetical benefit of wound VAC is the removal of infected secretions and edema with the improvement of microcirculation and the direct stimulation of reparative cellular proliferation to encourage granulation formation.88–90

Rupture of the Great Vessels When wound dehiscence results in the exposure of the carotid artery, it is more ominous, and its management more critical (Figure 36-20). The rupture of the carotid artery is perhaps the most feared complication of head and neck surgery, and its incidence is as high as 3% to 4% in some series.76,91–93 In 1965, Ketcham and Hoye’s92 series showed that the timing of rupture varied from 6 to 81 postoperative days, with a mean of 16 days. With

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wound is clean, Shumrick76 advocates immediate coverage of the exposed artery with a vascularized flap. The following doctrine is pertinent: “Don’t let the sun set on an exposed carotid artery.” However, infected or necrotic wounds may not be successfully covered in this manner. Flaps rotated into an infected bed have less chance of survival. The vessel must be kept clean and moist while preparing the wound for reliable coverage with vascularized tissue. Saliva from a fistula, if present, must be diverted away from the vessel with wound VAC or via a separate direct tract created iatrogenically, if necessary.

Figure 36-20. Exposure of carotid artery wound dehiscence and flap necrosis.

modern perioperative care, the incidence may now be somewhat lower. Alternatively, postoperative rupture of the internal jugular vein may be more common in this era of structure-sparing surgery. The thin wall of the IJ renders it more susceptible to the erosive action of infection, salivary digestion, and drying. Risk factors that contribute to great-vessel rupture are similar to those for wound breakdown. Massive tumor with persistence at or near the carotid artery and the violation of the adventitia while peeling disease off of the carotid artery are additional factors. Wound breakdown preceded rupture in 15 of 17 patients reported by Maran and colleagues,91 whereas 7 had recurrent tumor demonstrated at the time of surgery. The surgery preceding most cases of carotid artery rupture involved the en bloc resection of primary tumor with nodal dissection, but, in some of the cases reviewed by Shumrick,76 neck dissection alone had been performed. When wound infection and dehiscence occur after neck dissection, the possibility of carotid complications must be anticipated. “Carotid precautions” are initiated, including the maintenance of a blood sample in the blood bank at all times, the communication of concern to all personnel involved in the patient’s care, and meticulous wound care. Any loculated purulent material in the wound is drained completely, thereby avoiding the excessive disruption of suture lines. The gentle packing of the wound with moist gauze is replaced frequently to keep tissues clean and moist. The adventitia of the carotid is very susceptible to drying. Because the adventitia brings the blood supply to the rest of the carotid wall, keeping it moist and healthy is critical to preventing blowout. A moderately firm cover dressing with several large bolster sutures, if needed, helps to promote flap adherence to the floor of the dehiscent cavity and halts flap retraction with further vessel exposure. Antibiotics and hyperbaric oxygen therapy may be given to help minimize infection and to promote the formation of granulation tissue. If the

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Daily inspection of the exposed vessel provides a warning of impending rupture. Morbidity and mortality rates are much lower with planned carotid ligation than when surgery is performed in response to acute hemorrhage. Decay of the carotid wall requires 6 to 10 days to occur, during which a brown eschar forms on deeper and deeper portions of the wall and is debrided with successive dressing changes. During this time, intensive nutritional support, aggressive wound care, and hyperbaric oxygen therapy may render the wound ready for flap coverage. As the media is sloughed, however, the vessel may become aneurysmal. A “sentinel bleed” may herald catastrophic rupture by several days. As soon as this sequence of events is recognized as being inevitable, plans to manage the vessel either through ligation or endovascular embolization should be undertaken. The patient and family are counseled regarding the serious nature of the step to be taken. The greater risk of complications in the event of spontaneous rupture is made clear during the discussion. Of course, in the presence of recurrent or persistent unresectable disease, the decision to withhold surgical intervention in favor of supportive care alone is a valid alternative. Selective endovascular embolization performed under sedation or general anesthesia in an interventional radiology suite has been increasingly popular as a lessinvasive means of preventing carotid rupture or managing lesser head and neck bleeding. Balloons, platinum coils, and microparticles are available for use in appropriate circumstances. In several series, angiographic vascular control has been shown to have intermediateterm benefit with occasional resultant transient or permanent neurologic deficits.94,95 The most important factor to be considered intraoperatively during surgical carotid ligation is the maintenance of adequate blood pressure to ensure cerebral blood flow. Moore and Baker15 report an 87% incidence of death and a 63% incidence of stroke when hypotension occurred after vessel cross-clamping as compared with 28% and 16%, respectively, when pressure was maintained.

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Carotid rupture on the hospital ward is a dramatic and anxiety-inducing event for all concerned. The first care provider on the scene must apply direct digital pressure to stop the hemorrhage. This must be held constant while others ensure a safe airway, place several large intravenous lines, and establish fluid support to maintain blood pressure. Albumin or O-negative whole blood can be given immediately while awaiting cross-matched blood from the blood bank. No effort to find and clamp the vessel should be made on the ward. Two of three deaths in Ketcham and Hoye’s92 series occurred as a result of this ill-advised activity. Instead, the stabilized patient is transported to the operating room with digital pressure maintained on the artery. At this point, another care provider in surgical uniform and sterile gloves assumes the responsibility for control of the vessel; his or her hand is prepared in the field. Flaps are opened, and incisions are extended as needed to expose the vessel wall above and below the site of bleeding. The healthy vessel is clamped and ligated with size 0 silk ties and suture ligature. It may be necessary to resect the clavicular head to achieve proximal vessel control. Every effort should be made to ligate beyond any residual tumor. Because this was not done, a second blowout below the initial ligature occurred in 3 patients in Ketcham and Hoye’s series.92 Postoperatively, neurologic complications may be immediately obvious or delayed for hours to weeks. Leikensohn and colleagues93 report 5 deaths (25%) and 10 strokes (50%) in 20 patients undergoing carotid ligation. Six of the ten strokes occurred at least 8 hours after ligation. The authors advocate 5000 U of subcutaneous heparin sulfate every 12 hours after surgery. There was only one death and no strokes in the seven patients who were treated this way in their series. Pseudoaneurysm of the carotid artery is a very rare complication after head and neck surgery. Conley96 reported 3 cases from more than 3000 major head and neck surgical procedures. The false aneurysm is actually a late controlled rupture of the carotid with blood dissecting into the surrounding tissues to form a pulsatile mass. It may present up to several years after surgery. Arteriography confirms the suspicion of pseudoaneurysm. Consideration must then be given to surgical or angiographic management.

Local Recurrence of Tumor Local recurrence of carcinoma is a serious complication that is difficult to manage. The violation of surgical planes and the exposure of the great vessels allow for the spread and deep invasion of recurrent tumor beyond natural barriers. The recognition of recurrence is delayed by the swelling and subdermal scar formation that follows surgery and postoperative radiation therapy.

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Recurrence may be the result of incomplete dissection. This may be more common during this era of selective neck dissection; however, in many series, the site of recurrence is most often within the previously dissected region. One area that is particularly susceptible to this is the superiormost portion of the dissection. Level II nodes are common, and dissection in this area must be fastidious. The extracapsular spread of tumor also predisposes patients to recurrence. Attention to intraoperative measures such as irrigation of the wound with sterile water and the changing of gloves and instruments after the tumor has been removed may help to reduce the incidence of tumor recurrence. However, biologic aggressiveness related to factors that are currently poorly understood is probably more important. Recurrence as a result of tumor spillage may present as a small blister at the suture line that grows to an obvious fungating or ulcerative mass or as a diffuse and poorly demarcated mass beneath normal skin flaps (Figure 36-21). In many cases, radiation therapy has already been used, so further therapeutic options are limited. Surgical resection is feasible in some cases when recurrence has been detected early. This should be considered palliative therapy, with the ultimate prognosis in such cases being poor. Areas of skin involvement by tumor are resected together with bulk disease. Radioactive 125iodine seeds or catheters for subsequent iridium seed loading may be placed in the residual tumor bed and covered with a healthy vascularized flap (Figure 36-22). Skin breakdown with bleeding, infection, and pain may thus be prevented or postponed. In one series, 77% of 220 cases treated with interstitial brachytherapy achieved local control of recurrent tumor at 6 months.97 Newer technologies for limited reirradiation such as frameless stereotactic radiosurgery (i.e., CyberKnife [Accuray, Sunnyvale, CA]) are increasingly being applied with similarly promising (if limited) results.98 Reexploration of the neck for recurrent tumor (i.e., intraluminal or regional nodal) carries a greatly elevated risk of complication. If the jugular vein or other major venous structures were preserved during the original surgery, these structures will now be encased in scar. The scarring will be even more dense if postoperative radiation therapy has also been delivered. The identification of the vein under these circumstances can be quite difficult, and the control of venous bleeding elevates the risk to nearby neural structures, particularly to cranial nerves X, XI, and XII. Venous entry with troublesome hemorrhage can occur even during initial flap elevation. The surgical and anesthesia team must be prepared for this possibility. Sufficient time must be allotted to the case, recognizing that simple flap elevation and the identification of initial landmarks may consume many minutes. Wide exposure with the initial identification and control of structures in regions that are less affected by scarring is recommended.

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Figure 36-21 A, Fungating tumor in the incision line. B, Tumor recurrence presenting as an ulceration in the suture line (arrows) of a previous neck dissection.

Figure 36-22. Postoperative appearance after the resection of tumor involving the skin and the carotid artery, the placement of seeds, and a pectoralis major flap.

Shoulder Pain and Dysfunction Symptomatic problems with upper-extremity function after neck dissection are common and may occur after radical or modified comprehensive procedures that spare cranial nerve XI (described previously) and, to a lesser degree, after selective neck dissection. Postoperative physical therapy to assist with the mobilization and strengthening of the shoulder is recommended for all neck dissection patients, regardless of the status of the spinal accessory nerve.99 The loss of stability of the scapula with “winging” as a result of trapezius paralysis

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is made worse by the compensatory stretching of the rhomboid and levator scapulae muscles. Shoulder droop is also seen, and periarthritis of the scapulohumeral joint can occur (Figure 36-23). The dull aching pain that results is the most common complaint. The trapezius serves a supportive function when the arm is resting. Its major rotatory activity is seen when the arm is elevated from 35 degrees to 140 degrees in a coronal plain moving laterally. At more than 140 degrees, it again has a supportive role.100 Thus, after neck dissection, shoulder elevation but not abduction is limited; the passive range

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A

B

Figure 36-23. A, Right shoulder droop as a result of the spinal accessory nerve. B, The prominence of the scapular spine and the medial border (arrow) are the result of the rotation of the scapula and the loss of trapezius muscle bulk.

of motion is full. Physical therapy consultation is obtained on postoperative day 1 or 2, and exercise is advanced as soon as wound healing is adequate. Therapy includes heat, massage, and active and passive exercise to strengthen the shoulder musculature. Modified and selective neck dissection in which cranial nerve XI is preserved and exposed to less manipulation should result in improved shoulder function and comfort. The assessment of this potential benefit may be accomplished with the use of electrical neurophysiologic measurements, with objective assessments of range of motion and strength, or with quality-of-life tools. Using all of these approaches, investigators in Brescia, Italy, recently reported superior results among patients who did not have level V dissected. Only a few patients in the group undergoing level V dissection had disability that affected their daily activities, but some subclinical impairment was observed in the group that underwent only level II through IV dissection, ostensibly as a result of the dissection of the submuscular proximal course of cranial nerve XI.101 Other investigators report similar results, with a consistently better quality of life documented after selective nerve dissection that does not skeletonize cranial nerve XI in level V, as compared with cases involving comprehensive sparing but dissection of cranial nerve XI.102,103 In general, time and physical therapy help to mitigate the pain and dysfunction.

Neuroma Another cause of postoperative pain after neck surgery is the development of a traumatic neuroma. Traumatic neuromas are small, firm nodules that form at the cut end of sensory nerves as a result of disorganized neural regenerative growth. They may be mistaken for recurrent tumor when they are first discovered. However, neuromas rarely exceed 1 cm in diameter. They serve as trigger points for shooting pain, paresthesias, and unpleasant tingling. Typically a small (i.e., 2–3 mm), firm

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nodule is palpable at the point of pain. The injection of local anesthetic agents provides temporary pain relief. If this injection has no untoward side effects, it may be followed with ethanol for permanent effect. Burying the nerve endings into muscle may prevent neuroma formation, and this can be done secondarily if a neuroma forms.

Gustatory Sweating Frey syndrome (gustatory sweating) may occur after radical neck dissection.104 It may be present over the bed of the submandibular gland or the parotid tail.

First-Bite Syndrome First-bite syndrome is a distinctive pain phenomenon that occurs after surgery that involves tissues around the carotid artery, the cervical sympathetic trunk, the vagus nerve, the parapharyngeal space, and the parotid gland. It is described as a sharp, aggravating, or griping pain in the neck or jaw that occurs with the first bite of any meal and at times when salivating as a result of olfactory or other gustatory stimulation. Subsequent bites during the same meal are not painful. The problem is typically reported within weeks of surgery. It may resolve spontaneously months later, or it may persist. No effective therapy has been reported. The cause is postulated to be an imbalance between parasympathetic and sympathetic discharge to the parotid gland at the moment of major secretory stimulatory activity.105–107

CONCLUSION Surgery of the neck requires a high level of expertise and familiarity with the complex anatomy of the region. Attention to detail during the workup, the preoperative planning, and the procedure itself will prevent most complications. Factors outside of the surgeon’s control—including the aggressiveness of underlying

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COMPLICATIONS OF SURGERY OF THE NECK disease, prior therapy, and the nutritional and immune statuses of the patient—must be taken into account. The anticipation of common postoperative problems (e.g., shoulder dysfunction) with the appropriate use of available treatment modalities will help patients to return to an optimal quality of life.

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