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Head and neck emergencies
HEAD AND NECK EMERGENCIES ELLI(ST W. STRONG, M.D.
LIFE-THREATENING HEAD AND NECK EMERGENCIES are primarily those relating to airway obstruction and hemorrhage. As complications of cancer, neither occurs abruptly without preliminary warnings, which, to the astute observer, either patient or physician, should lead to appropriate investigation and treatment. Head and neck epidermoid carcinoma is usually sufficiently slowly growing that many weeks to months of growth are required before the tumor bulk reaches such size to produce these complications.
AIRWAY OBSTRUCTION Progressively enlarging neoplasms of the head and neck, particularly of the larynx, pharynx, base of tongue or thyroid, may ultimately produce airway compromise and obstruction. Such tumors generally produce other signs and symptoms long before the airway is compromised. However, patients still are seen initially with advanced cancers and increasing difficulty with swallowing, hoarseness, dyspnea and stridor, all indicative of impending airway obstruction. Such obstruction may be in the mouth or pharynx with locally advanced oral and/or pharyngeal tumors, in the larynx with bulky glottic or supraglottic lesions, in the trachea due to extrinsic compression by long-standing thyroid lesions or, more remotely, by direct tracheal invasion by aggressive thyroid cancers or, even more remotely, by primary tracheal neoplasms. A few patients will be seen with airway obstruction at the glottic level due to bilateral vocal cord paralysis in the adducted position, resulting from bilateral recurrent laryngeal nerve paralyses. Such paralysis may result from bilateral thyroid cancer, primary or metastatic pulmonary or other neoplasms or, rarely, may be idiopathic. In this setting, signs and symptoms may be more subtle and the cause of the recurrent laryngeal nerve dysfunction may not be immediately obvious. In the patient with signs and symptoms of increasing respiratory obstruction, prompt investigation and treatment are mandatory ifa fatal outcome is to be avoided. A brief history will usually direct the astute physician to the source of the problem. Expeditious head and neck examination is best accomplished without topical anesthesia, taking care not to tire the patient or otherwise further compromise the airway. Indirect examination with a laryngeal mirror will usually identify the site of obstruction. Repeated attempts to visualize and examine the hypopharynx 36
and larynx in the patient with a profoundly compromised airway may be sufficient to produce further decompensation demanding immediate emergency treatment. A plain chest roentgenogram may be helpful in identifying the level of airway compromise (and in ruling out intrinsic pulmonary disease), but soft tissue high kilovoltage roentgenograms may be even more helpful in outlining the pharyngeal, laryngeal and tracheal air columns, thus indicating the location of the airway obstruction. This information is of vital importance in identifying the nature and location of the problem and in deciding how to correct it. Tracheostomy will usually be required in those patients with bulky pharynx, larynx and thyroid neoplasms for the relief of airway obstruction. Attempts at peroral endotracheal intubation in the face of bulky, friable laryngeal and/or pharyngeal tumors are ill advised, often leading to bleeding, further edema and aggravation of the airway obstruction, precipitating the need for immediate emergency tracheostomy. Most patients with such lesions will require sufficiently prolonged intubation before their airway obstruction is relieved by appropriate tumor therapy as to require tracheostomy anyway. Whenever possible, tracheostomy should be done under controlled circumstances in the operating room with adequate assistance and illumination, appropriate instruments and tracheostomy tubes. I t is our policy to routinely use cuffed tracheostomy tubes, so that if controlled ventilation or cuff inflation to prevent aspiration is necessary, the cuff will be immediately available. The changing of tracheostomy tubes in the immediate postoperative period is dangerous because the tracheostomy tract will not have been well established and difficulties may be encountered in inserting the tube back into the trachea. Rarely, a patient's life is lost because of an inability to reinsert the tracheostomy tube in the presence of high-grade airway obstruction. It may be necessary to perform the tracheostomy with the patient under local anesthesia. Sedation may be contraindicated because of the high degree of respiratory obstruction. In those patients in whom it is anticipated that ultimate surgical removal of the tumor will be carried out, high tracheostomy may be indicated, in an attempt to avoid cutting directly through tumor, yet to allow total removal of the tracheostomy sinus at the time of the definitive surgery. In the acute emergency situation, cricothyroidotomy may be lifesaving; recent studies suggest that the procedure may not carry the high rate of complications once attributed to it. There appears to be no need for the use of tracheostomy tubes larger than no. 6. The tube must be appropriately positioned in the trachea so as not to traumatize the tracheal wall or carina. A tube that pulsates synchronously with the arterial pulse is probably resting against the anterior tracheal wall at the level of the innominate artery and should be replaced with a shorter tube to prevent erosion of that wall with life-threatening 37
hemorrhage. The tube must be appropriately positioned so that its distal lumen is entirely within the trachea and will be maintained there when the patient moves. It is imperative to securely fix the tube around the neck to insure its proper position. In the patient with a large, thick, short neck, maintenance of tube placement may be more difficult; under such circumstances, it may be appropriate to fix the tracheostomy tube directly in relationship to the trachea, with a suture througn the tube and the tracheal wall. Tube dislodgement may be catastrophic and must be prevented. Signs of such dislodgement include recurrent airway obstruction, no air flow via the tracheostomy tube when the patient breathes, a normal voice with the tracheostomy tube in place or failure to be able to suction via the tracheostomy tube. Any of these findings should alert the appropriate responsible attendant to this possibility and result in prompt investigation and correction of the problem. Tracheostomy is indicated in any patient in whom airway compromise is present or anticipated. Tracheostomy is routinely performed as part of the operative procedure for partial laryngectomy, either horizontal supraglottic or vertical partial, extensive surgery for pharyngeal wall neoplasms, with second or bilateral radical neck dissections or with interruption of the mandible with resultant loss of support of the tongue. Most emergency tracheostomies can be avoided by following these principles and performing the procedure at the appropriate time, rather than when it becomes mandatory and urgent. Appropriate management of the tracheostomy subsequent to its performance includes adequate suctioning for the removal of tracheal secretions, adequate humidification to maintain liquidity of such secretions and use of the inflated tracheal cuff only in instances where a closed circuit is necessary for assisted or controlled ventilation or for the temporary prevention of aspiration of pharyngeal secretions. Soft low-pressure cuffs have been demonstrated to produce less tracheal erosion and subsequent stenosis than high-pressure rigid-walled cuffs. Once the need for tracheostomy has been resolved, the tube should be removed and the tracheal sinus allowed to close spontaneously. In those patients requiring long-term tracheostemy, the use of a valve in the inner cannula may be helpful with phonation, precluding the need for the patient to occlude the tracheostemy orifice each time he talks. Not all patients will be able to tolerate such Tucker valves, and a trial is necessary. Tracheostomies in children represent a much more demanding situation because ofspacial relationships relative to the cross-sectional area of the tracheostomy tube and of the trachea. With such small tracheas, the tracheal tube occupies a much larger percentage of the cross-sectional area and may actually produce complete obstruction at the level of the tube contact with the tracheal mucosa. Irl most adults, even with a high degree of respi38
ratory obstruction, partial occlusion of the tracheostomy tube by retained secretions can be tolerated without disaster. In children with the small tracheostomy tube lumen and the often accompanying laryngeal and tracheal mucosal edema, such minimal retained secretions may be life-threatening. Constant and meticulous nursing care is mandatory, with constant humidification and suctioning of secretions to prevent a tracheostomy and airway obstruction. Newer silicone elastomer tracheostomy tubes have been most helpful, and no longer is a whole series oftracheostomy tubes required to fit the individual circumstances of length, curvature and diameter. Such tubes are also treated to diminish the adherence of tracheal secretions to their lumen. Inner cannulas, while desirable, may no longer be mandatory. If the problem of airway obstruction is to be properly resolved without life-threatening complications, careful attention to prompt expeditious investigation and vigorous therapy must be pursued. Once the airway has been safely established, then its maintenance for as long as necessary requires appropriate nursing management and ultimately patient education on self-care. All these factors are critically more important in the pediatric age group. What may be an acute life-threatening situation may be quickly and appropriately resolved by careful investigation and appropriate vigorous treatment.
HEMORRHAGE Hemorrhage may ensue from massive head and neck cancers eroding major vessels or spontaneously from exposed necrotic arterial walls, usually subsequent to radiation, surgery and oral cutaneous fistula formation. Seldom will attempts to locally control such major arterial hemorrhage in the face of massive necrotic tumor and wound infection be successful, and graft replacement of such vessels is almost never indicated. One of the most common sources of major arterial hemorrhage from the mouth is a deeply invasive tumor of the base of the tongue erodingbranches of the external carotid artery. Such hemorrhage may require ligation of the external carotid artery, usually bilaterally because of extensive cross-collateral circulation, in order to control the hemorrhage. Only by ligating the vessel and interrupting its continuity can recanalization of such vessels be totally prevented. Carotid artery hemorrhage resulting from tumor erosion or postoperative complications is one of the most acute life-threatening emergencies seen. Such hemorrhage rarely occurs de novo and is usually heralded by a small transient bleeding prior to the major vascular rupture. Such hemorrhage never occurs from beneath intact skin or mucosa and is always preceded by wound breakdown, exposure of the vessel and necrosis of its wall. None of these events occurs suddenly, so that such arterial hemorrhage can usually be anticipated and predicted. Only by very careful 39
observation of such patients at risk can the hemorrhage be instantly detected and controlled. While prophylactic ligation of the carotid artery at risk of rupture has been proposed and practiced, the complication rate has not been significantly reduced over those patients whose artery was ligated in the presence of frank hemorrhage. The most important immediate step is control of the bleeding, which can usually be accomplished by direct finger pressure over the small rent in the vessel wall. Bulky pressure dressings seldom provide adequate compression of the precise bleeding point and simply mask the continuing hemorrhage. After hemorrhage has been controlled, then restoration of blood volume with return of vital signs to normal is mandatory before attempting any vascular ligation. If the carotid artery is ligated with the patient in acute hypotension, the risk of subsequent neurologic deficit is significantly increased. There is apparently an irreducible number of patients with anomalies of the cerebral circulation who will undergo significant permanent neurologic deficit following common or internal carotid artery ligation. Since there is seldom any other alternative, this risk must be assumed and accepted. In the face of neurologic wounds, necrotic blood vessels, previous radiation therapy and oral cutaneous fistulas, the alternatives to vascular interruption are contraindicated. Seldom is there room or indication for graft replacement of such vessels and, if such is accomplished, it will usually fail by virtue of thrombosis and]or recurrent hemorrhage. Every attempt should be made to ligate the vessel(s) above and below the point of rupture and to interrupt its (their) continuity. Such procedures are best done in the operating room, and hopefully through intact skin and not the necrotic wound itself. Ligation of the vessel within the confines of the wound predisposes the patient to further vessel necrosis and repeat hemorrhage. On some occasions, it will be impossible to obtain distal control of the internal carotid artery due to inadequate length of that vessel at the base of the skull or its incorporation into dense fibrous scar tissue or tumor, rendering its identification impossible. Under such circumstances, packing and pressure dressing may suffice to produce thrombosis with no further hemorrhage. When such inaccessibility of the common carotid artery occurs in the base of the neck, then it may be necessary to resect the head of the clavicle or, even more radically, to proceed through a separate transthoracic approach to ligate the common carotid artery at its junction with the innominate or aortic arch through healthy tissue. Once such vascular ligation has been carried out, it is imperative to prevent hypotension from any cause, since this appears to be one of the major determinants of permanent neurological sequelae. Such neurological sequelae may appear immediately subsequent to the vessel interruption, and almost certainly result from inadequate cerebral circulation secondary to vascular anomalies, or may be delayed for hours to days and probably relate to hypotension or 40
inadequate blood volume or progressive a r t e r i a l thrombosis. The efficacy of postarterial ligation anticoagulation remains a subject for debate. M a n y o f t h e s e patients have necrotic open g r a n u l a t i n g wounds t h a t m a y represent a source of f u r t h e r bleeding, which may contraindicate the use of anticoagulation. Th e best t r e a t m e n t of life-threatening h e m o r r h a g e is prevention. Tumors detected ear l y and adequat el y and vigorously treated seldom bleed excessively. Postoperative vascular complications can be reduced by thoughtful choice of candidates for surgery, careful selection of neck incisions, meticulous a t r a u m a t i c handling of tissues, Wound closures without tension and the use of carotid a r t e r y protection with muscle flap or dermis grafts. Deliberate controlled fistulas m a y prevent uncontrolled wound breakdown with necrosis and slough. Major a r t e r i a l h e m o r r h a g e can usually be anticipated and, with appropriate m anagem ent , may be prevented. Once such h e m o r r h a g e occurs, its immediate detection and vigorous t r e a t m e n t is m a n d a t o r y if the patient's life is to be salvaged. REFERENCES 1. Chew, J. Y., and Cantrell, R. W.: Trach~stomy complicationsand their management, Arch. Otolaryngol.96:538, 1972. 2. Brantigan, C. O.,.and Grow, J. B.: Cricothyroidotomy:Elective use in respiratory problems requiring tracheostomy, J. Thorac. Cardiovasc. Surg. 71:72, 1976. 3. Gaudet, P. T., et al.: Pediatric tracheostomyand associated complications,Laryngoscope88:1633, 1978. 4. Moore, O., and Baker, H.: Carotid artery ligation in surgery of the head and. neck; Cancer 8:712, 1955. 5. Leikensohn~J., Miiko, D., and Cotton, R.: Carotidartery rupture: Management and prevention of delayed neurolog!csequelae with low-dose heparin, Arch~ Otolaryngol. 104:307, 1978.
41
LIFE-THREATENING HEAD AND NECK EMERGENCIES are primarily those relating to airway obstruction and hemorrhage. As complications of cancer, neither occurs abruptly without preliminary warnings, which, to the astute observer, either patient or physician, should lead to appropriate investigation and treatment. Head and neck epidermoid carcinoma is usually sufficiently slowly growing that many weeks to months of growth are required before the tumor bulk reaches such size to produce these complications.
AIRWAY OBSTRUCTION Progressively enlarging neoplasms of the head and neck, particularly of the larynx, pharynx, base of tongue or thyroid, may ultimately produce airway compromise and obstruction. Such tumors generally produce other signs and symptoms long before the airway is compromised. However, patients still are seen initially with advanced cancers and increasing difficulty with swallowing, hoarseness, dyspnea and stridor, all indicative of impending airway obstruction. Such obstruction may be in the mouth or pharynx with locally advanced oral and/or pharyngeal tumors, in the larynx with bulky glottic or supraglottic lesions, in the trachea due to extrinsic compression by long-standing thyroid lesions or, more remotely, by direct tracheal invasion by aggressive thyroid cancers or, even more remotely, by primary tracheal neoplasms. A few patients will be seen with airway obstruction at the glottic level due to bilateral vocal cord paralysis in the adducted position, resulting from bilateral recurrent laryngeal nerve paralyses. Such paralysis may result from bilateral thyroid cancer, primary or metastatic pulmonary or other neoplasms or, rarely, may be idiopathic. In this setting, signs and symptoms may be more subtle and the cause of the recurrent laryngeal nerve dysfunction may not be immediately obvious. In the patient with signs and symptoms of increasing respiratory obstruction, prompt investigation and treatment are mandatory ifa fatal outcome is to be avoided. A brief history will usually direct the astute physician to the source of the problem. Expeditious head and neck examination is best accomplished without topical anesthesia, taking care not to tire the patient or otherwise further compromise the airway. Indirect examination with a laryngeal mirror will usually identify the site of obstruction. Repeated attempts to visualize and examine the hypopharynx 36
and larynx in the patient with a profoundly compromised airway may be sufficient to produce further decompensation demanding immediate emergency treatment. A plain chest roentgenogram may be helpful in identifying the level of airway compromise (and in ruling out intrinsic pulmonary disease), but soft tissue high kilovoltage roentgenograms may be even more helpful in outlining the pharyngeal, laryngeal and tracheal air columns, thus indicating the location of the airway obstruction. This information is of vital importance in identifying the nature and location of the problem and in deciding how to correct it. Tracheostomy will usually be required in those patients with bulky pharynx, larynx and thyroid neoplasms for the relief of airway obstruction. Attempts at peroral endotracheal intubation in the face of bulky, friable laryngeal and/or pharyngeal tumors are ill advised, often leading to bleeding, further edema and aggravation of the airway obstruction, precipitating the need for immediate emergency tracheostomy. Most patients with such lesions will require sufficiently prolonged intubation before their airway obstruction is relieved by appropriate tumor therapy as to require tracheostomy anyway. Whenever possible, tracheostomy should be done under controlled circumstances in the operating room with adequate assistance and illumination, appropriate instruments and tracheostomy tubes. I t is our policy to routinely use cuffed tracheostomy tubes, so that if controlled ventilation or cuff inflation to prevent aspiration is necessary, the cuff will be immediately available. The changing of tracheostomy tubes in the immediate postoperative period is dangerous because the tracheostomy tract will not have been well established and difficulties may be encountered in inserting the tube back into the trachea. Rarely, a patient's life is lost because of an inability to reinsert the tracheostomy tube in the presence of high-grade airway obstruction. It may be necessary to perform the tracheostomy with the patient under local anesthesia. Sedation may be contraindicated because of the high degree of respiratory obstruction. In those patients in whom it is anticipated that ultimate surgical removal of the tumor will be carried out, high tracheostomy may be indicated, in an attempt to avoid cutting directly through tumor, yet to allow total removal of the tracheostomy sinus at the time of the definitive surgery. In the acute emergency situation, cricothyroidotomy may be lifesaving; recent studies suggest that the procedure may not carry the high rate of complications once attributed to it. There appears to be no need for the use of tracheostomy tubes larger than no. 6. The tube must be appropriately positioned in the trachea so as not to traumatize the tracheal wall or carina. A tube that pulsates synchronously with the arterial pulse is probably resting against the anterior tracheal wall at the level of the innominate artery and should be replaced with a shorter tube to prevent erosion of that wall with life-threatening 37
hemorrhage. The tube must be appropriately positioned so that its distal lumen is entirely within the trachea and will be maintained there when the patient moves. It is imperative to securely fix the tube around the neck to insure its proper position. In the patient with a large, thick, short neck, maintenance of tube placement may be more difficult; under such circumstances, it may be appropriate to fix the tracheostomy tube directly in relationship to the trachea, with a suture througn the tube and the tracheal wall. Tube dislodgement may be catastrophic and must be prevented. Signs of such dislodgement include recurrent airway obstruction, no air flow via the tracheostomy tube when the patient breathes, a normal voice with the tracheostomy tube in place or failure to be able to suction via the tracheostomy tube. Any of these findings should alert the appropriate responsible attendant to this possibility and result in prompt investigation and correction of the problem. Tracheostomy is indicated in any patient in whom airway compromise is present or anticipated. Tracheostomy is routinely performed as part of the operative procedure for partial laryngectomy, either horizontal supraglottic or vertical partial, extensive surgery for pharyngeal wall neoplasms, with second or bilateral radical neck dissections or with interruption of the mandible with resultant loss of support of the tongue. Most emergency tracheostomies can be avoided by following these principles and performing the procedure at the appropriate time, rather than when it becomes mandatory and urgent. Appropriate management of the tracheostomy subsequent to its performance includes adequate suctioning for the removal of tracheal secretions, adequate humidification to maintain liquidity of such secretions and use of the inflated tracheal cuff only in instances where a closed circuit is necessary for assisted or controlled ventilation or for the temporary prevention of aspiration of pharyngeal secretions. Soft low-pressure cuffs have been demonstrated to produce less tracheal erosion and subsequent stenosis than high-pressure rigid-walled cuffs. Once the need for tracheostomy has been resolved, the tube should be removed and the tracheal sinus allowed to close spontaneously. In those patients requiring long-term tracheostemy, the use of a valve in the inner cannula may be helpful with phonation, precluding the need for the patient to occlude the tracheostemy orifice each time he talks. Not all patients will be able to tolerate such Tucker valves, and a trial is necessary. Tracheostomies in children represent a much more demanding situation because ofspacial relationships relative to the cross-sectional area of the tracheostomy tube and of the trachea. With such small tracheas, the tracheal tube occupies a much larger percentage of the cross-sectional area and may actually produce complete obstruction at the level of the tube contact with the tracheal mucosa. Irl most adults, even with a high degree of respi38
ratory obstruction, partial occlusion of the tracheostomy tube by retained secretions can be tolerated without disaster. In children with the small tracheostomy tube lumen and the often accompanying laryngeal and tracheal mucosal edema, such minimal retained secretions may be life-threatening. Constant and meticulous nursing care is mandatory, with constant humidification and suctioning of secretions to prevent a tracheostomy and airway obstruction. Newer silicone elastomer tracheostomy tubes have been most helpful, and no longer is a whole series oftracheostomy tubes required to fit the individual circumstances of length, curvature and diameter. Such tubes are also treated to diminish the adherence of tracheal secretions to their lumen. Inner cannulas, while desirable, may no longer be mandatory. If the problem of airway obstruction is to be properly resolved without life-threatening complications, careful attention to prompt expeditious investigation and vigorous therapy must be pursued. Once the airway has been safely established, then its maintenance for as long as necessary requires appropriate nursing management and ultimately patient education on self-care. All these factors are critically more important in the pediatric age group. What may be an acute life-threatening situation may be quickly and appropriately resolved by careful investigation and appropriate vigorous treatment.
HEMORRHAGE Hemorrhage may ensue from massive head and neck cancers eroding major vessels or spontaneously from exposed necrotic arterial walls, usually subsequent to radiation, surgery and oral cutaneous fistula formation. Seldom will attempts to locally control such major arterial hemorrhage in the face of massive necrotic tumor and wound infection be successful, and graft replacement of such vessels is almost never indicated. One of the most common sources of major arterial hemorrhage from the mouth is a deeply invasive tumor of the base of the tongue erodingbranches of the external carotid artery. Such hemorrhage may require ligation of the external carotid artery, usually bilaterally because of extensive cross-collateral circulation, in order to control the hemorrhage. Only by ligating the vessel and interrupting its continuity can recanalization of such vessels be totally prevented. Carotid artery hemorrhage resulting from tumor erosion or postoperative complications is one of the most acute life-threatening emergencies seen. Such hemorrhage rarely occurs de novo and is usually heralded by a small transient bleeding prior to the major vascular rupture. Such hemorrhage never occurs from beneath intact skin or mucosa and is always preceded by wound breakdown, exposure of the vessel and necrosis of its wall. None of these events occurs suddenly, so that such arterial hemorrhage can usually be anticipated and predicted. Only by very careful 39
observation of such patients at risk can the hemorrhage be instantly detected and controlled. While prophylactic ligation of the carotid artery at risk of rupture has been proposed and practiced, the complication rate has not been significantly reduced over those patients whose artery was ligated in the presence of frank hemorrhage. The most important immediate step is control of the bleeding, which can usually be accomplished by direct finger pressure over the small rent in the vessel wall. Bulky pressure dressings seldom provide adequate compression of the precise bleeding point and simply mask the continuing hemorrhage. After hemorrhage has been controlled, then restoration of blood volume with return of vital signs to normal is mandatory before attempting any vascular ligation. If the carotid artery is ligated with the patient in acute hypotension, the risk of subsequent neurologic deficit is significantly increased. There is apparently an irreducible number of patients with anomalies of the cerebral circulation who will undergo significant permanent neurologic deficit following common or internal carotid artery ligation. Since there is seldom any other alternative, this risk must be assumed and accepted. In the face of neurologic wounds, necrotic blood vessels, previous radiation therapy and oral cutaneous fistulas, the alternatives to vascular interruption are contraindicated. Seldom is there room or indication for graft replacement of such vessels and, if such is accomplished, it will usually fail by virtue of thrombosis and]or recurrent hemorrhage. Every attempt should be made to ligate the vessel(s) above and below the point of rupture and to interrupt its (their) continuity. Such procedures are best done in the operating room, and hopefully through intact skin and not the necrotic wound itself. Ligation of the vessel within the confines of the wound predisposes the patient to further vessel necrosis and repeat hemorrhage. On some occasions, it will be impossible to obtain distal control of the internal carotid artery due to inadequate length of that vessel at the base of the skull or its incorporation into dense fibrous scar tissue or tumor, rendering its identification impossible. Under such circumstances, packing and pressure dressing may suffice to produce thrombosis with no further hemorrhage. When such inaccessibility of the common carotid artery occurs in the base of the neck, then it may be necessary to resect the head of the clavicle or, even more radically, to proceed through a separate transthoracic approach to ligate the common carotid artery at its junction with the innominate or aortic arch through healthy tissue. Once such vascular ligation has been carried out, it is imperative to prevent hypotension from any cause, since this appears to be one of the major determinants of permanent neurological sequelae. Such neurological sequelae may appear immediately subsequent to the vessel interruption, and almost certainly result from inadequate cerebral circulation secondary to vascular anomalies, or may be delayed for hours to days and probably relate to hypotension or 40
inadequate blood volume or progressive a r t e r i a l thrombosis. The efficacy of postarterial ligation anticoagulation remains a subject for debate. M a n y o f t h e s e patients have necrotic open g r a n u l a t i n g wounds t h a t m a y represent a source of f u r t h e r bleeding, which may contraindicate the use of anticoagulation. Th e best t r e a t m e n t of life-threatening h e m o r r h a g e is prevention. Tumors detected ear l y and adequat el y and vigorously treated seldom bleed excessively. Postoperative vascular complications can be reduced by thoughtful choice of candidates for surgery, careful selection of neck incisions, meticulous a t r a u m a t i c handling of tissues, Wound closures without tension and the use of carotid a r t e r y protection with muscle flap or dermis grafts. Deliberate controlled fistulas m a y prevent uncontrolled wound breakdown with necrosis and slough. Major a r t e r i a l h e m o r r h a g e can usually be anticipated and, with appropriate m anagem ent , may be prevented. Once such h e m o r r h a g e occurs, its immediate detection and vigorous t r e a t m e n t is m a n d a t o r y if the patient's life is to be salvaged. REFERENCES 1. Chew, J. Y., and Cantrell, R. W.: Trach~stomy complicationsand their management, Arch. Otolaryngol.96:538, 1972. 2. Brantigan, C. O.,.and Grow, J. B.: Cricothyroidotomy:Elective use in respiratory problems requiring tracheostomy, J. Thorac. Cardiovasc. Surg. 71:72, 1976. 3. Gaudet, P. T., et al.: Pediatric tracheostomyand associated complications,Laryngoscope88:1633, 1978. 4. Moore, O., and Baker, H.: Carotid artery ligation in surgery of the head and. neck; Cancer 8:712, 1955. 5. Leikensohn~J., Miiko, D., and Cotton, R.: Carotidartery rupture: Management and prevention of delayed neurolog!csequelae with low-dose heparin, Arch~ Otolaryngol. 104:307, 1978.
41