A brief account of diagnosis,assessing and airway management options of patients who develop neck haematoma after surgery in the neck. An anaesthetists perspective.

1. DR CHIRANJIB BHATTACHARYYA
ASSOCIATE PROFESSOR, DEPT. OF
ANAESTHESIOLOGY AND CRITICAL CARE
INSTITUTE OF POSTGRADUATE MEDICAL
EDUCATION AND RESEARCH, KOLKATA

2. 
 1% of neck surgeries require reexploration due to
postoperative bleeding
 Thyroid surgery
 Parathyroid surgery
 Carotid endarterectomy
 Anterior cervical spine surgery
 Int. jugular vein cannulation
 Diagnostic procedures like FNAC of neck mass
THE PROBLEM

3. 
 Compressive haematoma : ? Direct mechanical compression
 Intrinsic airway oedema : due to impaired venous &
lymphatic drainage from mass effect of a clot
 Marked supraglottic oedema can occur
 Epiglottis, aryetenoids appear deformed and obscured
 External neck swelling doesn’t match severity of supraglottic
oedema
 Resolution of oedema is typically slow
 Spontaneous respiration & Dir. Laryngoscopy seriously
impeded
HAEMATOMA & AIRWAY COMPROMISE

4. 
 Carmichael etal (Anesth Analg 1996;83:12-7)
 Preop & postop CT Scan of neck to assess airway dimensions
 Airway assessed at 6h postop by paed FFOB
 Bedside spirometry to assess airway obstruction based on
midexpiratory/midinspiratory flow ratio
 5 patients needed reintubation for postop airway
obstruction
 ‘Very difficult’ !
 Massive soft tissue swelling
 Shift of larynx away from side of surgery
CT ANALYSIS OF AIRWAY DIMENSIONS
AFTER CEA

5. 
 Haematoma detected in all pts of reintubation group
 Trachea deviated significantly in reintubation group
 Transverse diam of airway reduced by 62%
 A-P diam of airway reduced by 44%
 Retropharyngeal space increased more than 4 times
 Airway volume reduced by more than 62%
 Neck swelling extended bilaterally
 Significant swelling of tracheal mucosa
 Spirometry showed no significant difference
FINDINGS

6. 

7. 
POSTOP. WOUND HAEMATOMA : CL.
FEATURES

8. 
 Rapid and unpredictable deterioration of respiratory &
haemodynamic status
 Close monitoring by anaesthetic & surgical team
 ? Availability of senior & experienced personnel
 ? Availability of full range of airway equipment
 Unfamiliarity with pts earlier anaesthesia details
 ‘Easy’ airway in the morning now difficult
 Front of neck access may be difficult
 SGA placement may be difficult
 Readiness to face CICO situation
CHALLENGING MANAGEMENT ISSUES

9. 
o DL & endotracheal intubation : awake or under GA
o FFOB guided tracheal intubation
o Use of SGA to maintain airway eg LMA
o Rescue techniques eg cricothyrotomy, TTJV
o Surgical tracheostomy
AIRWAY MANAGEMENT OPTIONS

10. 
Shakespeare et al, Anesth Analg 2010;110(2):588-93

11. 
 Avoids a difficult DL
 Inherent safety as spont respn is maintained
 Pitfalls with use of FOB here :
 Definite failure rate due to altered anatomy and
mucosal oedema
 Pt must be stable enough to tolerate the procedure
 Epistaxis may complicate when marked nasal mucosal
congestion occurs
F F O B

12. 
CT SCAN

13. 
 DL using topical LA with or without mild sedation
 With impending respiratory arrest DL can be attempted
without spending time for topical airway anaesthesia
 DL after induction of GA is an option if reasonably
certain of being able to ventilate and intubate
 Post-induction haemodynamic instability may occur
 Role as a rescue technique after failed attempt with
FFOB.
 Second attempt DL may be successful after evacuation
of the haematoma
DIRECT LARYNGOSCOPY

14. 
 Has been successfully used to maintain airway in pts
presenting with significant dyspnoea with stridor
 Spont ventilation & sevoflurane inhalation followed by
evacuation of haematoma
 Allowed visualisation of laryngeal inlet & decision for
tracheostomy
 PLMA has been used in presence of failed FMV,DL & FOB
 Restored oxygenation & subsequent tracheal intubation
 LMA failure : cuff kinking, multiple attempts,severe
obstruction distal to cuff, size selection difficult, etc
L M A

15. 
 Percutaneous TTJV : immediate oxygenation in a CICO scene
 High intratracheal pr from JV may open collapsed v cords and
the airway
 Facilitates intubation by DL because of assisted visualisation
of laryngeal inlet
 Problems :
 Identifying the airway could be v difficult
 Barotrauma from incomplete exhalation because of
extremely narrowed airway, airway injury
 Special equipment, training to operate, technique not
standardised
RESCUE TECHNIQUES

16. 
 Repeated attempts at intubation to be avoided
 Decision for tracheostomy should be taken promptly
 Surgical team prepared from the onset
 Localisation of trachea difficult due to considerable deviation
of trachea
 Role of USG :
 Helps in localisation of the midline
 Detects aberrant vessels
 Must be immediately available & ready for use
 Skilled operator available
TRACHEOSTOMY

17. 
 Planned procedure
 Most require 12-24 hours of ventilation to let oedema
subside
 Safe to extubate when audible leak present with PPV of
15cm H2O
 Inspect airway with FOB before extubation
 Look for mobility of vocal cords
EXTUBATION

18. 
 Continuous high flow O2 to be administered while
airway is being secured
 Exploration of the wound under LA infiltration or
superficial cervical plexus block
 Haematoma evacuated and bleeding points secured
below platysma & deep fascia
 Avoid injury to vessels & nerves
 Haemodynamic support
GENERAL MEASURES

19. 
 No evidence based guidelines available
 Decision to intervene based on clinical findings
 Low threshold for surgical airway
 Most experienced anaesthetic & surgical personnel
available should take control of airway.
TO CONCLUDE

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