neck dissection oncosurgery

1. Dr. SANJAY MAHARJAN
1ST YR RESIDENT, ENT-HNS,
MTH, POKHARA.
Complication of neck dissection &
its management.

2. Introduction:
 Murphy’s pessimistic law, if anything can go
wrong, it will. Is a reminder that unless attempts are
made to avoid it, complications are likely to occur
 Complications following head and neck surgery are
inevitable
 An essential component of pre-operative counseling
and obtaining informed consent.

3. Classification:
 Major and minor
 Early, intermediate and late
 Local and systemic
 General and specific
 20% will have major complications
 Mortality rate 1%

4. Immediate local complication:
 Bleeding:
 Should be detected long before
changes in vitals
 Potential sources:
o Suture lines
o Skin flaps
o Major vessels: ECA, Thyrocervical, IJV
 May be due to use of small drain (12 Fr
preferred)

5.  Management of bleeding:
o Diagnosis of problem
o Resuscitation (wide bore cannula, volume
replacement, bld transfusion)
o Stopping the bleed
o Treating cause
o Re-exploration (to find and ligate)
 Delay  chance of major vessel exposure, infection
and rupture ↑
 Applying pressure dressings or packing bleeding

6.  Shock:
 D/to massive bld loss & insufficient volume
replacement
 Shock index = HR/systolic BP
o Index 1 to 1.5  impending shock
o Index 1.5 or higher  danger
 Rx:
o Immediate replacement of blood with packed red blood
cell transfusion

7.  Airway obstruction:
 Edema d/to extensive resection of tissue
 Blood, mucus or secretions plugging ET tube
 Prevention:
o Elective tracheostomy
o Aphorism; “if a tracheostomy comes in ones mind
then that is the time to do it."

8.  Increased intracranial pressure:
 ↑ 3 fold when 1 IJV is divided
 ↑ 5 fold when b/l IJV divided
 Often returns to normal in 24hrs
 Seldom cause symptoms unless Both IJV tied
simultaneously
 Signs and symptoms:
o Restlessness & headache
o Slowing of pulse
o ↑ BP

9.  Cyanosed lips and ears + pink & warm extremities
suggests ligation of major neck vein (NOT peripheral
caynosis)
 Reducing risk of raised ICP:
o Avoiding Dressings around neck
o Restricting neck hyper-extension
o Pt. in sitting position a.s.a.p. after surgery
 Mx:
o Pt. kept in sitting position
o 200 ml of 25% mannitol IV and urinary catheter
o Reversed within 10-15mins

10.  Carotid sinus
syndrome:
 ↑ carotid arterial pressure =
↓ pulse and BP
 d/to manipulation at
operation
 Post operative scarring may
leave sinus in highly
sensitive state

11.  Nerve injury:
 Nerves that may be
involved
o Facial nerve or its
Mandibular or cervical
division
o Hypoglossal and Lingual
nerves
o Vagus, Symphathetic
trunk, Phrenic nerve or

13. Immediate general complications:
 Pneumothorax:
 Cervical pleura may be damaged
 pt. becomes restless, cyanosed or dyspnoeic after OT
 Clinical features:
o Hyper-resonance to percussion
o Hyper-inflation
o Diminished breath sound
o Trachea deviated away (if under tension)

14.  Air embolism:
 Injury to IJV or subcalvian with dehiscent wall
 May occur after removal of neck drain
 Prevention:
o Pressure bandage for 1day after drain removal
o Direct digital pressure and trendelenberg position if
accidental opening of large veins before clamping
 Produces precipitous fall in BP, cogwheel mumur
 Rx:
o Pt. put in left lat position, air withdrawn by syringe via

15. Intermediate local complications:
 Chylous fistula
 Seroma
 Skull base syndrome
 Wound infection
 Failure of skin healing
 Carotid artery rupture
 Flap failure
 Fistula formation

16.  Chylous fistula:
 Occurs usu. while operating low on the left side of neck
 1-2.5%
 Should recognize at surgery
 Pt head down and leak exaggerated by modified
valsalva instigated by anesthesist
 Dramatic ↑ suction drainage volume after pt is fed
 May also occur from jugular lymph duct on R. & its
communicating branches

17.  Chyle duct injury may
manifest as:
o Chyloma: subcutaneous
fluid accumulation
o Chyle fistula: persistent
serous or milky secretion,
local tissue inflammation
o Chylous thorax: most
serious
 Severe leak leads to
hyponatremia,

18.  Small leaks (<400ml/day) : conservative Mx
 NPO
 Low fat enteral diet
 Pressure on supra-clavicular fossa
• Major leaks (>600ml/day) :
 Reopen lower part of neck, find injured duct &
oversew with silk

19.  Seroma:
 pocket of clear serous fluid, composed
of blood plasma and inflammatory fluid
 Occur in 1st 48 hrs after removal of drain
 In Supracalvicular fossa (most
dependent part)
 Fossa must have dip when pt. hunch his
shoulder
 Prevented by using suction drainage
 Mx:
o Daily wide bore needle aspiration and

20.  Skull base syndrome:
 Temporary paresis and dysfunction of lower cranial
nerves
 Temporary facial paresis, changes in voice or difficult
swallowing
 Conservative treatment

21.  Infection:
 four most important factors
o 1. Contamination of surgical field.
o 2. Contamination of surgical field as operation
involves in-continuity RND and primary excision
o 3. Postoperative hematoma which then becomes
infected.
o 4. Flap necrosis and wound breakdown.

22.  Failure of skin healing:
 Minor wound breakdown is not uncommon
 Prevented by use of
o meticulous surgical technique
o appropriate incisions
o prophylactic ab and
o post-op surgical drain
 General factors related are poor nutrition, cachexia,
uncontrolled diabetes, RF and anemia

23.  IJV rupture:
 Multiple small bleeding episodes, aggravated by
coughing
 Mx:
o Surgical exploration and ligation distant from site of
fistula

24.  Carotid artery rupture:
 d/to culmination of several
complications, i.e.
o Irradiated patient
o Wound break down d/to improper
incision, i.e. With vertical component
and 3 point junction
o Infections  Arteries exposed 
Gangrene of their walls and
thrombosis of vasa vasorum
Rupture of artery

25.  Common sites of rupture:
 Carotid bulb at bifurcation
 CCA Just inferior to bulb
 ICA, beyond bifurcation

26.  Prevention:
 Protected by m/s graft in irradiated pt.(dermal graft
harvested from thigh or levator scapulae flap)
 Saving arteries of vaso vasorum, thyrocervical trunk
 Avoiding stripping of adventitia of carotid sheath

27.  Mx:
 Never occurs unheralded, initial 100-200ml of brisk,
brief, self controlling bleed 24hrs. before rupture
 Cuffed tracheostomy tube
 4 units blood cross matched
 All dead tissue excised and artery covered by frequent
moist soaks
 Head down, BP and arterial CO2 tension maintained
 Carotid isolated under healthy skin & tissue, and tied
with trans fixation stitch

28.  Flap failure:
 Flaps need to be checked
for its;
o Color
o Temperature
o Presence or absence of
capillary refill time
o texture

29.  Predisposing factor for Necrosis of neck skin flap
 Less than 90 angle between incision lines
 Pre-operative radiotherapy
 Use of monopolar cautery near skin
 Constant traction by sutures anchoring skin to drapes
 Drying of tissue in absence of regular saline irrigation

30.  Fistula:
 Causes:
o Previous radiotherapy
o Inadequate control of nutritional status, diabetes and
anemia
o Poor operative technique, like poor suturing
o Untreated seroma, hematoma or abscess
o Post-op anemia, hypoalbuminemia
 Occurs when suture line gives a way or when tissue
becomes necrotic

31.  Mx:
 Fistula on suture line closes spontaneously
 Epithelium formation along edges of tract should be
prevented and fistula covered and packed with
dressing
 Established fistula, closure must be obtained both
internally & externally and gap filled in between with
vascularized tissue

32. Intermediate general complication:
 Basal collapse:
 u/l or b/l in 1st 48hrs
 Rx:
o Vigorous physiotherapy and appropriate ab
 Bronchopneumonia:
 Relates to coexistent smoking related lung dzs, associated
tracheostomy and lengthy operations
 Rx:
o Physiotherapy and ab

33.  Deep vein thrombosis:

34.  Prophylaxis for prevntion:
o Early mobilization
o Graduated compression stockings until fully mobile
o Peri & post-operative SC heparin until mobile
o Perioperative intermittent pneumatic compression

35. Late complications:
 Primary recurrence:
 m/c within 1st 2 yrs of initial treatment
 Parotid gland tail hypertrophy:
 Common complication
 FNAC provides further reassurance
 Swelling at amputated tail of parotid gland after few
weeks of RND

36.  Lymphoedma:
 When both IJVs are tied
 d/to interruption of lymphatic drainage from head
 Steps to minimize:
o Forgoing dressings
o Sitting upright
o Steroids
o Mannitol

37.  Hypertrophic scars: