Complication of neck dissection &

its management.
Dr. SANJAY MAHARJAN
1ST YR RESIDENT, ENT-HNS,
MTH, POKHARA.
 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.
Classification:
 Major and minor

 Early, intermediate and late

 Local and systemic

 General and specific

 20% will have major complications

 Mortality rate 1%
 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)
 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
 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
 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."

 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
 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

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

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)

 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

Intermediate local complications:
 Chylous fistula

 Seroma

 Skull base syndrome

 Wound infection

 Failure of skin healing

 Carotid artery rupture

 Flap failure

 Fistula formation
 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
 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,
 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

 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

 Skull base syndrome:

 Temporary paresis and dysfunction of lower cranial

nerves

 Temporary facial paresis, changes in voice or difficult

swallowing

 Conservative treatment
 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.

 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

 IJV rupture:

 Multiple small bleeding episodes, aggravated by

coughing

 Mx:

o Surgical exploration and ligation distant from site of

fistula
 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
 Common sites of rupture:

 Carotid bulb at bifurcation

 CCA Just inferior to bulb

 ICA, beyond bifurcation

 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

 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

 Flap failure:

 Flaps need to be checked

for its;

o Color

o Temperature

o Presence or absence of

capillary refill time

o texture
 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

 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
 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
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
 Deep vein thrombosis:
 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
 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
 Hypertrophic scars: