Carotid blowout following successful treatment with primary chemoradiotherapy a new problem?

Tuesday, October 8, 2013: 2:15 PM
El Muiz Mustafa MBBS BDS MRCS MSc DIC, Oral and Maxillofacial Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
Dilip Srinivasan BDS, FDS, MBBS, FRCS, Oral & Maxillofacial Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
Phillip Hollows MBChB,BDS,FDSRCS,FRCS,FRCS(OMFS),MSc, Oral and Maxillofacial Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
Iain McVicar BMedSci,BMBS,BDS,FDSRCSEng,FRCSEd,FRCSEng,MMedSci(Clin Ed), Oral and Maxillofacial Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
Carotid blowout following successful treatment with primary chemoradiotherapy – a new problem?

Carotid blowout syndrome (CBS) has been classified into three distinct categories. The first - “threatened bleeding”, is characterised by the exposure of the carotid vessels.  “Sentinel haemorrhage” is characterized by an episode of bleeding, which may resolve spontaneously. “Acute rupture” is characterized by profuse haemorrhage that may be difficult to control.

Historically, CBS was associated with those patients who had undergone a radical neck dissection and radiotherapy.  Many of these patients had disease progression and a lack of covering tissue led to haemorrhage.  In 2012, Esteller E et al (1) described two patients who represent a new group of patients with CBS.  These patients have had successful chemoradiotherapy, but develop necrosis secondary to treatment and have no evidence of recurrence.  Necrosis without histologically proven recurrence can cause exposure of the great vessels and CBS.

We describe three similar cases that had ulceration following chemoradiotherapy and went on to develop CBS.  All three survived acute ruptures following interventional radiology. Two cases had coverage of the carotid bifurcation with a sternomastoid flap, which was found to be easy to use and reliable. We propose a more active management of CBS in these patients, who are likely to become more common with the increasing use of primary chemoradiotherapy for oropharyngeal tumours.

  1. Esteller E et al  “Delayed carotid blow -out syndrome: a new complication of chemoradiotherapy treatment in phayngolaryngeal carcinoma” J Laryngol Otol 2012; 126:1189-119
  2. Coehn J et al “Contemporary management of carotid blowout.”Curr Opin Otolaryngol Head Neck Surg. 2004 Apr;12(2):110-5.