INTRODUCTION
Carotid blow-out syndrome (CBS) is one of the uncommon complications in head and neck cancer(1)(2). It may occur due to tumor invasion or fibrosis of adventitia of the artery as a complication of cancer treatment resulting in rupture of carotid artery(3). Common presenting symptoms are catastrophic bleeding from oral cavity, oropharynx or an exposed wound on the neck. Incidence of CBS in patients with major head and neck surgery ranges between 3-4.5%(4)(5), with 7.6 fold increase with previous history of irradiation(6). There are various risk factors such as prior radiotherapy, prior radical neck dissection, mucocutaneous fistula, flap necrosis, wound infection, poor nutrition and tumor recurrence(7); with previous curative radiotherapy being the main risk factor after salvage surgery, especially a total radiation dose over 70 Gy(5)(8). Incidence of CBS following re-irradiation may increase up to 17%(5). Another factor is tumor encasement of carotid artery, infiltration of carotid wall by tumor causing inflammation and weakening of carotid artery(5)(9). Although modern surgical reconstruction methods decreased the rate of CBS, morbidity and mortality still remains with rates up to 76% for mortality(10) and 16-60% for neurologic morbidity(11).
Prevention may be the most effective treatment by using various reconstructive procedures such as myocutaneous flaps to hinder the exposure of carotid artery and to avoid pharyngocutaneous fistula(7). Ligation of common carotid artery (CCA) or internal carotid artery (ICA) is the traditional management of CBS with higher rates of neurologic sequela(4). Yet another and more frequent option is embolization or stenting of carotid artery by endovascular approach with less complication rates. However, not every patient is suitable for endovascular approach; patients with open wound and active bleeding are still being managed by ligation.
There is no timeline for development of CBS in patients with uncontrollable tumors. In few reports regarding salvage surgery, carotid rupture was seen within 10-40 days following surgery(5), yet there is no knowledge in literature about the time to carotid rupture due to unresectable tumors or patients with open wounds. In this report we intended to review our cases with CBS with special emphasis on risk factors, timeline for carotid rupture as well as the outcomes following ligation.