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.