Complications in Head and Neck Surgery

Hemorrhage & Hematoma - Code Red Bleeds

• Types: Primary (intra-op), Reactionary (within 24 hrs, e.g., slipped ligature, post-op hypertension), Secondary (>24 hrs, often infection, vessel erosion). Hematoma: localized collection.
• ⚠️ Warning: Expanding neck hematoma → airway emergency! Secure airway immediately.
• Management:
  • Direct pressure, IV access, blood products.
  • Urgent surgical exploration: evacuate hematoma, identify & ligate bleeder.
  • Angioembolization for selected cases.

⭐ Carotid blowout (e.g., post-radiotherapy, fistula) is a catastrophic "Code Red" bleed; often heralded by sentinel bleeds (minor premonitory bleeding).

Wound Complications - Suture Setbacks

• Definition: Failure of sutures to maintain wound approximation, leading to healing issues.
• Types & Manifestations:
  • Dehiscence: Partial or complete separation of approximated wound layers.
  • Stitch Abscess: Localized infection with pus collection around a suture.
  • Suture Granuloma: Chronic inflammatory foreign body reaction to suture material.
• Key Causes: Infection, poor surgical technique (e.g., knots, spacing), excessive wound tension, patient factors (malnutrition, diabetes, steroids, smoking, prior radiation).
• Management: Address cause, local wound care, antibiotics for infection, consider resuturing or secondary intention healing.

  ⭐ Silk (non-absorbable, multifilament) is notorious for causing suture granulomas and stitch sinuses if left in situ.

Nerve Injuries - Circuit Breakers

• Facial N. (CN VII):
  • Marginal Mandibular Br.: Most common in neck dissection. ↓ Lower lip depressor function (asymmetric smile).
  • Temporal Br.: ↓ Frontalis function (eyebrow droop).
• Spinal Accessory N. (CN XI):
  • Neck dissection risk. Shoulder droop, ↓ trapezius function, weak arm abduction > 90°.

  ⭐ Winging of scapula is a classic sign of CN XI injury.

• Vagus N. (CN X) Branches:
  • Recurrent Laryngeal N. (RLN): Thyroidectomy risk. Unilateral: Hoarseness. Bilateral: Stridor, airway compromise.
  • Superior Laryngeal N. (SLN): ↓ Pitch control, voice fatigue (cricothyroid paralysis).
• Hypoglossal N. (CN XII):
  • Submandibular surgery risk. Tongue deviates to lesion side on protrusion.
• Lingual N.:
  • Floor of mouth/submandibular surgery. ↓ Sensation & taste (anterior ⅔ tongue).
• Phrenic N.:
  • Radical neck dissection risk. Diaphragm paralysis (elevated hemidiaphragm).

Airway & Swallowing Woes - Passage Perils

• Airway Obstruction: Critical, requires prompt action.
  • Causes: Hematoma (⚠️ rapid, neck swelling), edema (laryngeal, flap), secretions, bilateral RLN palsy.
  • Tracheostomy issues: Bleeding, infection, stenosis, tracheo-innominate fistula (TIF) - ⚠️ life-threatening, often presents with sentinel bleed.
• Swallowing Dysfunction (Dysphagia): Common, impacts recovery.
  • Causes: Cranial nerve palsies (CN IX, X, XII), post-op edema, fibrosis, flap bulk, severe pain.
  • Risks: Aspiration pneumonia, malnutrition, dehydration.
  • Assessment: Bedside swallow eval, FEES (Fiberoptic Endoscopic Evaluation of Swallowing), MBS (Modified Barium Swallow).
  • Management: Swallowing therapy, diet modification, enteral feeding (NGT/PEG).

⭐ Unilateral RLN injury causes hoarseness; bilateral injury can cause stridor & acute airway obstruction, often needing urgent tracheostomy.

Fistulas & Leaks - Leaky Pipes

• Pharyngocutaneous Fistula (PCF): Salivary leak post-laryngectomy/pharyngectomy.
  • Risks: Prior RT, malnutrition, DM, infection, tension.
  • Signs: Wound discharge (saliva/pus), erythema, fever.
  • Mx: Conservative (NPO, antibiotics, local care); surgical closure if fails.
• Chyle Leak: Thoracic duct (L > R) or major lymphatic injury.
  • Signs: Milky drain output (triglycerides >110 mg/dL), electrolyte imbalance.
  • Mx: Conservative (pressure, low-fat/MCT diet, octreotide); surgical ligation if persistent (e.g., >1 L/day or >5 days).

  ⭐ Chyle fluid: Triglycerides >110 mg/dL, +ve chylomicrons, lymphocyte predominant.

High‑Yield Points - ⚡ Biggest Takeaways

• Frey's syndrome: Gustatory sweating after parotidectomy; auriculotemporal nerve injury.
• Chyle leak: Typically after left neck dissection (thoracic duct); initial conservative management.
• Hypocalcemia: Common post-total thyroidectomy due to parathyroid injury/devascularization.
• RLN injury: Hoarseness (unilateral). SLN injury: Voice fatigue, high-note loss.
• Wound complications: Infection/dehiscence risk ↑ with radiation, malnutrition, pharyngocutaneous fistula.
• Carotid blowout: Rare, life-threatening; risk factors: salivary fistula, infection, radiation.
• Pneumothorax: Risk during neck dissection, particularly near lung apex.