Head And Neck

Tonsillectomy is probably the most common surgical procedure in otorhinolaryngology. Yet, the best way to achieve haemostasis in this procedure is often debated by surgeons. Pressure with plain packs or packs soaked with a haemostatic agent are used. Ice has also been used over the tonsillar beds after resection. In addition, ties have been used to ligate specific bleeding points. Other methods using electrical means include mono-polar, bi-polar, and coblator diathermy. Instrumentation, such as, harmonic scalpel, have also been tried.7 The most important technique, and the one used by probably all surgeons, is the haemostatic, pause. The act of waiting for several minutes and relaxing the pressure applied to the tissues aids in clotting and haemosta-sis, or discovering smaller bleeding points prior to completion. Early results of a national audit into tonsillectomy showed that the most used technique in tonsillectomy haemostasis is bipolar diathermy. The technique which produced the lowest proportion of primary or secondary haemorrhage after dissection, however, involved the use of ties alone.8

Another relatively common head and neck procedure undertaken is thyroidectomy and parathyroidectomy. Significant postoperative complications are bleeding and haematoma formation. The reason a haematoma is of particular concern with these procedures is the close anatomical relation to the trachea, with the potential of airway obstruction due to compression.

Head and neck cancers often pose difficulties in resection --- not least due to the challenges of the anatomy in that area, with significant neurovascular structures. With poorly differentiated or invasive tumours here, the risk of damage to these structures is increased. Sometimes, this occurs as a part of a patient's presenting symptoms, for example, hoarseness (in recurrent laryngeal nerve palsy). The external carotid artery may also be at risk, and the term carotid blowout refers to haemorrhage from the carotid artery, usually from erosion by an invasive neck carcinoma. It is almost impossible to gain haemostasis from such a haemorrhage. When these events occur, bleeding is so profuse that even if it occurs in hospital, resuscitation is commenced immediately. The patient is rushed straight to theatre, and the time involved in this is probably enough for the patient to have exsanguinated. If the patient is operated on, tying off the external carotid artery is the only chance of stopping the haemorrhage, to gain haemostasis (see Fig. 2). Unfortunately, patients who suffer such an event are the ones who are aware of their terminal diagnosis and may have undergone a debilitating course of chemotherapy or radiotherapy.

Apart from malignant causes, trauma is another cause of head and neck haemorrhage. Most likely to occur in the young adult age group, trauma may be divided into blunt or penetrating. Mechanisms can be through accidents, road traffic accidents, assaults, stabbings, gunshot injuries, sporting injuries, and falls. Haemostasis, as with haemostasis of malignant origin, can be difficult to achieve. Significant structures can be damaged due to the major vessels carried in the neck. As opposed to oncology cases, however, the anatomical structures may be much less distorted than in a large destructive invasive squamous cell carcinoma for example.

Any attempt to ligate bleeding vessels should always be carried out in a controlled environment, with a clear operating field. As mentioned earlier, apart from major vascular structures, major nerves are also present in the neck. Important nerves include the vagus, phrenic, and laryngeal nerves. Structures, such as, the trachea, oesophagus, and thyroid gland also have to be identified. This may be simple in elective procedures, but in emergency operations with significant haemorrhage, the picture may be completely different. Electrical tools, such as diathermy, to aid in haemostasis may cause thermal damage to these structures as well as damage caused by misplaced ligatures.

Embolisation, as mentioned earlier, can be a very useful therapeutic tool in controlling bleeding arising from the head and the neck. Principles and specific clinical applications of its use in the head and the neck have been considered. One study's results, for example, revealed not only good haemostasis, but the reduction of tissue mass and pain relief in malignant cases.9

Other strategies trialled include the use of vasopressin as a continuous infusion. Results showed haemostasis was established quickly in 80% of the cases, with no serious side effects. Therefore, its apparent beneficial effects could provide an alternative to external carotid artery ligation.10

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