Operative management of catastrophic bleeding in the head and neck

The otolaryngologist commonly performs several procedures in close proximity to the carotid and innominate arterial systems. In this article, we will discuss the management of catastrophic bleeding following adult tonsillectomy and tracheostomy, as well as the management of carotid blowout syndrome in head and neck cancer patients. Although the bleeding risk from tonsillectomy is considered very low, the acceptance of transoral robotic surgery as a treatment modality of oropharyngeal head and neck carcinomas makes the spectre of catastrophic oropharyngeal bleeding more real. Aggressive resection in this area can leave minimal parapharyngeal fat over the carotid artery and damage from manipulation of smaller vessels can lead to pseudoaneurysms. Tracheostomy also carries a very low but real risk of trachea-innominate artery fistula, which has devastating consequences. Finally, we will discuss how to identify head and neck cancer patients who are at risk for carotid blowout syndrome as well as appropriate interventions to manage this condition.