A head and neck oncologist faces challenges when dealing with malignant invasion of the carotid artery. Preoperative evaluation helps identify high-risk patients for neurologic complications, and carotid reconstruction should be considered to reduce risks.

Despite efforts to minimize complications patients undergoing carotid reconstruction still face neurologic risks. Long-term survival is often low in cases of malignant carotid involvement even with successful surgical resection.

High radiologic suspicion of carotid invasion in head and neck oncology may preclude surgery due to stroke risk.

Carotid resection in patients with prior radiotherapy and persistent/recurrent malignancy poses challenges for surgical salvage due to additional complications.

Carotid invasion challenging to predict using preoperative imaging in population. Surgeon must consider possibility of invasion without bulky disease or encasement.

Resected carotid arteries show invasion in only some pathologic series. Irradiated patients have weakened arterial walls due to fibrosis, elastic tissue destruction, and atherosclerosis acceleration.

Aggressive dissection may cause intraoperative or postoperative vessel rupture if wound complications endanger vessel protection.

Intensity-modulated radiotherapy is the standard for head and neck cancer but can lead to carotid injury in 30-50% of cases.

Concurrent chemotherapy for unresectable tumors achieves locoregional control while HPV-positive cancers respond better to treatment.

Carotid stenting or embolization used for tumor encasement or high-risk bleeding scenarios with rare postoperative pseudoaneurysm.

Pre-op tests and post-op care for carotid resection focus on blood flow regulation.

Maintain adequate systemic blood pressure is crucial for cerebral perfusion post-carotid resection without immediate neurologic symptoms.

Delayed symptoms and possible stroke can occur in patients with carotid occlusion if blood pressure drops.

Permanent brain injury timing from ischemia studied in primates, whereas symptoms from middle cerebral artery blockage can be reversible for up to 3 hours.

Stump pressure is vital for intraoperative decisions in cases of sudden rupture or unexpected carotid involvement.

Carotid artery involvement leads to poor prognosis with less than 30% with 5 years survival rates while recurrences require palliative care.

HPV-positive tumors respond well to chemoradiotherapy, while poor response suggests worse prognosis.

Carotid artery resection poses stroke and mortality risk, but revascularization success impacts outcomes greatly.

Collect details including history of present illness, presenting symptom, and medical history to understand clinical history of patient.

Neck examination

Neurological examination

Vascular examination

Respiratory examination

Acute symptoms are:

Sudden bleeding, severe pain, TIA, stroke carotid blowout, and dissection

Chronic symptoms are:

Slowly growing mass, mild cognitive deficits

Carotid reconstruction is challenging for patients with internal carotid artery resected close to skull base due to feasibility issues.

TBO and flow testing results suggest permanent balloon occlusion may reduce CVA rates over simple ligation preoperatively.

High embolization of the carotid eliminates post-ligation blood column that may lead to stump emboli formation.

Angiographic placement of balloons or coils near ophthalmic artery in carotid siphon requires patient heparinization and hemodynamic monitoring.

Carotid resection delayed for 2 weeks to fix coils and avoid surgery risks during vulnerable period.

Preoperative application of this technique carries risk if the carotid artery is ultimately found to be uninvolved during surgery.

Carotid resection patients of all risk levels may benefit from reconstruction for optimal management and better outcomes overall.

Otolaryngology

Plastic Surgery and Anesthetic Medicine

Use ergonomic chairs and computer screens to give proper position for eye level.

Remember for regular breaks to reduce tension in the neck and shoulders.

Use elevated headrests to reduce intracranial pressure on neck. Keep a quiet environment to prevent blood pressure increase.

Proper awareness about management of neck with carotid artery involvement should be provided and its related causes with management strategies.

Appointments with a plastic surgeon and preventing recurrence of disorder is an ongoing life-long effort.

Otolaryngology

Plastic Surgery and Anesthetic Medicine

Clopidogrel:

It prevents platelet aggregation in carotid artery stenosis.

Otolaryngology

Plastic Surgery and Anesthetic Medicine

Atorvastatin:

It stabilizes atherosclerotic plaques to decrease the risk of stroke and cardiovascular events.

Otolaryngology

Plastic Surgery and Anesthetic Medicine

Tissue plasminogen activator:

It dissolves clots and restores blood flow in cases of carotid artery thrombosis.

Otolaryngology

Plastic Surgery and Anesthetic Medicine

Losartan:

It prevents rupture of aneurysms to mitigate the risk of stroke from carotid stenosis.

Otolaryngology

Plastic Surgery and Anesthetic Medicine

Interventional procedures for carotid artery involvement are important for stroke prevention, revascularization, and treatment of complex conditions.

Otolaryngology

Plastic Surgery and Anesthetic Medicine

In the initial treatment phase, evaluation of medical history, physical examination and diagnostic test are conducted to confirm diagnosis.

Pharmacologic therapy is effective in the treatment phase as it includes use of antiplatelet agents, statins, and antihypertensives.

In supportive care and management phase, patients should receive required attention such as lifestyle modification and intervention therapies.

The regular follow-up visits with the plastic surgeon are scheduled to check the improvement of patients along with treatment response.