Blindness as a rare complication of neck dissection

Blindness following bilateral neck dissection. A case report and review of the literature

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Postoperative vision loss is a rare and devastating complication in head and neck surgery.

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Blindness can also occur after modified radical neck dissection.

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Patients undergoing high-risk procedures should have to be informed that there is a risk of vision loss.

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This complication should be highlighted in the standard declaration of consent.

Introduction

Visual loss is a very rare but dramatic complication of such an indispensable standard procedure in head and neck tumor surgery such as the cervical lymphadenectomy (neck dissection).

Presentation of case

We present a review of the literature and a new case of a postoperative blindness of a 65-year-old man with type 2 diabetes who underwent a unilateral radical neck dissection, a contralateral modified radical neck dissection and a hemimandibulectomy for an oropharyngeal squamous cell carcinoma.

Discussion

By now there have been only 15 clinical cases of total blindness published during the last 60 years. In 13 cases blindness followed a bilateral radical neck dissection whereas in 2 cases blindness occurred after a combined selective and modified radical neck dissection. Ischemia of the optic nerve due to intraoperative hypotension, blood loss and venous congestion were the major etiological aspects of blindness. Perioperative management of differentiated volume and blood administration, blood pressure management and a close postoperative ophthalmological check seem to be of a major importance for prevention and early detection of visual deterioration. Nevertheless, there are no clear predicative factors for blindness after neck dissection and the prognosis is unfavorable.

Conclusion

Even though postoperative vision loss is a rare and devastating complication, this current case and the review of the literature show that it occurs every once in a while following standard operations to the head and neck. Patients undergoing high-risk procedures should have to be informed that there is a slight risk of perioperative vision loss and this should be highlighted in the standard declaration of consent.

Anterior ischemic optic neuropathy after unilateral radical neck dissection: case report and review

BACKGROUND

Blindness or visual deterioration after neck dissection is a known and a rare complication of the operation. Visual impairment usually occurs immediately after bilateral radical neck dissections either performed synchronously or in a stepwise manner, resulting in permanent blindness. Hypotension and blood loss during long operations, elevated venous pressure postoperatively result in optic neuropathies, which are anterior ischemic optic neuropathy (AION) or mostly posterior ischemic optic neuropathy (PION) affecting different portions of the nerve.

METHODS

Review of literature and case report.

RESULTS

To date there are only three cases of AION after neck dissection reported in the literature, with a different visual prognosis.

CONCLUSION

Vision loss may be reversible when both internal jugular veins are preserved, but permanent when any of them are resected. Here we present the first case of anterior ischemic optic neuropathy developed after unilateral radical neck dissection, resulting in partial visual deterioration.

Spontaneous carotid dissection presenting lower cranial nerve palsies

Cranial nerve palsy in internal carotid artery (ICA) dissection occurs in 3--12% of all patients, but in 3% of these a syndrome of hemicranias and ipsilateral cranial nerve palsy is the sole manifestation of ICA dissection, and in 0.5% of cases there is only cranial nerve palsy without headache. We present two cases of lower cranial nerve palsy. The first patient, a 49-year-old woman, developed left eleventh and twelfth cranial nerve palsies and ipsilateral neck pain. The angio-RM showed an ICA dissection with stenosis of 50%, beginning about 2 cm before the carotid channel. The patient was treated with oral anticoagulant therapy and gradually improved, until complete clinical recovery. The second patient, a 38-year-old woman, presented right hemiparesis and neck pain. The left ICA dissection, beginning 2 cm distal to the bulb, was shown by ultrasound scanning of the carotid and confirmed by MR angiogram and angiography with lumen stenosis of 90%. Following hospitalisation, 20 days from the onset of symptoms, paresis of the left trapezius and sternocleidomastoideus muscles became evident. The patient was treated with oral anticoagulant therapy and only a slight right arm paresis was present at 10 months follow-up. Cranial nerve palsy is not rare in ICA dissection, and the lower cranial nerve palsies in various combinations constitute the main syndrome, but in most cases these are present with the motor or sensory deficit due to cerebral ischemia, along with headache or Horner's syndrome. In the diagnosis of the first case, there was further difficulty because the cranial nerve palsy was isolated without hemiparesis, and the second case presented a rare association of hemiparesis and palsy of the eleventh cranial nerve alone. Compression or stretching of the nerve by the expanded artery may explain the palsies, but an alternative cause is also possible, namely the interruption of the nutrient vessels supplying the nerve, which in our patients is more likely.

Surgical management of head and neck cancer

Head and neck cancer surgery continues to evolve through the years and undergo improvement and refinement. In this article, the current state of head and neck cancer surgery is summarized in a site-by-site basis. The most important developments include organ-sparing surgery and microvascular free-tissue transfer for reconstruction.