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

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

•

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

•

Blindness can also occur after modified radical neck dissection.

•

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

•

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.

Emergency Cricothyroidotomy for Difficult Airway Management After Asynchronous Bilateral Neck Dissections: A Case Report and Literature Review

PURPOSE

This report describes a case that required emergency cricothyroidotomy for an upper airway obstruction owing to laryngeal edema after asynchronous bilateral neck dissections.

PATIENT AND METHODS

A 57-year-old man was diagnosed with multicentric squamous cell carcinoma of the tongue (T1 and 2N0M0), and partial glossectomy with primary closure was performed. Three months after surgery, secondary metastases in the right cervical lymph nodes were detected, and a right radical neck dissection was performed. Contrast-enhanced computed tomographic (CT) scan taken 2 weeks after the right neck dissection visualized a possible third metastasis in the left cervical lymph node. Four weeks after the right radical neck dissection, left supraomohyoid neck dissection was carried out. In this surgery, the left internal jugular vein (IJV) was preserved. Nine hours after surgery, severe swelling of the face and pharynx was recognized, resulting in a stoppage of respiration and then an emergency cricothyroidotomy.

RESULTS

The patient's life was saved without any encephalopathy or airway trouble. Contrast-enhanced CT scan taken the next day confirmed the preserved left IJV patency.

CONCLUSION

Oral and maxillofacial surgeons should be aware of the possibility of life-threatening laryngeal edema associated with bilateral neck dissections even if the unilateral IJV is preserved and should know the procedure for emergency cricothyroidotomy.

Visual loss following head and neck surgery

INTRODUCTION

Non-arteritic ischaemic optic neuritis is a known post-operative complication of ophthalmological and maxillofacial surgery, but has not been widely described as a potential consequence of head and neck surgery.

AIM

To highlight non-arteritic ischaemic optic neuritis as a potential risk in patients undergoing head and neck surgery.

SUBJECT AND METHOD

Case report of a 60-year-old man undergoing total laryngectomy and bilateral neck dissection for laryngeal squamous cell carcinoma.

RESULT

On day 14 post-operatively, the patient suffered substantial oral bleeding secondary to an internal jugulo-neopharyngeal fistula. Following emergency haemostatic measures, the patient was immediately aware of visual disturbances. The ophthalmologists concluded that these were due to non-arteritic ischaemic optic neuritis, caused by acute hypoxaemia secondary to substantial blood loss.

CONCLUSION

The prognosis of non-arteritic ischaemic optic neuritis is poor. Thus, it is crucial that otolaryngologists are aware of this complication of head and neck surgery, as immediate diagnosis and treatment can help prevent worsening visual loss.

Ischemic optic neuropathy and implications for plastic surgeons: report of a new case and review of the literature

BACKGROUND

Postoperative visual loss is a rare and devastating complication after nonocular as well as ocular surgery. A case of such a complication arising as a consequence of nonocular surgery prompted a review of the literature, and an appraisal of current theories on etiology, risk factors, and potential treatment options, as well as implications for informed consent. It is clear from our review that all patients undergoing both reconstructive and cosmetic surgery are at risk.

METHODS

A literature review was performed to identify all cases of ischemic optic neuropathy (both anterior and posterior subtypes) subsequent to any type of plastic, reconstructive, and aesthetic surgery procedures. An analysis of current knowledge regarding risk factors, etiology, prevention, and treatment options was undertaken.

RESULTS

A total of 38 patients aged between 16 and 76 years affected by ischemic optic neuropathy were identified, many as a consequence of routine and sometimes minor operative procedures.

CONCLUSIONS

Ischemic optic neuropathy can be a devastating complication of surgery. Plastic surgeons need to be aware of the risks, as well as the signs and symptoms, and counsel at-risk patients accordingly because of the potentially devastating nature of this complication. There are significant implications in relation to informed consent, underscored by the legal case of Rogers v Whitaker, 67 ALJR 47 (Aust 1992), which highlights the importance within the consent process of complications threatening sight, no matter how small.

Perioperative visual loss in ocular and nonocular surgery

Incidence estimates for perioperative vision loss (POVL) after nonocular surgery range from 0.013% for all surgeries up to 0.2% following spine surgery. The most common neuro-ophthalmologic causes of POVL are the ischemic optic neuropathies (ION), either anterior (AION) or posterior (PION). We identified 111 case reports of AION following nonocular surgery in the literature, with most occurring after cardiac surgery, and 165 case reports of PION following nonocular surgery, with most occurring after spine surgery or radical neck dissection. There were an additional 526 cases of ION that did not specify if the diagnosis was AION or PION. We also identified 933 case reports of central retinal artery occlusion (CRAO), 33 cases of pituitary apoplexy, and 245 cases of cortical blindness following nonocular surgery. The incidence of POVL following ocular surgery appears to be much lower than that seen following nonocular surgery. We identified five cases in the literature of direct optic nerve trauma, 47 cases of AION, and five cases of PION following ocular surgery. The specific pathogenesis and risk factors underlying these neuro-ophthalmic complications remain unknown, and physicians should be alert to the potential for loss of vision in the postoperative period.