Carotid stenting and "extarterectomy" in the management of head and neck cancer involving the internal carotid artery: technical case report

OBJECTIVE AND IMPORTANCE

Head and neck cancer that invades the internal carotid artery (ICA) represents a significant management challenge. We describe a novel technique that allows for aggressive tumor removal without disrupting blood flow through the affected ICA.

CLINICAL PRESENTATION

A 62-year-old man was referred to our institution for management of a neck malignancy involving the ICA. Cerebral angiography suggested that there was good collateral flow from the opposite hemisphere, but the patient reported visual loss in the ipsilateral eye during balloon test occlusion of the ICA.

INTERVENTION

A self-expanding stent was deployed in the ICA; it spanned the entire length of the artery involved by tumor. One month later, the patient underwent tumor resection. During surgery, a long ICA arteriotomy was performed directly down to the mesh of the stent. A neoendothelium had formed within the stent, which prevented arterial bleeding. The carotid wall was dissected from the stent without difficulty and removed en bloc with the surrounding tumor. The exposed stent was wrapped circumferentially with a synthetic patch material. The patient tolerated the procedure well, and postoperative angiography demonstrated normal filling of the ICA.

CONCLUSION

We describe a novel approach to a patient with head and neck cancer involving the cervical ICA. Preliminary stenting, which allows time for endothelialization before surgery, may permit aggressive tumor resection without interrupting flow through the ICA. This technique obviates the need for complicated carotid reconstruction procedures and avoids the risk of delayed ischemia from carotid sacrifice.

Mandibular distraction osteogenesis in a neonate

Children with craniofacial anomalies are predisposed to airway obstruction and frequently require airway intervention. Tracheotomy is performed when the airway obstruction is severe and refractory to other less invasive interventions. Tracheotomy is associated with significant morbidity, and there is a trend noted in the literature toward achieving earlier decannulation by the institution of definitive structural changes to the mandible. Mandibular distraction osteogenesis has been shown to alleviate airway obstruction in the pediatric population. We report a case in which mandibular distraction osteogenesis was successfully carried out in a neonate with acute airway obstruction at birth as a result of combined Pierre Robin sequence and Klippel-Feil syndrome. After 1 year, the patient still had an adequate airway with tolerable scarring and no neurologic sequelae.