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Carotid Sinus Sensitivity due to Deep Neck Scar after Neck

Dissection: Surgical Management with Interposition STSG

Aaron Dezube, BS1; Reza Ehsanian, MD PhD2; Scott Stephan Scott, MD2

Tufts University School of Medicine1, Vanderbilt Medical Center Department of Otolaryngology2, Nashville, TN

INTRODUCTION DISCUSSION

RESULTS

Figure 1. Computerized tomography (CT) at the level of the carotid

bifurcation demonstrating scar extension to the level of the carotid sinus.

ABSTRACT

METHODS AND MATERIALS

CONCLUSIONS

REFERENCES

CONTACT

2 months following scar release and STSG placement

(figure 3). There was full graft take and she noted

improvement in head motion with approximately 45 degree

contralateral head turning past the midline without

difficulty. Additionally, there was complete resolution of her

bradycardic symptoms and no syncopal episodes. She continues with full range of motion neck physical therapy.

The carotid sinus is an arterial baroreceptor located at

the bifurcation of the external and internal carotids.

This receptor responds to stretching of the arterial

wall leading to increases in firing frequency of action

potentials and vice versa if arterial blood pressure

suddenly decreases. The sinus nerve of Hering, a

branch of the glossopharyngeal nerve, innervates the

carotid sinus baroreceptors, which is different than the

baroreceptors located in the aortic arch innervated by

the vagus nerve.1 Efferent fibers from both receptors

descend in the vagus and cervical sympathetic

nerves respectively to the cardioinhibtory and

vasomotor centers. 2

Neck dissection is known to be associated with

multiple complications both intra-operatively and post-

operatively including scarring, bleeding, air leaks,

chylous fistulas, facial and cerebral edema, damage

to neurovasculature in the neck in addition to many

others.3 Post surgical scar causing contraction,

problems with cosmesis and functional movement

restriction following neck dissections has been a well-

documented entity.4 However, operation scars in

addition to enlarged lymph nodes, and head and neck

malignancies has only recently been postulated to

produce carotid sinus hypersensitivity,5,6,7,8,9.

: Recurrent episodes of asystole from carotid sinus

hypersensitivity triggered by positioning for head and

neck surgery.

In the case of our patient, she developed extensive

deep neck scarring as a result of neck dissection and

subsequent complications and revisions. Computed

topography illustrated the proximity of the scar to her

carotid sinus, which in the context of lightheadedness

and bradycardia with head turning suggested the scar

as the underlying cause. Therefore, while z-plasty is a

known technique for scar revision, little literature

exists discussing surgical revision of the scar as a

functional management of deep neck scar-induced

carotid sinus hypersensitivity following surgical

dissection of head and neck malignancies.

On Sept. 2014, the patient presented for revision of

her left neck scar. Intraoperative findings showed

tethering of the skin to a fibrosed supraclavicular

fascial flap and trapezius muscle edge from the

lateral clavicle to the level of the carotid bifurcation in

the setting of extreme left neck volume loss and

fibrosis (Figure 3) after failed free flap, infection, and

radiation. A serial Z-plasty scar revision was

performed with 8 2x2cm transposition flaps designed

with 45-degree angles of each limb.

During follow up the patient continued to experience a

symptomatic scar. The patient was noted to have two

more non-syncopal bradycardic episodes in rehab

confirming her previous diagnosis.

Revision surgery was performed which included full

thickness release of the supraclavicular fascial bands,

trapezius muscle down to fat. The head was placed

in full extension and contralateral head turn to

delineate the full area of skin deficiency and

immediate split thickness skin graft from the thigh

was interposed within this defect (Figure 2).

1 .Lown B, Levine SA: The carotid sinus. Clinical value of its stimulation. Circulation

1961. 23: 766-789.

2. Walter PF, Grawley IS, Dorney ER: Carotid sinus hypersentivity and syncope. Am J

Cardiol 1978, 42:396-403.

3. Flint PW, Haughey BH, Lund VJ, Niparko JK, Richardson MA, Robbins KT, Thomas

JR. (2010). Cummings Otolaryngology: Head and Neck Surgery (5th ed).

Philadelphia, PA: Mosby/Elsevier

4. Chugh SN (2012): Textbook of Clinical Electrocardiography for Postgraduates,

Residents and Practicing Physicians (3rd ed). Panama City, Panama. Jaypee

Brothers Medical Publishers

5. Patel AK, Yap VU, Fields J, Thomsen JH: Carotid sinus syncope induced by

malignant tumors in the neck. Arch Intern Med 1978, 42:396-403.

6. Farr HW: Carotid body tumors: a 40-year study. CA Cancer J Clin 1980, 30:260-265.

Noroozi N, Modabber A, Holze, Branchschweig T, Riediger D, Gerressen M,

Ghassemi A: Carotid sinus syndrome as the presenting symptom of

cysadenolymphoma. Head & Face Medicine 2012, 8:31.

7. Sutherland JA, Stobie P, Swarup V, Tierney SP, Lin-AC, Burke MC: Hypertensive

carotid sinus syndrome due to neurofibromatosis-1 and manifested by repeated

episodes of syncope. Pacing Clin Electrophysiol 2004, 27:1571-1573.

8. Trung AT, Sturgis EM, Rozner MA, Truong DT: Recurrent episodes of asystole from

carotid sinus hypersensitivity triggered by positioning for head and neck surgery.

Head Neck. 2013 Jan, 35(1): E28-30

Aaron Dezube, BS Tufts University School of Medicine Vanderbilt Medical Center Dept. of Otolaryngology Aarondezube@gmail.com Phone: 617-306-0961

Neck dissection for head and neck

malignancies is associated with

multiple complications post

operatively. While scar is a known

complication, little literature exists

about functional changes due to scar

including carotid sinus sensitivity or

the surgical management of scar-

induced carotid sinus.

We herein describe a 70-year-old

woman who developed extensive left

sided deep neck scar following

chemoradiation, and surgical

management of her squamous cell

carcinoma (SCCa), which led to a

painful scar suspected of causing

carotid sinus sensitivity due to its

position relative to the carotid

bifurcation. Our case suggests a role

for surgical management of this

condition to improve not only

cosmesis but functional status as well.

This case report illustrates a complication of neck

dissection causing cicatricial carotid sinus sensitivity.

In addition, it describes a successful approach to

alleviate the functional sequelae of this cervical scar

contracture using scar revision and an interposition

STSG.

A 70-year-old Caucasian woman was initially treated

with chemoradiation for a right base-of-tongue

squamous cell carcinoma (SCCa). Twelve years later,

she was then diagnosed new T1N1 1.5 cm poorly

differentiated SCCa with basaloid features located on

her left posterior pharyngeal wall. She underwent a

posterior glossectomy with a left modified neck

dissection, infratemporal fossa resection of deep

extension of tumor and a retropharyngeal lymph node

and extended lateral pharyngectomy resulting in

closure with a secondary right anterolateral thigh free

flap for reconstruction. Due to venous congestion of

the free flap it was removed and replaced with a left

supraclavicular flap in 2013, which was complicated by

local infection, and subsequent sepsis and and

pneumonia.

On presentation to our Facial Plastics and

Reconstructive Surgery clinic, she complained of

prominent and painful scar band on the lateral left neck

extending down to the supraclavicular area. She had 3

documented episodes of syncope induced by neck

rotation or extension, other subclinical episodes of

lightheadedness and bradycardia with less prominent

head movement.

Computerized tomography (CT) showed extension of

the neck scar contracture into the plane of the

bifurcation of the carotid artery (Figure 1).

This represented a case of post-surgical cicatricial

carotid sinus hypersensitivity.

Level of carotid

sinus

Dense scar

tissue extending

from skin down

to carotid sinus

Figure 2: Intra-operative photo of scar band (left), release (middle) and

interposition STSG placement (right).

Figure 3: (Left) Pre-operative

photos demonstrating the scar,

level of volume loss and extent of

fibrosis present in patients left

neck. (Right) 2 months post-

operative showing graft take and

release of scar band.