Carotid Sinus Sensitivity due to Deep Neck Scar after Neck Dissection: Surgical Management with Interposition STSG Aaron Dezube, BS 1 ; Reza Ehsanian, MD PhD 2 ; Scott Stephan Scott, MD 2 Tufts University School of Medicine 1 , Vanderbilt Medical Center Department of Otolaryngology 2 , 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 (5 th ed). Philadelphia, PA: Mosby/Elsevier 4. Chugh SN (2012): Textbook of Clinical Electrocardiography for Postgraduates, Residents and Practicing Physicians (3 rd 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 [email protected] 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.