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PubMed1996

Recurrence of cervical artery dissection. A prospective study of 81 patients.

BACKGROUND AND PURPOSE: Spontaneous cervical artery dissection (SCAD) is a common cause of stroke in the young; however, its recurrence has been rarely studied. Recurrent SCAD at the level of the previously dissected vessel has been reported in only six patients. METHODS: We prospectively evaluated and followed a series of 81 patients seen in our center with carotid (n = 66) or vertebral (n = 15) artery dissection, in whom the diagnosis was confirmed by angiography, MRI, or both. Repeated clinical and ultrasound examinations were performed in all patients during a mean follow-up of 34 months (range, 12 to 57 months). RESULTS: Three patients died of the consequences of stroke, and four patients were unavailable for follow-up. Three of the remaining 74 patients (4%) had a recurrent carotid dissection while under prophylaxis with aspirin (n = 2) or anticoagulation (n = 1). None of the patients had a recurrent vertebral dissection. Recurrent carotid dissection occurred 16 months to 4 years after the first episode and presented with acute head and neck pain (n = 2) and hemispheric transient ischemic attack (n = 1). In one patient recurrence was documented by Doppler and MRI at the level of the first dissection. CONCLUSIONS: We confirm that recurrence of SCAD is uncommon and usually represents a benign condition. Delayed recurrence seems to be more common than previously suggested and can occur at the level of the previously dissected vessel.

Adult↗

PubMed1996

Transcranial Doppler in the evaluation of internal carotid artery dissection.

BACKGROUND AND PURPOSE: A subject with dissection of the internal carotid artery (ICA) may present with a variety of symptoms, from headache to stroke. Thus far, it has not been possible to identify the subset of patients at risk for cerebral ischemia. Because the majority of these ischemic events are secondary to embolic phenomena, we used transcranial Doppler (TCD) evaluation with emboli monitoring to study 17 consecutive patients with ICA dissection treated at Harborview Medical Center, Seattle, Wash, during a 2-year period from 1992 until 1994. METHODS: Ten patients with ICA dissection secondary to trauma and seven with spontaneous ICA dissection were diagnosed by carotid angiography and studied by TCD from the time of diagnosis through initiation of therapy. Emboli monitoring was performed in the middle cerebral artery (MCA) ipsilateral to the dissection at the initial evaluation and intermittently thereafter to ensure that the emboli stopped with treatment. RESULTS: Emboli were detected in the MCA distal to the dissection in 10 of 17 patients (59%). Patients with microemboli detected by TCD presented with a stroke (70%) much more frequently than those without emboli (14%) (P=.0498). The presence of a pseudoaneurysm did not increase the risk of either microemboli or stroke. CONCLUSIONS: We have demonstrated a high incidence of intracranial microemboli in the MCA distal to carotid dissections and a significant correlation between the presence of emboli and stroke. TCD can therefore be used as an adjunctive tool to manage patients with suspected carotid dissection and may prove useful in evaluating the efficacy of treatment in reducing microemboli and subsequent stroke.

Adolescent↗

PubMed1997

Magnetic resonance angiography demonstrates vascular healing of carotid and vertebral artery dissections.

BACKGROUND AND PURPOSE: Dissection of the carotid and vertebral arteries is most accurately diagnosed with conventional angiography. MR techniques are sensitive for detecting the abnormalities associated with dissection but may lack specificity. We hypothesized that MR may be useful for serial monitoring of dissection and may therefore guide therapy. METHODS: All patients with angiographically proven carotid and/or vertebral artery dissection from July 1994 to June 1996 were followed for a median duration of 10.5 months. Of these 29 patients (44 vessels), 18 were concurrently evaluated with MR, and a target group of 9 patients (17 vessels) was prospectively followed with MR at 3-month intervals. RESULTS: In the 18 patients with both imaging studies at baseline, angiography revealed 30 dissected vessels while MR detected 27 (90%). In the target group of 9 patients, initial MR identified 15 of the 17 dissections diagnosed with angiography. Serial MR revealed complete healing in 5 vessels, improvement in 6 vessels, no change in 4 vessels, and worsening in 2 vessels. The radiographic features most likely to resolve were stenosis and mural hematoma, while occlusion and luminal irregularity tended to persist. Late ischemic events occurred in 2 patients, both with persistent MR evidence of dissection, one while subtherapeutic on warfarin therapy and the other occurring 1 week after warfarin was discontinued. CONCLUSIONS: MR is a reliable noninvasive method for following the vascular response to treatment and may guide the course of a clinical trial comparing medical therapies for carotid and vertebral artery dissection.

Adolescent↗

PubMed2003

Obstructive sleep apnea and thoracic aorta dissection.

Obstructive sleep apnea syndrome (OSAS) is a process that is associated with the development of arterial hypertension, the main risk factor for aortic dissection and during obstructive episodes of the upper airways with marked increases in transmural pressure of the aorta wall. The aim of this work was to study the association between aortic dissection and OSAS. Nineteen consecutive patients with thoracic aorta dissection and 19 hypertensive patients of similar age, sex, and body mass index were studied by clinical questionnaire and polysomnography. Snoring and nonrefreshing sleep were common in both groups. Thirteen patients (68%) from each group showed an apnea-hypopnea index of more than 5 per hour. However, patients with aortic dissection presented a higher apnea-hypopnea index (28 [30.3] versus 11.1 [10.4], p=0.032). Seven patients with dissection presented an apnea-hypopnea index of more than 30 versus 1 patient in the control group (p=0.042). Patients with thoracic aorta dissection presented a high prevalence of previously undiagnosed and frequently severe OSAS. Further studies, including this diagnosis as a prognostic variable in the follow-up of patients with aortic dissection, are required. Our results suggest that in patients with aortic dissection and symptoms consistent with OSAS, a sleep study should be considered in their clinical management.

Adult↗

PubMed2001

Association of left ventricular hypertrophy and aortic dilation in patients with acute thoracic aortic dissection.

This study was designed to evaluate the impact of left ventricular mass on aortic diameters in patients who presented with acute thoracic aortic dissection where aortic dilation is common. Retrospective review of transthoracic and transesophageal echocardiograms was conducted for 63 patients treated for acute thoracic aortic dissection and for 16 normal subjects who were comparable for gender prevalence, age, heart rate, and blood pressure. The diameter of the aortic root was measured by transthoracic echocardiography. Diameters of the ascending aorta, and of the aorta at locations of 25, 30, and 35 cm from the dental arch were measured by transesophageal echocardiography. The findings indicated that all aortic diameters were significantly larger in patients with aortic dissection. Patients with aortic dissection also presented with greater left ventricular mass indices (p<0.00001) than normal subjects. Fractional shortening and left atrial diameter measurements obtained in patients with aortic dissection were similar to those obtained in the control group. Overall, the left ventricular mass index exhibited univariate relationships with aortic root diameter (r=0.27, p<0.02) and aortic diameters at 25 cm (r=0.51, p<0.00001), 30 cm (r=0.58, p<0.00001), and 35 cm (r=0.55, p<0.00001) distal to the arch but not with the diameter of the ascending aorta. After adjusting for gender, body mass index, history of hypertension and aortic dissection extent (Stanford types) by separate multivariate models, the authors found that the left ventricular mass index was independently associated with aortic diameters at 25 cm (beta=0.32, p<0.001), 30 cm (beta=0.38, p<0.0001), and 35 cm (beta=0.34, p < 0.0005) distal to the arch. They conclude that left ventricular mass is independently associated with aortic arch and descending aorta diameters in patients with acute thoracic aortic dissection. Left ventricular hypertrophy may be considered a risk factor for aortic enlargement and subsequent dissection.

Acute Disease↗

PubMed1996

Cervicocranial artery dissection. Detection by Doppler ultrasound and MR angiography.

PURPOSE: To evaluate pulsed Doppler ultrasound and MR angiography (MRA) in the diagnosis of cervicocranial dissection. MATERIAL AND METHODS: Fourteen patients with cervicocranial artery dissection were examined over a 3-year period. Twelve patients had dissection of the extracranial part of the internal carotid artery, and 2 had vertebral artery dissection. All patients were examined with pulsed Doppler ultrasound. In addition, all patients had conventional angiography (n = 9) and/or MR imaging including MRA (n = 9). RESULTS: Doppler ultrasound disclosed unspecific abnormalities in 11 of 14 dissected vessels; 3 patients had false-negative Doppler findings. MRA showed vessel abnormalities in 9 of 9 patients; 2 vessels were occluded, and 7 vessels had changes typical of dissection (double lumen and/or string sign). Twelve patients had follow-up examinations with pulsed Doppler ultrasound (n = 12), conventional angiography (n = 3), and MRA/MR (n = 11). Follow-up Doppler showed complete or partial normalization in 6 of 9 patients, all confirmed by either angiography or MRA. CONCLUSION: Our findings suggest that Doppler ultrasound may be used in follow-up of pathologic Doppler findings in known dissections, and that MRA may replace angiography in the confirmative diagnosis of cervicocranial dissection.

Adult↗

PubMed2006

Craniocervical arterial dissection in children: clinical and radiographic presentation and outcome.

Craniocervical arterial dissection is a recognized cause of arterial ischemic stroke in children. Whether children with craniocervical arterial dissection have dissection characteristics different from those of adults is unclear. A retrospective review of children, 1 month to 18 years of age, with dissection from two Canadian pediatric ischemic stroke registry centers was conducted. From 213 patients with arterial ischemic stroke, 16 (7.5%) were identified with dissection, 37.5% had warning symptoms, and 50% had a history of head or neck trauma. The clinical presentation included headache (44%), altered consciousness (25%), seizures (12.5%), and focal deficits (87.5%). Dissection involved extracranial vessels in 75% and anterior circulation in 56%. Follow-up included complete recovery in 43%, mild to moderate deficits in 44%, and severe deficits in 13%. Fourteen (87.5%) children received antithrombotic treatment. Follow-up angiography showed resolution of abnormalities in 60% of vessels. Total occlusion had the worst outcome for recanalization. In conclusion, the etiology of arterial dissection in the majority of children appears to be either trauma or idiopathic. Long-term angiography shows variable outcomes, depending on the initial findings. The relationship of angiographic outcomes with recurrent strokes requires further study in pediatric dissection. (J Child Neurol 2006;21:8-16).

Adolescent↗

PubMed2004

Reversal of end-stage renal disease after aortic dissection using renal artery stent: a case report.

BACKGROUND: Medical management is the conventional treatment for Stanford Type B aortic dissections as surgery is associated with significant morbidity and mortality. The advent of endovascular interventional techniques has revived interest in treating end-organ complications of Type B aortic dissection. We describe a patient who benefited from endovascular repair of renal artery stenosis caused by a dissection flap, which resulted in reversal of his end-stage renal disease (ESRD). CASE PRESENTATION: A 69 y/o male with a Type B aortic dissection diagnosed two months earlier was found to have a serum creatinine of 15.2 mg/dL (1343.7 micromol/L) on routine visit to his primary care physician. An MRA demonstrated a rightward spiraling aortic dissection flap involving the origins of the celiac artery, superior mesenteric artery, and both renal arteries. The right renal artery arose from the false lumen with lack of blood flow to the right kidney. The left renal artery arose from the true lumen, but an intimal dissection flap appeared to be causing an intermittent stenosis of the left renal artery with compromised blood flow to the left kidney. Endovascular reconstruction with of the left renal artery with stent placement was performed. Hemodialysis was successfully discontinued six weeks after stent placement. CONCLUSION: Percutaneous intervention provides a promising alternative for patients with Type B aortic dissections when medical treatment will not improve the likelihood of meaningful recovery and surgery entails too great a risk. Nephrologists should therefore be aggressive in the workup of ischemic renal failure associated with aortic dissection as percutaneous intervention may reverse the effects of renal failure in this population.

Aged↗

PubMed1988

Dissection of the intracranial vertebral artery.

We describe four patients and review prior reports to clarify the clinical, radiographic, and pathologic findings of intracranial vertebral artery (VA) dissection. A 43-year-old man and a 33-year-old woman had chronic bilateral VA dissecting aneurysms. The man had multiple episodes of subarachnoid hemorrhage (SAH) and necropsy showed multiple dissections and defects in the internal elastica. The woman had many brainstem TIAs and strokes during 3 years. Two other patients had SAH and unilateral dissections. Intracranial VA dissection causes four overlapping syndromes: (1) brainstem infarcts are usually due to subintimal dissection extending into the basilar artery, affect younger patients, and often are single fatal events; (2) SAH is due to subadventitial or transmural dissection; (3) aneurysms cause mass effect on the brainstem and lower cranial nerves; and (4) chronic dissections due to connective tissue defects cause extensive bilateral aneurysms and repeated TIAs, small strokes, and SAH.

Adult↗

PubMed1994

Spontaneous dissections of cervicocephalic arteries in childhood and adolescence.

Among 263 consecutive patients with spontaneous cervicocephalic arterial dissections evaluated at the Mayo Clinic, 18 (6.8%) were 18 years of age or younger (mean age, 12 years). The dissection involved the cervical arteries in 11 patients and the intracranial arteries in seven. Extracranially, the internal carotid artery was involved in eight patients, the vertebral artery in two, and both arteries in one. Intracranially, only the anterior circulation was affected. All the patients had cerebral or retinal ischemic symptoms, usually preceded by headache. Death occurred in a 13-year-old boy with intracranial arterial dissection and coarctation of the aorta. For the 17 remaining patients, the follow-up period ranged from 1 to 21 years. A complete or good clinical recovery occurred in 10 of the 11 patients with cervical arterial dissection but in only four of the seven with dissection of intracranial arteries. Recurrent arterial dissection occurred in two patients with cervical arterial dissections and in one patients with intracranial arterial dissection.

Adolescent↗

PubMed2004

Anatomy of the anterior temporal lobe and the frontotemporal region demonstrated by fiber dissection.

OBJECTIVE: The white matter structure of the anterior temporal lobe and the frontotemporal region is complex and not well appreciated from the available neurosurgical literature. The fiber dissection method is an excellent means of attaining a thorough knowledge of the three-dimensional structure of the white matter tracts. This study was performed to demonstrate the usefulness of the dissection technique in understanding the white matter anatomy and the effects of current surgical approaches on the subcortical structure of the region. METHODS: Seventeen brain specimens obtained at routine autopsy were dissected by use of Klingler's fiber dissection technique after preparation by fixation and freezing. The dissections were performed with an operating microscope and followed a stepwise pattern of progressive white matter dissection. RESULTS: The dissection is described in an orderly fashion showing the white matter tracts of the anterior temporal lobe and the frontotemporal region. An insight is gained into the three-dimensional course of the anterior loop of the optic radiation, the temporal stem, the anterior commissure, and the ansa peduncularis. CONCLUSION: The anterior temporal lobe and the frontotemporal region contain several important white matter tracts that can be uniquely understood by performing a white matter dissection of the region. Surgical procedures on the anterior temporal lobe differ substantially as to their repercussions on the subcortical white matter tract anatomy, as shown by the findings in this study.

Autopsy↗

PubMed1998

Quality of history taking in patients with aortic dissection.

STUDY OBJECTIVES: Aortic dissection generally is an acute catastrophe. Rapid diagnosis is critical. We hypothesized that the quality of history taking contributes to the accuracy of diagnosis in patients with dissection. DESIGN: Retrospective chart review of 83 patients, whose diagnosis of aortic dissection was confirmed by autopsy, surgery, CT scan, echocardiogram, or angiogram. The quality of the initial history was reviewed using predetermined criteria. The physicians' initial clinical impressions were recorded. RESULTS: The examining physician correctly suspected aortic dissection after the initial clinical evaluation in 54 of 83 patients (65%). Only 33 of 78 patients with symptoms (42%) were asked about the quality, location, and onset of their pain, the three descriptors identified a priori as important. In 19 patients (24%), only zero or one descriptor was recorded. When all three questions were asked, dissection was suspected in 30 of 33 patients (91%); when zero, one, or two questions were asked, dissection was suspected in 22 of 45 patients (49%). CONCLUSION: Despite important advances in diagnostic imaging, accurate diagnosis of aortic dissection requires an accurate history. In our series, the quality of initial history was associated with the accuracy of the initial clinical impression in patients with aortic dissection.

Aortic Dissection↗

PubMed2000

Epidemiology and clinicopathology of aortic dissection.

STUDY OBJECTIVES: To determine the incidence and mortality as well as to analyze the clinical and pathologic changes of aortic dissection. DESIGN AND SETTING: A population-based longitudinal study over 27 years on a study population of 106,500, including 66 hospitalized and 18 nonhospitalized consecutively observed patients. MEASURES: Analysis of data from the medical, surgical, and autopsy records of patients with aortic dissection. RESULTS: Altogether, 86 cases of aortic dissection were found in 84 patients, corresponding to a 2.9/100,000/yr incidence. Sixty-six of the 84 patients (79%) were admitted to the hospital, and 18 patients (21%) died before admission. Their ages ranged from 36 to 97 years, with a mean of 65. 7 years. The male/female ratio was 1.55 to 1. A total of 22.7% of the hospitalized patients died within the first 6 h, 33.3% within 12 h, 50% within 24 h, and 68.2% within the first 2 days after admission. Six patients were operated on, with a perioperative mortality of two of six patients and a 5-year survival of two of six patients. All patients who were not operated on died. Pain was the most frequent initial symptom. Every patient had some kind of cardiovascular and respiratory sign. Neurologic symptoms occurred in 28 of 66 patients (42%). Five patients presented with clinical pictures of acute abdomen and two with acute renal failure. Trunk arteries were affected in 33 of the 80 autopsied cases (41%), and rupture of aorta was seen in 69 cases (86%). In five cases, spontaneous healing of dissection was also found. The ratio of proximal/distal dissections was 5.1 to 1. All 18 prehospital cases were acute. Fifty-nine cases (89.4%) were acute at admission, and 7 cases (10.6%) were chronic dissections. Hypertension and advanced age were the major predisposing factors. CONCLUSION: Aortic dissection was the initial clinical impression in only 13 of the 84 patients (15%). Thus, 85% of the patients did not receive immediate appropriate medical treatment. For this reason, these late-recognized and/or unrecognized cases may be regarded as an untreated or symptomatically treated group, whose course may resemble the natural course of aortic dissection.

Adult↗

PubMed2006

De novo vertebral artery dissecting aneurysm after contralateral vertebral artery occlusion--two case reports.

Two patients developed de novo vertebral artery dissecting aneurysm after contralateral vertebral artery occlusion. A 36-year-old man presented with brainstem ischemia and was treated non-surgically. Subsequent angiography showed spontaneous vertebral artery occlusion at the site of dissection. A 45-year-old man developed subarachnoid hemorrhage due to vertebral artery dissecting aneurysm. He underwent endovascular occlusion of the vertebral artery proximal to the dissecting aneurysm. These patients developed de novo dissecting aneurysm on the contralateral vertebral artery at 13 months and 11 days after unilateral vertebral artery occlusion, respectively. These cases strongly suggest that changes in hemodynamic stress due to unilateral vertebral artery occlusion are related to de novo dissecting aneurysm on the contralateral side. The risk of de novo dissecting aneurysm may be increased by proximal occlusion or trapping of dissecting aneurysm of the contralateral vertebral artery.

Adult↗

PubMed1994

Unilateral hyperlucent thorax on plain chest radiographs after neck dissection: importance of atrophy of the trapezius muscle.

OBJECTIVE: A hyperlucent thorax on plain chest radiography indicates a decrease in the radiographic density of the thorax, which can be caused by intra- or extrapulmonary diseases. The purpose of this study was to assess the prevalence and mechanisms that may be responsible for unilateral hyperlucency of the thorax after neck dissection and to determine if atrophy of the trapezius due to the transection of the accessory nerve is a cause of hyperlucent thorax. MATERIALS AND METHODS: Differences in the radiographic density between the right and left lung were evaluated and correlated with transection of the accessory nerve in 21 patients who had had a radical or a modified neck dissection for a malignant tumor of the head and neck. Twenty-eight neck dissections were performed on these 21 patients (seven had a simultaneous bilateral neck dissection). In 14 of the 21 patients, the accessory nerve had been severed during the neck surgery. In six patients, mechanisms responsible for a hyperlucent thorax were investigated with follow-up thoracic CT scans. RESULTS: In the radiographs, eight patients had a hyperlucent thorax on the side of the neck dissection. In all of these cases, the accessory nerve on the side of this neck dissection had been severed during a radical or a modified neck dissection. Prior to surgery, no such hyperlucency was noted. CT scans showed atrophy of the denervated trapezius muscle. CONCLUSION: Our findings show that atrophy of the denervated trapezius muscle after neck dissection is a cause of unilateral hyperlucent thorax on plain chest radiographs. Therefore, this finding should be anticipated as a postoperative change in patients who have had this surgery.

Accessory Nerve↗

PubMed2002

Dissecting aneurysms of the vertebral artery: a management strategy.

OBJECT: The authors present a retrospective analysis of their experience in the treatment of vertebral artery (VA) dissecting aneurysms and propose a management strategy for such aneurysms, with special emphasis on the most formidable VA dissecting aneurysms, which involve the origin of the posterior inferior cerebellar artery (PICA). METHODS: Since 1998, 18 patients with VA dissecting aneurysms, 11 of whom presented with subarachnoid hemorrhage (SAH), have been treated by endovascular surgery at the authors' institution. Obliteration of the entire segment of the dissected site with coils (internal trapping) was performed for aneurysms without involvement of the origin of the PICA (12 cases; among these the treatment-related morbidity rate was 16.7%). The treatment strategy applied to PICA-involved VA dissecting aneurysms presenting with SAH (three cases) included proximal occlusion of the parent artery followed by internal trapping of the aneurysm (one case), proximal occlusion of the parent artery followed by occipital artery (OA)-PICA bypass (one case), and two-staged internal trapping of the aneurysm involving double PICAs (one case). For PICA-involved VA dissecting aneurysms that were not associated with SAH at presentation (three cases), OA-PICA bypass was performed and followed by internal trapping of the aneurysm (two cases). In the remaining case in which a fetal-type posterior communicating artery was present, internal trapping was performed following successful balloon test occlusion (BTO). Overall, there was no sign of infarction in the PICA territory, despite complete occlusion of aneurysms involving the PICA. There was no recurrent bleeding or ischemic symptoms during the follow-up periods. The overall treatment-related morbidity rate for the VA dissecting aneurysms involving the PICA was 16.7%. CONCLUSIONS: Dissecting VA aneurysms that do not involve the PICA can be safely treated by internal trapping. For those lesions that do involve the PICA, a decision-making algorithm is advocated to maximize the efficacy of the treatment as well as to minimize the risks of treatment-related morbidity based on BTO.

Aged↗

PubMed1989

[Appropriate lymph node dissection in thyroid adenocarcinoma].

Thirty-four patients underwent thyroid surgery for papillary and follicular adenocarcinomas in the period from 1985 to 1989. Fourteen patients were treated with local neck dissection and 20 patients, with modified or radical neck dissection. Cervical lymph node metastasis was found in 25 patients (74%). Our recent policy for lymph node dissection is as follows: When deep cervical lymph node metastasis is clinically demonstrated, radical or modified neck dissection is performed. In patients without clinically demonstrated metastasis, local neck dissection and sampling of the internal jugular chain are performed. When microscopic metastasis is found in frozen sections, modified neck dissection is added. Thus we could select patients for modified neck dissection and choose appropriate neck dissection for more complete cancer clearance without losing postoperative functions.

Adenocarcinoma↗

PubMed1995

[Three cases of postoperative laryngopharyngeal edema following nonsimultaneous bilateral radical neck dissection].

Three cases of postoperative laryngopharyngeal edema following nonsimultaneous radical neck dissection are presented. Case 1 was a 65-year-old male with tongue cancer and left cervical lymph node metastases. Hemiglossectomy, reconstruction of the floor of the mouth with a free rectus abdominis flap, and left radical neck dissection had been performed. Postoperatively, the tongue and left upper neck were irradiated. Seven months later, right cervical lymph node metastases were observed. Right radical neck dissection was performed, and immediately after extubation, upper airway stenosis due to severe laryngopharyngeal edema occurred. Emergent tracheostomy saved his life. Case 2 was a 55-year-old female with tongue cancer and right cervical lymph node metastases. Radium needles had been implanted in the tongue, and right radical neck dissection was performed. Three months later, left cervical lymph node metastases were found. Left radical neck dissection was performed and, as in Case 1, upper airway stenosis revealed immediately after extubation. Since the situation was anticipated, an immediate tracheostomy was done. Case 3 was a 43-year-old male with laryngeal cancer and left cervical lymph node metastasis. Irradiation of the larynx and the bilateral upper neck followed by left radical neck dissection and partial laryngohypopharyngectomy had been performed. Five years later, right cervical lymph node metastasis was observed. Right radical neck dissection was performed, and laryngoscopic examination before extubation revealed severe laryngopharyngeal edema. In this case, tracheostomy was performed before extubation. To our knowledge, there have been only five cases of postoperative laryngopharyngeal edema, following nonsimultaneous radical neck dissection, reported in the literature.

Adult↗