Ramnik Patel, FRCSEd Balgopal Eradi, FRCS George K. Ninan, MS, FRCSEd.Ire, Glas; FRCS (Paed Surgery) Department of Paediatric Surgery, Children’s Hospital, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, UK doi: 10.1111/j.1445-2197.2010.05327.x Dear Editor, Balloon test occlusion for the management of head and neck tumour Despite advances in radiotherapy, chemotherapy and technologies, occlusion of internal carotid artery or common carotid artery remained an important procedure in managing patients with head and neck tumours, as part of preoperative assessment or manage- ment of complication such as pseudoaneurysm. 1–4 Here, we reviewed our management result of a combined approach of clinical assessment with hypotensive challenge and angiographic assessment of venous drainage for patients with head and neck tumours between August 1996 to November 2008. There were 19 men and 10 women. Age (mean  SD) was 51.1  11.8 years. The diagnosis at the time of treatment included nasopharyngeal carcinoma (12/29, 42%) and other head and neck tumours (17/29, 58%). Balloon occlusion was performed using a peripheral balloon occlusion catheter or a balloon catheter (Sentry, Boston Scientific, Natick, MA, USA; Hyperglide, ev3, Irvine, CA, USA) coaxially through a 6F guiding catheter. The patient was monitored clinically for new neurological deficits such as visual loss, limb weakness or dysphasia. After 10 min, intravenous bolus of antihypertensive medications (typically labetalol) would be given to lower the sys- tolic blood pressure by 10–15% of the baseline for 10–20 min. Meanwhile, clinical monitoring would be continued. The symmetry of the cortical veins filling between the occluded territory and con- tralateral artery was assessed. The test occlusion was considered to be negative in radiological assessment if the delay in venous drain- age between the occluded and contralateral hemispheres was not more than 2 s. Twenty-two (76%) patients passed the balloon test occlusion. In the cohort of patients passed the balloon test occlusions, there was one (1/22, 4.5%) permanent and one (1/22, 4.5%) transient neuro- logical complications occurred, which were related to subsequent tumour and parent artery excisions. In conclusion, a combined approach of clinical assessment with hypotensive challenge and angiographic assessment of venous drainage is effective in screening out patients at risk of ischemia after parent artery occlusion and can serve as a guideline for selection of patients requiring extracranial- intracranial bypass. References 1. Adams GL, Madison M, Remley K, Gapany M. Preoperative permanent balloon occlusion of internal carotid artery in patients with advanced head and neck squamous cell carcinoma. Laryngoscope 1999; 109: 460–6. 2. Verhaeghe JL, Montagne S, Belotzerkovski I et al. Is carotid resection a valuable option in advanced option in advanced head and neck squamous cell carcinomas. Bull. Cancer 2003; 90: 607–13. 3. Johnson MH, Chaing VL, Ross DA. Interventional neuroradiology adjuncts and alternatives in patients with head and neck vascular lesions. Neurosurg. Clin. N. Am. 2005; 16: 547–60. 4. Wong GK, Chan KK, Yu SC, Tsang RK, Poon WS. Treatment of profuse epistaxis in patients irradiated for nasopharyngeal carcinoma. ANZ J. Surg. 2007; 77: 270–4. George Kwok Chu Wong,* FRCSEd(SN) Michael Chi Fai Tong,† FRCSEd MD Simon Chun Ho Yu,‡ FRCR MD Wai Sang Poon,* FRCS (Glasgow) FRCSEd *Division of Neurosurgery and †Department of Otorhinolaryngology and ‡Department of Diagnostic Radiology and Organ Imaging, Head and Neck Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong doi: 10.1111/j.1445-2197.2010.05328.x Dear Editor, Blood clot cast of the tracheobronchial tree A 57-year-old woman on chronic prednisone therapy for a history of progressive systemic lupus erythematosus with pulmonary involve- ment was admitted to the intensive care unit with dyspnea. She was diagnosed with pneumocystis carinii pneumonia and required intu- bation due to acute respiratory failure. Ultimately, due to prolonged ventilator support, a tracheotomy was performed after 22 days of peroral endotracheal intubation. The patient was subsequently weaned off of ventilator support to tracheotomy collar and trans- ferred to a ward unit. Two weeks post-operatively, the tracheotomy tube was uneventfully downsized. Three weeks postoperatively, the patient experienced an episode of massive haemoptysis, 2 L in volume. The patient was emergently taken to the operating room. The patient became difficult to bag ventilate and became hypoxic. Flexible bronchoscopy revealed large blood clots in the tracheobronchial tree, which could not be removed with flexible instruments. A rigid bronchoscopy was performed, and clot extracted with rigid cupped forceps (Fig. 1). At this point, oxy- genation was improved. There was no bleeding source identifiable in the soft tissues of the neck or in the trachea. An arteriogram of the aortic arch, innominate artery, and carotid arteries was performed by the vascular surgery service, and was negative for extravasation. A CT scan of the neck and chest revealed a cavitary lesion of the right upper lobe, consistent with mycetoma. A bronchial artery angiogram was then performed by the interventional radiology service. Extrava- sation was observed from a branch of the right bronchial artery, which was embolised. The blood clot cast in this patient’s tracheobronchial tree impaired adequate ventilation until it was extracted. Rigid bron- choscopy and instrumentation permitted en bloc removal and immediate improvement in oxygenation. We have only identified one prior published photograph in the literature of a partial bron- chial blood clot cast. 1 Letters to the editor 473 © 2010 The Authors Journal compilation © 2010 Royal Australasian College of Surgeons