Postoperative cervical edema is present in every anterior neck procedure to some degree and occurs in cervical laminectomy because of prone positioning. In carotid endarterectomy patients, computed tomographic studies have shown a 25% to 60% reduction in airway volume and a 200% to 250% increase in retropharyngeal mass as a result of edema alone. Edema of the larynx and pharynx is thought to be caused by venous and lymphatic disruption, as well as direct tissue trauma with increased capillary permeability secondary to release of local inflammatory mediators. Tissue edema can be difficult to gauge clinically if the patient has remained in the supine position. There can be significant internal compression of airway structure with little
or no change in neck circumference, and stridor may not be heard until the airway has narrowed to 4 mm. Also, unilateral tissue disruption can cause bilateral edema. Edema is rarely the sole cause of respiratory distress leading to reintubation, but it compounds the effects of other problems that might arise (such as hematoma) and can make visualization of the vocal cords for reintubation extremely difficult. If the edema has occurred because of prone positioning, elevating the head of the bed to 30 degrees during emergence can reduce soft tissue edema.

Significant hematoma occurs in about 1.4% to 10.0% of carotid endarterectomy patients, with higher frequency in cases involving coagulopathies and heparin use without reversal. Frequently, hematomas do not develop until several hours into the postoperative phase, and the “carotid take-back” patient is often hypertensive, hypercarbic, and partially obtunded as well. Reintubation in this situation can be one of the most difficult airway situations to manage, and the airway can quickly become a truly emergency situation. Surgical evacuation of the hematoma without regard for aseptic technique may be sufficient to relieve the obstruction until oral direct laryngoscopy can be performed. The authors recommend that anesthesia providers have available maximum airway support in terms of personnel and equipment when reintubating any patient who has developed significant hematoma after carotid or cervical neck surgery.