Post-irradiated Carotid Blowout Syndrome in patients with Nasopharyngeal Tumor: about 3 cases

Introduction
Rupture of the internal carotid artery (Carotid blowout syndrome) is a rare complication of irradiated nasopharyngeal tumor.
We report three cases nasopharyngeal tumors treated with radiotherapy complicated with bleeding of the internal carotid artery presenting as a massive epistaxis.

Case Series
The first case presented a few episodes of small nose bleeding before a massive one. Internal carotid embolisation was performed to stop the bleeding. Unfortunately, few month later, he presented a meningitis related to skull base osteoradionecrosis and died from sceptic shock.

The second case was transferred to our hospital with severe repetitive epistaxis that had been occurring for hours. No endovascular treatment was possible in his case and he died in intensive care unitthe dayof his admission.

The thrid case presented one massive epistaxis which stopped without any treatment or compression. A spontaneous occlusion of his internal carotid artery occured without any neurological defects. He recently benefited from a nasopharyngeal muscle flap for the coverage of the carotid artery.

These three patients all presented with a history of nasopharyngeal tumor handled by radiotherapy. Pathogenesis, treatment, and outcome are discussed on the light of a comprehensive literature review.

Conclusions
Carotid blowout syndrome secondary to radiation therapy is rare but life-threatening. Re-irradiation and skull base osteoradionecrosis are strong predisposing factors.