Hidden danger in the neck-a problem of differential diagnostics: benign chronic lymphadenitis following carotid endarterectomy and patch angioplasty (CEAP) or a metastasis due to a squamous cell cancer of the tongue.

Introduction: Oncological head and neck operations as well as carotid endarterectomy are common surgical procedures. In some occasions, both procedures have occurred in the past, leading to possible diagnostic and therapeutic challenges when follow-up operations seem indicated.

Case Report: We report of a patient presenting with carotid endarterectomy including patch operation 8 years ago and neck dissection due to a squamous cell cancer of the tongue 3 months ago, now showing up with a suspected metastatic tumor of the neck during routine follow-up. Intraoperatively, nearly fatal bleeding occurs due to a partial release of the carotid patch and needs to be managed immediately.

Discussion: The primarily pre-operated neck remains challenging for the radiologist in terms of differentiating between chronic lymphadenitis and metastasis. Furthermore, it remains challenging for the oncological surgeon in case these entities are in the near proximity of the previously operated carotid artery. The operative treatment according to the guidelines can lead to major bleeding during the second surgery. During the diagnostic process, metastases and chronic lymphadenitis after alloplastic carotid operations must be differentiated remaining however difficult, due to only scarce data in the literature.

Conclusion: In the case of previous neck surgery, the decision to operate must be chosen individually regarding the specific conditions and their sometimes vital risks. In case an operation is indicated, the team must be trained to treat life-threatening intraoperative bleeding. In reviewing the literature, we were unable to find published recommendations on how to tackle these challenges.