TheAnatomiser

The film director and screenwriter Anthony Minghella has died unexpectedly, a week after undergoing surgery for what sounds like tonsillar cancer.

Ever since I found out about its existence, tonsillar cancer has been top of my list of things-I-don’t-want-to-get. It’s a horrible disease, just like other forms of cancer. But this one is particularly nasty as it tends to present late, and the treatment is particularly aggressive and often disfiguring.

By ‘present late’ we doctors mean that a disease is quite well advanced by the time it is spotted. If you take skin cancer on the face as an opposite example, this is usually picked up early because the patient, or an acquaintance, notices that strange spreading mole on the cheek. But when the cancer is tucked away at the very back of your throat, there can be nothing in the way of symptoms for a long time. In fact a secondary deposit of the cancer in another part of the body, or in a lymph node in the neck or head area, may be the first sign of tonsillar cancer.

The disfiguring treatment is also related to the anatomical site of the cancer. Many of the organs in the head and neck share lymphatic drainage, and this needs to be taken into account when planning surgery. As well as the actual tumour (which can be difficult to locate exactly) portions of the jaw, neck, tongue and even face may have to be operated on. This experience was detailed by John Diamond, the journalist husband of Nigella Lawson, who died of oral cancer in 2001.

But from all accounts, the initial operation appears to have gone well for Anthony Minghella. He suffered a fatal haemorrhage several days after the operation.

Bleeding several days ‘post-op’ is usually caused by infection. Many wounds get infected after surgery - modern so-called ’superbugs’ usually have nothing to do with it. Most of the time the body shrugs off the infection and the surgical tampering heals. But if you’re unlucky, the infection will become established. And if you’re really unlucky, the infection will involve a large blood vessel (of which there are plenty around the head and neck). If a small abscess erodes through the wall of even a fairly small artery, the bleeding can be catastrophic. And once again, the position of the operation site is a factor here. Bleeding from any artery can usually be stopped very efficiently simply by pressing on the bleeding point. But if the bleeding is coming from somewhere deep in the neck or throat, pressing on it is simply impossible.

The ‘bleeding post-op tonsil’ is a classic exam scenario for both surgeons and anaesthetists. It doesn’t just happen in cancer treatments - in fact the vast majority of postoperative tonsillar haemorrhages occur in young people having ‘routine’ tonsillectomies (a far rarer operation nowadays than in the past - for a brief glimpse of the operation’s shady history, click here.) About 7-10 days after the apparently successful operation, a child can present with copious bleeding from the mouth, enough to require intravenous fluid and/or blood replacement. They also need to be anaesthetised for an operation to stop the bleeding. But their blood pressure is low (because of the bleeding) which limits the anaesthetic techniques which can be used. And the back of their throat is full of blood, so it is difficult to ‘maintain an airway’ (ensure an unobstructed passage for air to get into the lungs.) Bleeding post-op tonsils are a nightmare, and can be a challenge for even the most experienced physicians.

In Mr. Minghella’s case it would seem that he has succumbed to just that event, albeit one complicated by the presence of a tumour of some kind - so his surgery will have been more extensive than that for a simple tonsillectomy.

It has been a strange week for celebrity deaths caused by bleeding from major neck vessels. There’s another one here.

Tags: Celebrity health news, Medical //