Postoperative massive hemorrhage in oral cancer surgery nursing interventions and outcomes: A case report

Abstract

BACKGROUND

Post-operative massive hemorrhage is a critical concern in oral cancer surgery, associated with severe complications and heightened morbidity and mortality rates.

CASE SUMMARY

A 46-year-old male with advanced poorly differentiated squamous cell carcinoma (ypT4aN3bN0M0) of the oral floor underwent extensive surgery, including total glossectomy, partial mandibulectomy, and free flap reconstruction. Postoperatively, he developed life-threatening hemorrhage on day 3 due to wound dehiscence. Rapid nursing interventions-prompt suture removal, pressure hemostasis, and multidisciplinary collaboration-controlled bleeding. Postoperative care emphasized hemodynamic monitoring, infection prevention, and rehabilitation. Despite comorbidities (hypertension, diabetes, prior stroke), the patient achieved functional recovery: Oral flap epithelialization, restored swallowing (water swallow test: Grade 1), 70% tongue mobility, and 80% preoperative chewing efficiency at 6-month follow-up. This case underscores the critical role of structured nursing protocols in managing postoperative hemorrhage and optimizing outcomes in high-risk oral cancer surgery.

CONCLUSION

This case report highlights the pivotal role of structured nursing interventions in managing life-threatening postoperative hemorrhage following complex oral cancer surgery. By integrating meticulous preoperative risk stratification, intraoperative hemostatic collaboration, and vigilant postoperative monitoring (e.g., timely suture management, pressure hemostasis, blood product administration), the interdisciplinary team achieved rapid hemorrhage control. Comprehensive psychological care and rehabilitation protocols further facilitated functional recovery, enabling the patient to regain swallowing, speech, and mobility despite advanced disease and comorbidities. The findings underscore that standardized nursing workflows, balancing procedural rigor with holistic patient support, are essential for mitigating complications and enhancing outcomes in high-risk head and neck surgical populations.

Key Words: Massive hemorrhage; Oral cancer; Surgery; Nursing; Case report

Core Tip: Postoperative massive hemorrhage in oral cancer surgery, driven by anatomical complexity and comorbidities, demands structured nursing interventions. Critical components include preoperative risk stratification, intraoperative hemostatic collaboration, and postoperative multimodal monitoring. Prompt suture removal, pressure hemostasis, and blood product support enabled rapid hemorrhage control. Integrated psychological care and rehabilitation ensured functional recovery. Standardized workflows are indispensable for optimizing outcomes in high-risk oral cancer surgeries.

INTRODUCTION

Oral cancer, which exhibits varying incidence rates across the globe, predominantly affects middle-aged adults and males[1,2]. Its etiology is frequently associated with smoking, alcohol consumption, betel nut chewing, poor oral hygiene, and certain occupational exposures[3-5]. Globally, the incidence of oral cancer has demonstrated an upward trend from 1990 to 2019[5]. This condition inflicts severe physical and psychological burdens, encompassing pain, impairment of daily functioning, and mental health challenges. The economic repercussions are considerable, and while early detection can lead to a more favorable prognosis, late diagnosis often results in poor outcomes. The treatment of oral cancer typically adopts a multidisciplinary approach, integrating surgery, radiation therapy, and chemotherapy, tailored to the stage and location of the tumor.

Post-operative massive hemorrhage is a significant concern in the context of oral cancer surgery, where it can lead to serious complications and increased morbidity and mortality. The incidence of postoperative complications, including bleeding, is notably high in patients undergoing surgical resection for oral cancers. A study assessing postoperative complications in 100 patients who underwent surgical resection with free or pedicled flap reconstruction for oral cavity carcinoma found that 40 patients developed surgical complications, which included two deaths[6]. This highlights the potential severity of complications associated with such surgeries. Therefore, patients undergoing oral cancer surgery must be closely monitored for signs of bleeding and be prepared for prompt and effective management of any complications that arise.

Post-operative massive hemorrhage is a serious complication of oral cancer surgery that requires careful preoperative planning, intraoperative vigilance, and effective postoperative management strategies to mitigate risks and improve patient outcomes. The importance of nursing interventions in managing post-operative hemorrhage in oral cancer surgery cannot be overstated. Recently, our team successfully managed a case of severe post-operative hemorrhage following oral cancer surgery, which underscored the critical role of nursing care in such situations. By sharing our experience and insights, we hope to contribute to the ongoing improvement of care practices in this area, ultimately leading to better patient outcomes and reduced complications in oral cancer surgery.

CASE PRESENTATION

Chief complaints

A 46-year-old male patient was admitted to our hospital due to the discovery of a large mass in the floor of the mouth persisting for over six months.

History of present illness

The patient initially noted a painless, submucosal mass in the right floor of the mouth approximately six months prior, roughly the size of a “soybean” (approximately 1.0 cm in diameter), which he initially disregarded. Three months later, the mass gradually enlarged to the size of a “quail egg” (approximately 3.0 cm × 2.5 cm), causing a foreign body sensation during meals but no dysphagia, hoarseness, or respiratory distress. He denied systemic symptoms such as fever or weight loss and did not seek medical evaluation. One month prior, the mass exhibited accelerated growth, with ulceration, bleeding, halitosis, and persistent dull pain radiating to the ipsilateral mandibular region, exacerbated at night and interfering with sleep. Simultaneously, he reported restricted tongue movement and slurred speech, prompting his visit to our institution. During the disease course, his weight decreased by approximately 5 kg (from a baseline of 65 kg).

History of past illness

The patient’s medical history included hypertension, diabetes mellitus, and a prior cerebral infarction. He denied a history of tuberculosis, hepatitis, or other infectious diseases, as well as drug allergies. His social history was notable for a 30-year smoking history (20 cigarettes/day) and a 20-year alcohol consumption history (50 mL of baijiu/day).

Personal and family history

The patient had no relevant family history of malignancies or hereditary disorders.

Physical examination

A large, firm mass with local infiltrative features was palpable in the right paramedian floor-of-mouth, measuring approximately 6.0 cm × 4.5 cm × 3.0 cm. The surface exhibited a cauliflower-like ulceration with irregular, poorly demarcated margins and adjacent mucosal induration, bleeding easily upon touch. The mass displaced the tongue to the contralateral side with mild elevation, resulting in slight tongue movement restriction and slurred speech, though no significant respiratory distress was observed. Multiple enlarged, hard, and immobile lymph nodes were palpable in the bilateral submandibular and upper deep cervical regions, with the largest measuring approximately 2.0 cm in diameter; some were fused without tenderness. Palpation of the ulcerative floor-of-mouth mass revealed close adhesion to the mylohyoid muscle, with preserved cortical continuity but localized tenderness over the mandible, suggesting potential bony involvement.

Laboratory examinations

Laboratory examinations revealed mild anemia (haemoglobin 102 g/L, reference range 120-160 g/L) and hypoalbuminemia (32 g/L, reference range 35-55 g/L), likely attributed to chronic tumor-related or impaired oral intake. Coagulation parameters (prothrombin time/activated partial thromboplastin time/international normalized ratio) were within normal limits, ruling out bleeding diathesis.

Imaging examinations

Imaging examinations demonstrated a 6.0 cm × 4.5 cm heterogeneous mass in the right floor of the mouth on contrast-enhanced computed tomography, infiltrating adjacent muscles (mylohyoid and genioglossus) without definitive mandibular bone erosion. Multiple enlarged lymph nodes with central necrosis were identified in levels II-III of the neck (largest 2.2 cm).

FINAL DIAGNOSIS

Tongue cancer (ypT4aN3bN0M0 tongue cancer).

TREATMENT

Following admission, preoperative preparations were initiated, and a pathological biopsy confirmed the diagnosis of poorly differentiated squamous cell carcinoma. On the eighth day of admission, the patient underwent a comprehensive surgical procedure including bilateral extended resection of the malignant oral floor mass, total glossectomy, partial mandibulectomy, sublingual glandectomy, neck dissection, left fibula free flap transfer for reconstruction, and tracheotomy.

The postoperative pathological staging indicated ypT4aN3bN0M0 tongue cancer. The patient’s condition remained stable, and he was transferred back to our department from the emergency intensive care unit (Figure 1). Physical examination revealed mild swelling of the maxillofacial region, with adequate blood supply to the oral floor and total tongue flap. The patient’s mouth opening was approximately one finger-width, and his vital signs were stable. The flap survived the surgical procedure.

Figure 1 The postoperative pathological staging. A: Postoperative day 1, condition after returning to the ward from the intensive care unit; B: Postoperative day 3, after sutures were removed due to bleeding; C: Postoperative day 6, daily dressing changes, with no further bleeding from the wound; D: At the time of discharge, the intraoral flap showed good survival.

On the third postoperative day (ninth day of admission), at 10:00 AM, after the metal tracheal cannula was replaced, the patient experienced frequent coughing. At 11:00 AM, during a nursing round, fresh blood was observed being coughed out from the tracheal cannula, amounting to approximately 50 mL. Significant swelling was noted at the submental and neck wounds. Considering the possibility of massive hemorrhage, the nursing protocol was activated. The nurse assisted the surgeon in removing the submental wound sutures at the bedside to explore and ligate the bleeding points (Figure 1). A disposable tracheal cannula was placed, and the patient received oxygen therapy, electrocardiographic and blood oxygen monitoring, suctioning, accelerated fluid replacement, and blood tests as per the doctor’s instructions. These interventions effectively controlled the bleeding.

From the fourth to seventh postoperative days, the previous treatment plan was continued. The surgeon was assisted daily in cleaning the accumulated blood and fluid from the submental wound, and no further bleeding occurred (Figure 1). On the eighth postoperative day (16^th day of admission), the submental wound was resutured, and the metal tracheal cannula was replaced. The patient’s flap remained viable, with no signs of redness, swelling, or fluid leakage at the chin or left leg wounds. On the 15^th postoperative day (23^rd day of admission), the patient was discharged with a gastric tube and metal tracheal cannula in place (Figure 1).

OUTCOME AND FOLLOW-UP

Seven days after discharge (22^nd postoperative day), the patient returned for a follow-up visit. The intraoral flap had adequate blood supply, with a red and soft appearance. The submental and left leg wounds healed well. The metal tracheal cannula was removed, and the patient resumed spontaneous oral breathing without respiratory distress. Speech clarity improved compared to the preoperative state, though a mild hoarseness persisted.

Six-month postoperative follow-up: The oral mucosal flap achieved complete epithelialization, with color and texture indistinguishable from adjacent mucosa. No contractures or fistulas were observed. The left lower limb donor site exhibited stable scarring, and the cervical incision healed well. Swallowing function normalized to allow soft diet intake without aspiration (water swallowing test: Grade 1). Speech intelligibility reached 85%, though a mild nasal tone persisted. Tongue mobility recovered to 70% of the contralateral side. Chewing efficiency, restored to 80% of preoperative levels via prosthodontic rehabilitation, facilitated adequate dietary intake. Neck magnetic resonance imaging and laryngoscopy confirmed no tumor recurrence or vocal cord motility abnormalities. The patient’s weight stabilized at 62 kg (from a preoperative 65 kg). Currently, the patient is independent in activities of daily living and adheres to regular outpatient follow-ups.

DISCUSSION

Oral cancer, being a malignant tumor, typically exhibits favorable prognosis when detected and treated early. However, if left untreated, the tumor may gradually enlarge, invading surrounding blood vessels and nerves, leading to massive hemorrhage. Oral cancer is frequently diagnosed at an advanced stage, requiring extensive surgical resection and complex reconstructive procedures often utilizing various free tissue transfers, including skin flaps[7-11]. Given the abundant blood supply in the oral and maxillofacial region, surgical alterations to the native anatomical structures can readily predispose patients to life-threatening postoperative hemorrhage. Massive hemorrhage following oral cancer surgery is a multifaceted issue, primarily influenced by surgical technique and anatomic location, anticoagulant/antiplatelet therapy, patient characteristics such as age, comorbidities, and nutritional status, infection and inflammation, technical complications during surgery, and delayed bleeding due to pseudoaneurysms or vessel erosion. Understanding these factors is crucial for minimizing bleeding risks and managing postoperative complications effectively.

This case is unique due to its multifaceted clinical complexity and favorable post-treatment outcomes in a patient with advanced oral cavity malignancy. The patient presented with a rapidly enlarging, floor-of-mouth tumor associated with cervical lymphadenopathy, bony invasion potential, and significant functional impairments (dysphagia, dysarthria, tongue restriction). Despite aggressive tumor growth and a history of comorbidities (hypertension, diabetes, prior cerebral infarction) - coupled with high-risk behaviors (30-year smoking, 20-year alcohol consumption) - the patient achieved remarkable recovery after surgical resection and tracheostomy decannulation. Key highlights include complete epithelialization of the oral flap without contractures or fistulas, restoration of near-normal swallowing (water swallowing test: Grade 1) and speech intelligibility (85%), and preservation of tongue mobility (70% of contralateral side) and chewing efficiency (80% of preoperative levels). Notably, the absence of tumor recurrence on magnetic resonance imaging/Laryngoscopy and stable weight (62 kg) at six-month follow-up underscore successful oncologic and functional rehabilitation, demonstrating resilience in a high-risk patient profile.

This case underscores the interplay of surgical precision, multidisciplinary rehabilitation, and patient-centered care in optimizing outcomes for advanced head and neck cancers. The prompt recognition and management of this complication were essential to prevent further deterioration in the patient’s condition. The nursing team played a vital role in assisting the surgeon in removing the submental wound sutures to explore and ligate the bleeding points, which effectively controlled the bleeding. Nursing plays a crucial role in the management of post-oral cancer surgery hemorrhage, yet there lacks a systematic summary of rescue protocols for such situations. By reviewing the rescue process of a case involving massive hemorrhage after oral cancer surgery, we have formulated the following essential nursing protocols, aiming to enhance the success rate of emergency interventions for post-oral cancer surgery hemorrhage[12-17] (Table 1).

Table 1 Optimize the emergency intervention nursing plan for post-oral cancer surgery hemorrhage.

Nursing phase	Core principles	Key actions
Preoperative	Risk assessment & preparedness	Evaluate bleeding history, coagulation status, and surgical site anatomy
		Develop personalized prevention plans (e.g., hemostatic drugs, blood transfusion)
		Multidisciplinary collaboration for emergency protocols and equipment readiness
	Patient & family education	Educate families on bleeding risks, signs, and emergency response
		Provide written care manuals and guidance
Intraoperative	Real-time monitoring & team coordination	Assist surgeons in hemostatic techniques (suturing, ligation)
		Monitor vital signs and bleeding status
		Prepare hemostatic materials (clips, coagulation factors)
Postoperative	Continuous monitoring & early intervention	Track vital signs (HR, BP, SpO2) and bleeding characteristics (volume, timing)
		Apply pressure dressings, elevate head, and administer fluids/hemostatic agents as needed
		Escalate to surgical team if bleeding persists
	Personalized nursing care	Tailor plans for wound care, pain management, and nutrition
		Increase surveillance frequency for high-risk patients
	Personalized nursing care	Tailor plans for wound care, pain management, and nutrition
		Increase surveillance frequency for high-risk patients
	Psychological support & pain management	Provide emotional reassurance and clear communication
		Use multimodal pain relief (pharmacological, physiotherapy)
	Rehabilitation & follow-up	Monitor for complications (hematoma, infection)
		Adjust care plans during recovery; provide rehabilitation guidance
		Conduct regular follow-ups to assess outcomes
System-wide	Continuous quality improvement	Regular training on latest techniques and evidence-based practices
		Retrospective reviews to refine protocols

HR: Hazard ratio; BP: Blood pressure; SpO₂: Oxygen saturation.

In summary, massive bleeding after oral cancer surgery poses significant challenges to nursing care, requiring comprehensive preoperative, intraoperative, and postoperative assessments and the formulation of personalized comprehensive nursing plans. The integration of various nursing elements is crucial for improving patient treatment outcomes and ensuring a safe rehabilitation process. However, limitations arise from its retrospective, single-patient design, which precludes generalizability and statistical validation of outcomes. The absence of preoperative functional baselines (e.g., standardized speech/swallowing metrics) and long-term survival data further restricts conclusions about treatment durability. Future studies incorporating larger cohorts, prospective follow-up, and validated outcome measures could address these gaps and enhance the clinical applicability of such findings.

CONCLUSION

This case report underscores the critical role of structured nursing interventions in managing life-threatening postoperative hemorrhage following complex oral cancer surgery. Through meticulous preoperative risk assessment, tailored hemostatic collaboration during surgery, and vigilant postoperative monitoring-including prompt suture removal, pressure hemostasis, and blood product support-the interdisciplinary team achieved rapid hemorrhage control. Integrated psychological care and rehabilitation strategies further optimized functional recovery, enabling the patient to regain swallowing, speech, and mobility despite advanced disease and comorbidities. The findings highlight that standardized nursing workflows, combining procedural expertise with holistic patient support, are indispensable for mitigating complications and improving outcomes in high-risk head and neck surgical settings.