Review of 15 cases of carotid artery exposure or rupture in patients with no recurrent tumor demonstrated several important principles. Irradiation was a risk factor in 90% of cases of carotid blowout. Only one of five patients (20%) with carotid exposure who had not had irradiation had carotid perforation. Immediate death occurred in two of 15 (13%), and delayed death in five of 15 (33%). The neck wound was successfully controlled in 11 of 15 cases, requiring extracervical vascularized muscle or skin in eight of the 11 cases. Only one of seven pectoralis major flaps failed to control infection in the neck. This review reaffirms the importance of irradiation and orocutaneous fistula as risk factors. A rationale for prophylaxis, treatment of carotid exposure, and treatment of carotid rupture is presented.