Retropharyngeal Hematoma: Uncommon Airway Obstruction

Introduction:

Retropharyngeal hematoma is a rare, uncommon cause of airway obstruction that is rather difficult to identify and often turns out to be a fatal complication in the emergency department. Hematoma develops following an injury in the retropharyngeal region, causing airway obstruction. The incidence is higher in trauma patients receiving anticoagulant therapies, spinal injuries, neck surgeries, retropharyngeal infections, and traumatic emergency cannulation procedures. Diagnosis becomes inconclusive in the initial radiographic studies. Airway stabilization in patients suffering from airway obstruction is the mainstay of the treatment, delay in which can cause severe complications and death.

What Is Retropharyngeal Hematoma?

Retropharyngeal space is a deep region of the neck extending from the base of the skull to the mediastinum. The collection of blood in the retropharyngeal space leads to the formation of retropharyngeal hematoma.

What Are the Causes of Retropharyngeal Hematoma?

• Patients on oral anticoagulant therapy for atrial fibrillation (irregular and rapid heartbeat).

• Warfarin therapy.

• Cough.

• Whiplash injuries (sudden movement of the head in the backward and forward direction) are often encountered in car accidents.

• Traumatic cannulation of the internal jugular vein.

• Bleeding diathesis (increased tendency of bleeding).

• Arteriography (also known as angiography, which is used to detect blockage and narrowing of the blood vessels).

• Ingestion of foreign bodies.

• Gastric tube intubation.

• Carotid artery aneurysm (bulging of the artery).

• Retropharyngeal infection.

• Massaging the carotid sinus.

• Carcinoma of the neck involving the retropharyngeal region.

• Closed cervical neck trauma.

• Cervical vertebral fractures located above C6 can develop into retropharyngeal hematomas.

What Happens in the Retropharyngeal Space Following the Formation of Hematoma?

• Bleeding due to an injury or any other reason results in the collection of blood in the retropharyngeal space, which can turn out to be a life-threatening emergency.

• The complex anatomy of the pharyngeal muscles does not offer any resistance to the expanding hematoma.

• The expanding hematoma impinges on the arytenoid cartilage of the larynx (windpipe), obscuring the vocal cords and obstructing the upper airway, causing difficulty in speaking and breathing.

What Are the Clinical Features of Retropharyngeal Hematoma?

The characteristic presentation of the triad of symptoms, such as airway obstruction, anterior displacement of the trachea, and bruising in the neck and chest region, is also called Capp’s triad.

• Sore throat.

• Coughing, sneezing.

• Straining of the throat due to the presence of hematoma.

• Hoarseness of the voice.

• Posterior neck pain.

• Syncope.

• Dysphagia (difficulty in eating).

• Odynophagia (pain while swallowing).

• Dyspnea (difficulty in breathing).

• Stridor (noisy breathing).

• Dysphonia (difficulty in speaking).

How Is Retropharyngeal Hematoma Diagnosed?

• Retropharyngeal hematoma can be best viewed on lateral cervical X-ray, which shows characteristic thickening of the prevertebral space.

• CECT (contrast-enhanced computed tomography) is an important diagnostic tool in detecting and measuring the extent of hematoma.

• The presence of active bleeding gives a clue to the diagnosis.

• Associated vertebral fractures should be ruled out to arrive at an accurate diagnosis.

• MRI is an important diagnostic tool as it gives precise diagnosis in the case of imaging blood and blood products, aids in the exact location of the lesion due to its anatomic precision qualities, and is crucial in follow-up check-ups to determine the treatment outcomes.

• An angiogram is advised to locate the origin of bleeding, such as from a damaged artery or vein.

• Pharyngolaryngeal swelling can be conferred through laryngoscopic inspection and can rule out the possibility of an infection or a tumor.

• Clinical and laboratory investigations reveal fever, dysphagia, leukocytosis, and increased ESR count, which are usually seen in the case of retropharyngeal hematoma.

What Are the Differential Diagnosis of Retropharyngeal Hematoma?

The differential diagnosis of retropharyngeal hematoma is as follows:

• Retropharyngeal infection.

• Acute calcific prevertebral tendinitis (inflammation of the prevertebral tendon).

• Retropharyngeal effusion (collection of fluid in the retropharyngeal space).

How Is Retropharyngeal Hematoma Treated?

• Management of retropharyngeal hematoma is quite a challenging task.

• The first line of treatment involves stabilizing the airway in case of obstruction, which, if delayed, can lead to death.

• Moreover, the presence of hematoma disrupts the retropharyngeal anatomy, obscuring the vocal cords and poses a great challenge for oral intubation when cervical fractures can not be ruled out.

• Such a situation is best managed by surgical intervention, as endoscopic intubation poses a high risk of hematoma perforation.

• Tracheostomy-assisted awake endoscopic intubation can be opted for as it provides better laryngeal visualization and is also associated with a lesser risk of perforation of hematoma. With this technique, the cervical spine alignment can also be preserved.

• Once a patent airway is established, patients are put on the conservative mode of treatment, which includes continuous monitoring of the regression of hematoma with serial CT and MRI scans, which usually resolve in four to five weeks.

• Supportive treatment involves administering IV (intravenous) antibiotics and glucocorticoids.

• In case of a hematoma that expands rapidly, obstructs the airway, and fails to regress, surgical management is the treatment of choice.

• Postoperative aggressive antibiotic therapy is initiated as the surgery carries a higher risk of infection.

• Stabilized airway should be evaluated regularly, and immediate intervention has to be made in case of infection or recurrence of hematoma.

Conclusion:

Retropharyngeal hematoma is an unusual cause of airway obstruction that can be a life-threatening emergency at times if left underdiagnosed or delayed in providing treatment. History taking plays a vital role as it is closely associated with anticoagulant therapy or a previous history of trauma, which can lead to the diagnosis. Securing the airway is the mainstay of the treatment, which can prevent further airway obstruction. Choosing the appropriate method for securing the airway is critical and demands an experienced interprofessional collaborative approach to prevent further complications and contribute to better treatment outcomes.