Teaching Case

A 68-year-old woman under treatment with anticoagulation for atrial fibrillation presented to the emergency department with dysphagia after a previous minor contusion falling down the stairs with neck hyperextension. There were no neurological deficits nor any airway impairment. The neck was non-tender without area of ecchymosis. Examination of the oropharynx was unremarkable.

A CT scan of the neck revealed a midline hypoattenuating retropharyngeal hyperdense collection (Fig. 1) that ventrally displaced the posterior pharyngolaryngeal wall, without peripheral enhancement or active bleeding after IV contrast media administration  (Fig. 2). The mass extended to the superior mediastinum space, below the Lewis’s angle of the sternum, measuring 3 cm by 6 cm by 20 cm (Fig. 3). It was located in close proximity to the oesophagus, which was compressed (Fig. 4). The airway was not significantly constricted.  No cervical spine injuries were also detected (Fig. 5). The diagnosis of post-traumatic large retropharyngeal hematoma was confirmed and the patient underwent a surgical debridement.

A retropharyngeal hematoma forms when blood collects in the retropharyngeal space, deep space in the neck [1]. A hematoma in this potential space can be an immediate life-threatening emergency, with potential for airway compromise [2]. While the frequency of retropharyngeal hematoma is unknown, it is thought to be rare [3]. Various precipitating factors have been described: bouts of vomiting, whiplash injury, blunt head and neck trauma, foreign body ingestion, retropharyngeal infection, internal jugular vein cannulation and coagulopathic states [4, 5]. Precipitating factors such as episodes of coughing, sneezing, straining, or vomiting indirectly contributes to a retropharyngeal hematoma by increasing venous pressure and causing a rupture in the venous system. In traumatic cases, retropharyngeal hematoma is thought to be caused by a tear in the anterior longitudinal ligament. Patients may experience a sore throat, dysphagia, odynophagia, trismus, a muffled voice, the sensation of a lump in the throat, and/or pain in the back and shoulders upon swallowing [4, 5]. A CT scan of the neck and chest is the investigative technique of choice: it delineates the hematoma, helps differentiate blood from pus, shows the level of obstruction and the extent of the hematoma, and reveals small vertebral body fractures. Data obtained with a CT scan can facilitate the planning of anaesthesia and surgery [1, 2, 6]. Most researchers advise that patients with small nonexpanding hematomas can be treated conservatively. If the hematoma continues to expand or ventilation becomes difficult despite surgical evacuation of the hematoma is indicated. This may be done using an oral or transcervical approach [7]. Complications of retropharyngeal hematoma may result from mass effect, rupture, or infection. After the initial airway insult is managed, an uncomplicated recovery is the goal. However, among patients with spontaneous onset reported in the literature, few have survived. This suggests an especially poor prognosis for this subgroup of patients [8].