Acute airway obstruction secondary to retropharyngeal hematoma

Abstract

tient without a surgeon's assistance. Tracheal intubation prior to transport was desired. However, the physician made an optimistic prediction that the patient would not choke during transport because he was not stridorous at that time. He was transported to Iida Municipal Hospital by ambulance. During transport, he felt dyspneic in the supine position and was placed in the sitting position with 5 l/min of oxygen.About 1 h later the ambulance arrived and a surgeon examined the patient. Physical examination revealed the patient had dyspnea but was making an effort to breathe deeply in the sitting position. Respiratory rate was about 20-25 breaths per minute. His neck was short and thick with no palpable mass. There was no area of ecchymosis on his posterior neck. SpO 2 was 95%-96% on 5 l/min of oxygen. Approximately 30 min after the patient's arrival, the surgeon decided to carry out CT to reevaluate the size of the hematoma before operation. During the CT scan, dyspnea developed suddenly and the patient became tachypneic. The surgeon tried tracheal intubation over and over again with an inside diameter (I.D.) 8.0-mm tracheal tube, but was unsuccessful. The surgeon gave diazepam 10 mg intravenously to the patient to sedate him for easy tracheal intubation. Then the patient became cyanosed and the SpO 2 fell below 85%. The surgeon called an anesthesiologist urgently for assistance of airway management.The anesthesiologist attempted to intubate with an I.D. 7.5-mm tracheal tube, but was also unsuccessful. Then the anesthesiologist reattempted, directing the surgeon to prepare fiberoptic intubation and emergent tracheostomy. The anesthesiologist successfully intubated blindly with an I.D. 6.0-mm tracheal tube. The patient was quickly relieved from dyspnea with no resistance to breathing. CT scan revealed no further extension of retropharyngeal hematoma and showed that the tracheal tube, which was fixed at a right oral angle at a depth of 26 cm from its end, was placed about 5.5 cm proximal from tracheal bifurcation and the most

Retropharyngeal Hematoma Secondary to Minor Blunt Trauma Neck: A Rare Case Report

“…3,5,6 It can occur spontaneously in patients with bleeding disorders. 7 Three such cases were reported in patients taking anticoagulants by Owens et al Traumatic retropharyngeal hematoma is thought to be due to the rupture of the small anterior branches of the vertebral arteries during hyperextension injury, which can be isolated or associated with cervical spine or occipital condyle fractures. Tearing of longus coli muscles or the anterior longitudinal ligament is another cause.…”

“…Tearing of longus coli muscles or the anterior longitudinal ligament is another cause. 7,9 Elderly patients have multiple risk factors for ligamentous injury, fractures and hematoma formation, including laxity of connective tissue, presence of degenerative osteophytes, ankylosing spondylitis and pharmacologic anticoagulation. 5,10 Minor bleeding in the retropharyngeal space will thus usually stop spontaneously in young patients, while the bleeding may continue in elderly patients.…”

“…Patients with small, non-expanding hematomas can be treated conservatively with cervical spine immobilization. 7 In case of rapid expansion of the hematoma or secondary bacterial infection of the retropharyngeal hematoma, surgical drainage may be emergently needed to relieve the tracheal compression. 1,3 Two routes of drainage have been describedtransoral aspiration and external drainage.…”

Severe upper airway obstruction due to delayed retropharyngeal hematoma formation following blunt cervical trauma

“…As blood enters the retropharyngeal space, the expanding hematoma can cause tracheal compression, which may rapidly progress to acute airway obstruction [1,3]. The incidence of airway obstruction resulting from retropharyngeal hematomas is low, but its occurrence can be life threatening [2,4,7].…”

“…Clinicians should maintain a high degree of suspicion when evaluating patients presenting with symptoms of airway compression whose mechanism of injury is consistent with those associated with retropharyngeal hematomas because these initial symptoms may progress rapidly to lethal airway obstruction. In particular, dyspnea should be considered a key clinical indicator of a possible airway crisis because significant airway compression must occur prior to a healthy patient reporting a dyspneic sensation [3]. …”