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What would the diagnosis be and the therapeutic approach?
¿Cuál sería su diagnóstico y actitud terapéutica?

An 84 year old patient, with a history of chronic atrial fibrillation undergoing treatment with acenocoumarol (oral anticoagulant, vitamin K antagonist), presented to the emergency services with clinical fatigue, breathing difficulties, much expectoration, with occasional traces of blood and inflammation in the right preauricular area which she had been experiencing for 24 hours.

On physical examination, parotiditis on the right side was noted and a submucosal hematoma on the retromolar trigone, pharyngeal pillars and soft palate on right side with uvula displacement towards the left side. On flattening the tongue, it is observed that the hematoma descends like a "sheet" down the retropharyngeal space on the right side. Tests showed an increase in urea (89 mg/dl) and creatinine (1,4 mg/dl) and coagulation tests were abnormal with undetectable times*. The lateral cervical radiography showed this image: (Fig. 1)

Retropharyngeal hematoma
Hematoma retrofaríngeo

A. Riaño Argüelles¹, M.Á. Bada García², R. Martino Gorbea², A. Etayo Pérez¹, J.L. Castiella Iribas², R. Palomero Rodríguez³

1 Médico Interno Residente
2 Médico Adjunto
3 Jefe de Servicio
Servicio de Cirugía Oral y Maxilofacial
Hospital Virgen del Camino. Pamplona

Correspondencia:
Ana Riaño Argüelles
Plaza Rafael Alberti nº9, 1ºC
31010 Barañain (Navarra)

The lateral cervical radiography showed a prevertebral space of unusual dimensions, which led to the suspicion that, together with the tests and the examination, that the patient presented a considerable retropharyngeal hematoma.

With this diagnosis, and before any further examination is carried out (nasofibroscope), the Hematology Service is consulted and a decision is made to administer recombinant factor VII in an attempt to normalise coagulation. After half an hour, the level of prothrombin is 15%, but given the critical state of the patient, a decision is made to attempt elective intubation, but not before administering more factor VII following the recommendation of the Hematology Service. With a certain degree of difficulty orotracheal intubation is achieved. The patient is taken to intensive care where she is kept under sedation and coagulation is closely controlled. Following this a CT scan of cervical spine is made, and a considerable hematoma is observed which descends from the nasopharynx to the uppermost portion of the hypopharynx (Figs. 2 and 3), confirming the need to continue with intubation although, following the recommendation of the Intensive Care Unit, a tracheotomy is performed and maintained until the complete resolution of the case (with CT control).

Retropharyngeal hematoma is very rare but it can have fatal repercussions given how quickly the airway becomes obstructed. With regard to its etiology various factors can be described: infections, cervical trauma, trauma of large cervical vessels, violent cervical movements, iatrogenic complications (cardiac catheterisation or celebral angiography), haemorrhages because of parathyroid adenoma, ingestion of a foreign body, haemophilia A, acetylsalicylic acid abuse or, as in our case, anticoagulant therapy. To be more precise, a case like this may appear in 2-4% of anticoagulated patients.¹

Clinical presentation may include cervical pain, dysphagia, dyspnea or muffled voice. Capps et al. describe a clinical triad of subcutaneous reddening of anterior neck and superior thorax, tracheal and oesophageal compression and ventral displacement of trachea.¹ It is common for patients to be underdiagnosed in the early stages, as at first there is a little discomfort in the upper airways, and this can be confused with a simple case of pharyngitis. It is 12 to 48 hours later that alarming symptoms of airway compromise occur, and urgent intubation is required or a tracheotomy so as to guarantee permeability. This prolonged period of time is due to the peculiar structure of the retropharyngeal space, as the surrounding muscles do not offer resistance to hematoma induced space expansion.

This space is situated between the pharynx and the spine. The posterior aspect of the retropharyngeal space is made up of the prevertebral fascia, anatomically described as an unfolding with an anterior lamina called «fascia alar» and another posterior lamina that is the prevertebral fascia, with a virtual space called the «danger space». It extends from the base of the skull to the posterior mediastinum and it is limited laterally by the fusion of both laminas by the transverse apophysis of the adjacent vertebral bodies. Infections of the retropharyngeal space can spread to the danger space, and from here progress to the posterior mediastinum with serious life threatening risk.

Hematoma prognosis is good if diagnosed and treated quickly. It has been demonstrated that patients with retropharyngeal hematoma secondary to coagulation problems (haemophilia, hemorrhagic diathesis, anticoagulant therapy, ...) develop the hematoma more silently and that intubation or a tracheotomy, once the diagnosis has been reached, is more difficult.¹ Bulging of the posterior wall of the pharynx is a sign of a hematoma in an advanced stage, as described by Field and DeSaussure.

As an additional test, the lateral cervical radiography (Fig. 4) provides fundamental information. A normal prevertebral space should have 4mm maximum thickness of soft areas on a C2 level, and 14 mm at a C6 level (due to the presence of the oesophagus). According to Wholey, a warning sign should be if the C2 level measurement of the anteroposterior retropharyngeal space is greater than 7 mm. If it were possible to perform, a flexible laryngoscope would confirm diagnosis of hematoma diagnosis.

Airway stability is of prime importance and intubation should be performed orally if a cervical fracture is suspected, or nasal if there is damage from the hematoma.2 If intubation is unsuccessful a tracheotomy should be performed. Once airway stability has been achieved, a study can be completed with a CT cervical scan which will show the extension of the hematoma perfectly.

A differential diagnosis has to be made between a retropharyngeal hematoma and other entities such as a retropharyngeal abscess, arterial aneurysm, a malformation or prominence of vertebral bodies, and an adenoiditis.

Treatment will depend on the size, location and clinical evolution of the patient. In small hematomas, treatment tends to be conservative, and a spontaneous resolution is sought.² If over a two-week period no improvement is observed, evacuation should be the next step, using a cervical approach. Immediate opening of the hematoma, in order to start aspiration seems to increase the risk of infection extending to the mediastinum. On the other hand, if the hematoma is large, which would indicate the unlikelihood of re-absorption, or if it has extended rapidly, surgical evacuation in the operating room and controlling the source of the bleeding, once the patient has been stabilized, is generally desirable.

References

1. Chin KW, Sercarz JA, Wang MB, Andrews R. Spontaneous cervical hemorrhage with near-complete airway obstruction. Head & Neck 1998; 20(4):350-3.        [ Links ]

2. El Kettani C, Badaoui R, Lesoin FX, Le Gars D, Ossart M. Traumatic retro pharyngeal hematoma necessitating emergency intubation. Anesthesiology 2002;97(6):1645- 6.        [ Links ]

3. Otto RA, Noorily AD, Otto PM. Deep Neck Infections. En: Shockley WW, Pillsbury HC: The neck. Diagnosis and surgery. Mosby 133-171.        [ Links ]