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Traumatic retropharyngeal hematoma—A cause of acute airway obstruction
The Journal of Emergency Medicine, Vol13, No 2, pp 165-167, 1995 Copyright 0 1995Elsevier ScienceLtd Printed in the USA. All rights reserved 0736-4679/95 $9.50 + .oO
Pergamon
0736-4679(94)00137-5
CIhiCd
Communications
TRAUMATIC RETROPHARYNGEAL HEMATOMAA CAUSE OF ACUTE AIRWAY OBSTRUCTION Robert 0. Mitchell,
MD,
and B. Todd Heniford,
MD
Department of Surgery, Trauma institute, University of Louisville School of Medicine, Louisville, KY Reprint Address: Robert 0. Mitchell, MD, Department of Surgery, University of Louisville, Louisville, KY 40292
0 Abstract-Blunt trauma causing a retropharyngeal hematoma without an associated cervical fracture is a relatively rare occurrence. This article presents the case of a patient with airway compromise from a retropharyngeal hematoma, and discusses the diagnosis, airway management, and treatment of this condition.
automobile struck a deer at an unknown rate of speed. The deer entered the front windshield and exited the rear window. The patient reported a brief loss of consciousness but was awake and alert on arrival of emergency personnel. She was transported to the nearest emergency facility on a backboard and with a cervical collar. Her complaints at that time were only of posterior neck and right shoulder pain. Vital signs on arrival included a blood pressure of 124/72 mmHg; pulse rate, 108 breaths/min; and respiratory rate, 16 beats/min. Physical examination of the head and neck was significant only for a superficial abrasion on the right side of the neck. No further physical findings regarding the neck examination were noted in the medical record. The chest and abdominal examinations were normal. There were no obvious signs of trauma to the extremities. The patient was noted to speak in a muffled voice without stridor. Further examination revealed weakness of the flexor/extensor muscles of the right arm. No arterial blood gaseswere obtained. Lateral cervical radiograph showed marked prevertebral soft-tissue swelling without fracture (Figure 1). Fortuitously, this could be compared to normal cervical radiograph of the same patient taken 18 months earlier (Figure 2). The emergency physician at the outside hospital felt uncomfortable in treating this patient without surgical and anesthesia personnel available. The pa-
0 Keywords - hematoma; retropharyngeal; blunt trauma; airway obstruction
INTRODUCTION
Traumatic retropharyngeal hematoma is a relatively rare occurrence. Our Medline search of the English literature over the past 25 years revealed fewer than 18 reported casesof retropharyngeal hematoma from blunt trauma that is not associated with a cervical fracture. Early recognition of prevertebral soft tissue swelling on lateral cervical radiograph and aggressive airway management are the mainstays of successful treatment. We report the case of a 28-year-old woman sustaining an isolated traumatic retropharyngeal hematoma after striking a deer with her automobile. CASE REPORT
A 28-year-old woman was the unrestrained nonintoxicated driver in a motor vehicle accident in which her
Cliuical Communications (Adults) is coordinatedby Ron M. Walls, MD, of Brigham and Women’s Hospital and
Harvard Medical School, Boston, Massachusetts RECEIVED: 8 June 1993; FINAL SUBMISSION RECEIVED: 18 March 1994; ACCEPTED: 15 July 1994 165
R. 0. Mitchell and B. T Hemfora
Figure 1. Lateral cervical radiograph with marked prevertebra1 soft-tissue swelling indicated by arrows.
tient Wasurgently transported to our facility by helicopter. After an approximate 20-minute helicopter transport, the patient arrived stridorous. Physical examination did not reveal crepitance, tracheal displacement, anterior cervical tenderness, or swelling. Pulse oximetry measured an arterial oxygen saturation of 90% on 2 liters per minute of oxygen by nasal cannula. The patient was nasotracheally intubated with surgical standby for operative placement of an airway if necessary. Postintubation computed tomography (CT scan) of the neck demonstrated a retropharyngeal hematoma with the trachea outlined only by the endotracheal tube (Figure 3). The patient received a tracheostomy on the second postinjury day. The tracheostomy was removed at approximately 4 weeks, and follow-up 1 month later revealed no vocal difficulties or breathing problems. Neurosurgical consultation diagnosed a brachial plexus stretch injury to be the etiology of the right arm weakness. These symptoms had nearly resolved at last follow up.
Figure 2. Normal lateral cervical radiograph taken 18 months prior. No prevettebral swelling noted.
DISCUSSION Isolated retropharyngeal hematoma from blunt trauma without cervical fracture is a rare occurrence, with only about 18 casesreported in the last 25 years. Etiologies have ranged from blunt trauma alone to whiplash injuries and foreign body ingestion ( l-3 ). The retropharyngeal space is bounded anteriorly by the buccopharyngeal fascia and posteriorly by the prevertebral fascia. This space extends from the base of the skull to the level of the first thoracic vertebra (4). A prevertebral soft-tissue thickness of greater than 5 mm on lateral cervical radiograph suggests significant pathology and impending airway compromise (5). Symptoms may include hoarseness, stridor, and dysphagia. Physical examination may indicate cervical bruising or edema on inspection. Careful palpation might reveal crepitance with subcutaneous emphysema or laryngeal displacement. The conscious patient will invariably complain of neck pain and stiffness.
Traumatic Retropharyngeal
167
Hematoma
These injuries are life threatening, and rapid diagnosis with aggressive airway control are the keys to successful outcome. A number of features in this case warrant further discussion. First, the patient was transferred to our facility without prior airway stabilization. The referring physician recognized the potential hazards of this situation. Ideally, airway stabilization prior to transport is desired. However, the physician was not comfortable in undertaking what might be a difficult intubation without readily available surgical support personnel and without experience in fiberoptic intubation techniques. Additionally, the patient was not stridorous at the time of transport and a level 1 trauma center was 20 minutes away by helicopter. At arrival of the patient at our facility, it was obvious that the patient’s airway was in jeopardy. Each breath was stridorous and the patient was becoming agitated. With evidence of acute airway compromise on clinical evaluation, immediate airway stabilization is of the utmost importance. Waiting for arterial blood gas results and chest radiographs can impose dangerous and unnecessary delays. In this patient we chose nasotracheal intubation because of our personal bias and experience in using this technique in patients with spontaneous respirations (6,7). The fiberoptic bronchoscope should be available at the patient’s bedside, and bronchoscopicassisted intubation would be our choice should there be difficulty with nasotracheal intubation. Oral intubation would be acceptable, depending on the circumstances and experience of the physician, but we feel it would not offer any particular advantage over nasal intubation, and in our hands it often results in coughing and gagging despite topical anesthesia. Additionally, oral intubation is difficult if the neck cannot be hyperextended and we did not have the luxury of time to rule out a cervical fracture.
Figure 3. Computed axial tomographic scan of the neck demonstrating retropharyngeal hematoma. Note the only open space is the endotracheal tube stenting the trachea.
We performed a tracheostomy within 48 hours, as we learned that it may take 3 to 4 weeks for the hematomas to resolve. Some authors even recommend tracheostomy as the initial method of airway stabilization (8). However, early airway protection is the overriding concern, and tracheostomy always can be performed later when circumstances are more favorable.
REFERENCES 1. Kuhn JE, Graziano GP. Airway compromise as a result of retropharyngeal hematoma following cervical spine injury. J Spinal Disord. 1991;8:264-9. 2. Myssiorek D, Shalmi C. Traumatic retropharyngeal hematoma. Arch Otolaryngol Head Neck Surg. 1989;115:1130-2. 3. Clark WGB, Monks CJ. Retropharyngeal haematoma. J Laryngol Otol. 1969;83:1039-42. 4. Buser KB, Bart G. Surgical implications of the retropharyngeal space. Am. Surg. 1984;50:33-35. 5. American College of Surgeons Committee on Trauma. Advanced trauma life support manual. Chicago: American College of Surgeons Publishing; 1988.
6. Danzle DF, Thomas DM. Nasotracheal intubation in the emergency department. Crit Care Med. 1980;8:677. 7. Danzle DF. Advanced airway support. In: Tintinalli JE, Rothstein RJ, Krome RL, eds. Emergency medicine-A comprehensive study guide. New York: McGraw-Hill Book Co.; 1985:20-31. 8. O’Neill JV, Toomey JM, Snyder GG III. Retropharyngeal hematoma secondary to minor blunt trauma in the elderly patient. J Otolaryngol. 1977;6:43-6.
Pergamon
0736-4679(94)00137-5
CIhiCd
Communications
TRAUMATIC RETROPHARYNGEAL HEMATOMAA CAUSE OF ACUTE AIRWAY OBSTRUCTION Robert 0. Mitchell,
MD,
and B. Todd Heniford,
MD
Department of Surgery, Trauma institute, University of Louisville School of Medicine, Louisville, KY Reprint Address: Robert 0. Mitchell, MD, Department of Surgery, University of Louisville, Louisville, KY 40292
0 Abstract-Blunt trauma causing a retropharyngeal hematoma without an associated cervical fracture is a relatively rare occurrence. This article presents the case of a patient with airway compromise from a retropharyngeal hematoma, and discusses the diagnosis, airway management, and treatment of this condition.
automobile struck a deer at an unknown rate of speed. The deer entered the front windshield and exited the rear window. The patient reported a brief loss of consciousness but was awake and alert on arrival of emergency personnel. She was transported to the nearest emergency facility on a backboard and with a cervical collar. Her complaints at that time were only of posterior neck and right shoulder pain. Vital signs on arrival included a blood pressure of 124/72 mmHg; pulse rate, 108 breaths/min; and respiratory rate, 16 beats/min. Physical examination of the head and neck was significant only for a superficial abrasion on the right side of the neck. No further physical findings regarding the neck examination were noted in the medical record. The chest and abdominal examinations were normal. There were no obvious signs of trauma to the extremities. The patient was noted to speak in a muffled voice without stridor. Further examination revealed weakness of the flexor/extensor muscles of the right arm. No arterial blood gaseswere obtained. Lateral cervical radiograph showed marked prevertebral soft-tissue swelling without fracture (Figure 1). Fortuitously, this could be compared to normal cervical radiograph of the same patient taken 18 months earlier (Figure 2). The emergency physician at the outside hospital felt uncomfortable in treating this patient without surgical and anesthesia personnel available. The pa-
0 Keywords - hematoma; retropharyngeal; blunt trauma; airway obstruction
INTRODUCTION
Traumatic retropharyngeal hematoma is a relatively rare occurrence. Our Medline search of the English literature over the past 25 years revealed fewer than 18 reported casesof retropharyngeal hematoma from blunt trauma that is not associated with a cervical fracture. Early recognition of prevertebral soft tissue swelling on lateral cervical radiograph and aggressive airway management are the mainstays of successful treatment. We report the case of a 28-year-old woman sustaining an isolated traumatic retropharyngeal hematoma after striking a deer with her automobile. CASE REPORT
A 28-year-old woman was the unrestrained nonintoxicated driver in a motor vehicle accident in which her
Cliuical Communications (Adults) is coordinatedby Ron M. Walls, MD, of Brigham and Women’s Hospital and
Harvard Medical School, Boston, Massachusetts RECEIVED: 8 June 1993; FINAL SUBMISSION RECEIVED: 18 March 1994; ACCEPTED: 15 July 1994 165
R. 0. Mitchell and B. T Hemfora
Figure 1. Lateral cervical radiograph with marked prevertebra1 soft-tissue swelling indicated by arrows.
tient Wasurgently transported to our facility by helicopter. After an approximate 20-minute helicopter transport, the patient arrived stridorous. Physical examination did not reveal crepitance, tracheal displacement, anterior cervical tenderness, or swelling. Pulse oximetry measured an arterial oxygen saturation of 90% on 2 liters per minute of oxygen by nasal cannula. The patient was nasotracheally intubated with surgical standby for operative placement of an airway if necessary. Postintubation computed tomography (CT scan) of the neck demonstrated a retropharyngeal hematoma with the trachea outlined only by the endotracheal tube (Figure 3). The patient received a tracheostomy on the second postinjury day. The tracheostomy was removed at approximately 4 weeks, and follow-up 1 month later revealed no vocal difficulties or breathing problems. Neurosurgical consultation diagnosed a brachial plexus stretch injury to be the etiology of the right arm weakness. These symptoms had nearly resolved at last follow up.
Figure 2. Normal lateral cervical radiograph taken 18 months prior. No prevettebral swelling noted.
DISCUSSION Isolated retropharyngeal hematoma from blunt trauma without cervical fracture is a rare occurrence, with only about 18 casesreported in the last 25 years. Etiologies have ranged from blunt trauma alone to whiplash injuries and foreign body ingestion ( l-3 ). The retropharyngeal space is bounded anteriorly by the buccopharyngeal fascia and posteriorly by the prevertebral fascia. This space extends from the base of the skull to the level of the first thoracic vertebra (4). A prevertebral soft-tissue thickness of greater than 5 mm on lateral cervical radiograph suggests significant pathology and impending airway compromise (5). Symptoms may include hoarseness, stridor, and dysphagia. Physical examination may indicate cervical bruising or edema on inspection. Careful palpation might reveal crepitance with subcutaneous emphysema or laryngeal displacement. The conscious patient will invariably complain of neck pain and stiffness.
Traumatic Retropharyngeal
167
Hematoma
These injuries are life threatening, and rapid diagnosis with aggressive airway control are the keys to successful outcome. A number of features in this case warrant further discussion. First, the patient was transferred to our facility without prior airway stabilization. The referring physician recognized the potential hazards of this situation. Ideally, airway stabilization prior to transport is desired. However, the physician was not comfortable in undertaking what might be a difficult intubation without readily available surgical support personnel and without experience in fiberoptic intubation techniques. Additionally, the patient was not stridorous at the time of transport and a level 1 trauma center was 20 minutes away by helicopter. At arrival of the patient at our facility, it was obvious that the patient’s airway was in jeopardy. Each breath was stridorous and the patient was becoming agitated. With evidence of acute airway compromise on clinical evaluation, immediate airway stabilization is of the utmost importance. Waiting for arterial blood gas results and chest radiographs can impose dangerous and unnecessary delays. In this patient we chose nasotracheal intubation because of our personal bias and experience in using this technique in patients with spontaneous respirations (6,7). The fiberoptic bronchoscope should be available at the patient’s bedside, and bronchoscopicassisted intubation would be our choice should there be difficulty with nasotracheal intubation. Oral intubation would be acceptable, depending on the circumstances and experience of the physician, but we feel it would not offer any particular advantage over nasal intubation, and in our hands it often results in coughing and gagging despite topical anesthesia. Additionally, oral intubation is difficult if the neck cannot be hyperextended and we did not have the luxury of time to rule out a cervical fracture.
Figure 3. Computed axial tomographic scan of the neck demonstrating retropharyngeal hematoma. Note the only open space is the endotracheal tube stenting the trachea.
We performed a tracheostomy within 48 hours, as we learned that it may take 3 to 4 weeks for the hematomas to resolve. Some authors even recommend tracheostomy as the initial method of airway stabilization (8). However, early airway protection is the overriding concern, and tracheostomy always can be performed later when circumstances are more favorable.
REFERENCES 1. Kuhn JE, Graziano GP. Airway compromise as a result of retropharyngeal hematoma following cervical spine injury. J Spinal Disord. 1991;8:264-9. 2. Myssiorek D, Shalmi C. Traumatic retropharyngeal hematoma. Arch Otolaryngol Head Neck Surg. 1989;115:1130-2. 3. Clark WGB, Monks CJ. Retropharyngeal haematoma. J Laryngol Otol. 1969;83:1039-42. 4. Buser KB, Bart G. Surgical implications of the retropharyngeal space. Am. Surg. 1984;50:33-35. 5. American College of Surgeons Committee on Trauma. Advanced trauma life support manual. Chicago: American College of Surgeons Publishing; 1988.
6. Danzle DF, Thomas DM. Nasotracheal intubation in the emergency department. Crit Care Med. 1980;8:677. 7. Danzle DF. Advanced airway support. In: Tintinalli JE, Rothstein RJ, Krome RL, eds. Emergency medicine-A comprehensive study guide. New York: McGraw-Hill Book Co.; 1985:20-31. 8. O’Neill JV, Toomey JM, Snyder GG III. Retropharyngeal hematoma secondary to minor blunt trauma in the elderly patient. J Otolaryngol. 1977;6:43-6.