To the Editor:—
In patients with cervical spine trauma (CST) it is possible for a hematoma to form in the potential space between the pharynx and cervical spine. Retropharyngeal hematoma (RPH) large enough to require tracheal intubation is rare, but can be a life threatening emergency.
A 37-yr-old man was admitted to the emergency department of the Amiens University Hospital 1 h after being injured in a motor vehicle collision. After a brief loss of consciousness, the patient noted pain at the base of the neck. His cervical spine had been immobilized at the scene of the accident. When he arrived at the hospital, he was alert and orientated. His pulse was 90 beats/min, blood pressure 140/70 mmHg and his respiratory rate was 12 breaths/min. Neurologic examination revealed no motor deficit and all cranial nerves were intact. The patient was not dyspneic, his chest was clear, and his heart had a regular rate and rhythm. The abdominal examination was normal.
The laboratory values were within normal limits. A chest radiograph revealed a fracture of the right clavicula. A computed tomography (CT) scan of the cervical spine showed a fracture of the body of the sixth cervical vertebra with a hematoma that extended from the forth cervical vertebra to the upper mediastinum and occupied the pharyngeal space (fig. 1). The head CT scan was normal.
The neurosurgeon recommended continuation of strict cervical spine immobilization, and the patient was transferred to the Department of Neurosurgery.
Ten hours after the patient's admission, he began complaining of dysphagia and neck pain, and he quickly developed marked stridor and dyspnea. Peripheral saturation of oxygen was 86%.
The patient was immediately transferred to the intensive care unit. An awake fiberoptic nasal intubation was done. During endoscopy a posterior soft tissue swelling that extended from oropharynx to the glottis was noted. The vocal cords were easily visualized; a 7.5 mm endotracheal tube was passed over the bronchoscope. After intubation, the patient remained alert, cooperative, and neurologically intact. He was sedated (Midazolam 5 mg/h and Sufentanil 15 μg/h and received mechanical ventilation. On the sixth day after admission, a direct laryngoscopic examination of the airway revealed a diminution of the soft tissue swelling. The patient was weaned easily from the ventilator and the trachea was extubated. He was then able to maintain adequate oxygenation on 2 l/min of oxygen by nasal cannula; he was comfortable with no dyspnea or stridor.
A conservative approach with cervical brace was chosen and the patient was discharged home 9 days after initial presentation.
Although soft-tissue swelling is common with cervical spine injuries, there are few reports of airway obstruction secondary to retropharyngeal hematomas in the literature. 1Penning 2reported that 18 of 30 patients hospitalized for CST had widening of prevertebral soft tissue due to hematoma.
In trauma patients, retropharyngeal hematomas are associated with a range of conditions including cervical extension and flexion severe injury and whiplash injury in great-vessel trauma, 3minor blunt head trauma with hyperextension of the neck 4, or minor motor vehicle collision with air bag deployment. 5The possibility of RPH should be taken into account after CST or head trauma in all patients regardless of age, severity of trauma, or lack of symptoms.
The mechanism of hemorrhage is unclear. One possible mechanism involves tearing of the longus colli muscles along the anterior aspect of the vertebral bodies during hyperextension. Alternatively, hyperextension injuries may rupture the anterior muscular and spinal branches of the vertebral column. 2
The signs of RPH include those of superior mediastinal obstruction and bruising on the neck and spreading to the chest wall. The symptoms may include neck pain, dysphagia, dyspnea, and a hoarse voice. Although most retropharyngeal hematomas present immediately or within hours after they arise, delays of 2–5 days from the onset of initial symptoms to airway obstruction have been reported. 1
A lateral radiograph or CT scan of the neck, which will show a widening of prevertebral space, aids the diagnosis. Symptoms may take hours to develop and initial cervical radiographs often fail to show evidence of retropharyngeal swelling and impending airway obstruction. The majority of the hematomas occurred at C1–C4 and this phenomenon has not been reported in injuries below C6. 1The normal width of the prevertebral soft tissue is 3.2 mm measured at C2. In our patient the width of prevertebral soft tissue at C5 was 8 mm.
Treatment depends on the location and size of the hematoma as well as the clinical course of the patient. Patients with small, nonexpanding, hematomas should be observed in hospital. 6Resolution of the hematoma can be assessed regularly radiographically. Penning also reported that radiographic resolution of the prevertebral hematomas occurred within 14 days. 2
Symptomatic patients should be strictly monitored to promptly establish airway patency. Equipment should be assembled and ready for immediate use. In the case of lower RPH after CST, tracheal intubation may be needed and great care should be taken to protect the spinal cord. Blind nasotracheal approach can be attempted but oral or nasal fiberoptic intubation has become a mainstay in the management of patients with CST. An oral fiberoptic intubation would have been attempted if the patient had signs or documentation of nasal or basilar skull fractures, or if it was believed that nasal approach might rupture the hematoma. Direct laryngoscopy with a rigid blade may produce some movements of the column, but it is the only choice in anemergency setting, the physician should avoid lateral and rotational movements and remember that extension of the neck widens, rather than constricts, the spinal canal. 7
A tracheostomy may be needed if there is upper airway obstruction or a difficult intubation. Surgical evacuation of the hematoma is indicated when there is life threatening airway obstruction or a rapidly expanding hematoma, and in those that fail to reabsorb. 6
Retropharyngeal hematomas must be considered as a cause of airway obstruction following cervical spine trauma. A high index of suspicion and early lateral neck radiograph is essential for safe management of this rare but potentially life-threatening injury.