Images in Clinical Medicine. Spontaneous Retropharyngeal Hematoma

Spontaneous epiglottic hematoma secondary to direct oral anticoagulant: A case report

Spontaneous hemorrhage is a known risk for patients on anticoagulation therapy. Most previous spontaneous airway hemorrhage cases reported involve warfarin, and of the few that involved a direct oral anticoagulant, none involved the epiglottis. The following case describes a spontaneous epiglottic hematoma in a patient one week after starting a direct oral anticoagulant. An 85-year-old man presented to the emergency department with acute onset of neck swelling, odynophagia and sublingual ecchymosis. Evaluation in the emergency department included advanced imaging of the neck and consultation with otolaryngology. Flexible fiberoptic laryngoscopy showed a markedly enlarged and ecchymotic epiglottis. The patient received medical management including rivaroxaban reversal, steroids, and broad-spectrum antibiotics, but no airway management was deemed necessary. After close monitoring, the patient was discharged on hospital day two. Further research and risk profiling could benefit patients and emergency clinicians when considering spontaneous hemorrhage in the airway in patients taking a direct oral anticoagulant.

Unusual cause of acute upper airway obstruction: spontaneous pharyngeal haematoma

Spontaneous pharyngeal haematoma is a rare but life-threatening cause of acute upper airway obstruction, and the clinical manifestation may mimic haemoptysis. A 65-year-old man presented to our emergency department with symptoms of sore throat and haemoptysis. He had no medical history. At arrival, O₂ saturation was 95% on 5 L/min of oxygen with a mask. Results of a blood examination including a coagulation test were normal. Laryngoscopy showed enlargement of the left pharynx and a narrowed airway. Contrast-enhanced CT showed extravascular leakage of contrast medium inside the left pharyngeal haematoma. Fortunately, the haematoma did not lead to airway obstruction, and it decreased spontaneously. We finally diagnosed this case as spontaneous pharyngeal haematoma. When we examine a patient with a symptom of haemoptysis accompanied by sore throat, it is necessary to consider pharyngeal haematoma and to prepare emergency airway protection for acute upper airway obstruction.

Prediction of difficult airway management in traumatic cervical spine injury: influence of retropharyngeal space extension

Background

Retropharyngeal hematoma following cervical spine trauma may lead to life-threatening upper airway obstruction and difficult airway management. This retrospective study was performed to investigate whether the extension of retropharyngeal space (RPS) was associated with difficult intubation by direct laryngoscopy in traumatic cervical spine injury.

Patients and methods

Sixty-two patients who had undergone direct endotracheal intubation under general anesthesia for cervical spine surgery were retrospectively identified. Laryngoscopic grade by Cormack–Lehane (C-L) classification was collected; grade 1 or 2 was categorized as easy laryngoscopy, whereas grade 3 or 4 was categorized as difficult laryngoscopy. In these patients, RPS thickness and the proportions of RPS to the vertebral bodies were measured at the 2nd, 5th and 7th cervical spine levels using magnetic resonance imaging (MRI) of the cervical spine. Measures of RPS were compared between easy and difficult laryngoscopy. Relationships between measures of RPS and difficult laryngoscopy were analyzed with logistic regression analysis.

Results

RPS thickness at C2 was significantly greater in difficult laryngoscopy (median 14.29 mm, IQR: 9.75–18.04) than easy laryngoscopy (median 5.10, IQR: 4.33–5.94, p<0.001). Proportion of RPS to the C2 vertebral body were significantly higher in difficult laryngoscopy than in easy laryngoscopy (p<0.001). RPS thickness and the proportion of RPS to the vertebral body were significantly associated with difficult laryngoscopy (OR=2.13, 95% CI: 1.38–3.30; p<0.001 and OR=1.13, 95% CI: 1.05–1.21; p<0.001, respectively).

Conclusion

RPS extension at the upper cervical spine level is associated with difficult direct laryngoscopy in traumatic cervical spine injury.

Retropharyngeal Hematoma as an Unusual Presentation of Myelodysplastic Syndrome: A Case Report

Patient: Male, 90

Final Diagnosis: Spontaneous retropharyngeal hematoma

Symptoms: Dysphagia

Medication: —

Clinical Procedure: —

Specialty: Hematology