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Pelman A, Deere J, Schneider K, Van Heukelom J. Spontaneous epiglottic hematoma secondary to direct oral anticoagulant: A case report. Am J Emerg Med 2022; 59:216.e7-216.e9. [PMID: 35718657 DOI: 10.1016/j.ajem.2022.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Alexander Pelman
- Cascade Medical, Leavenworth, Washington, Department of Emergency Medicine, University of Iowa, Iowa City, IA, United States of America
| | - Jackson Deere
- Department of Otolaryngology, University of Iowa, Iowa City, IA, United States of America
| | - Katherine Schneider
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, United States of America.
| | - Jon Van Heukelom
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, United States of America
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Wen S, Unuma K, Watanabe R, Makino Y, Uemura K. Forensic evaluation of fatal-suffocating retropharyngeal haematoma secondary to cervical fractures: Report of two cases. J Forensic Leg Med 2021; 85:102274. [PMID: 34800774 DOI: 10.1016/j.jflm.2021.102274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Traumatic retropharyngeal haematoma, a condition of low incidence, often occurs secondary to cervical injuries. Owing to the adjacent anatomical location and its insidious formation, retropharyngeal haematoma is prone to cause airway obstruction, which can occasionally be fatal. Though well known in clinical practice, retropharyngeal haematomas are rarely encountered in forensic practice and are not sufficiently explored from a forensic perspective. CASE PRESENTATION Herein, we present two cases of fatal-suffocating retropharyngeal haematoma following cervical vertebral fractures. In both cases, the time from injury to death was evident, showing unusually long periods from injury to death, specifically 4 days and 2 days, respectively. The causes of death were illustrated, and the delayed onset of fatal airway obstruction was explained. The important points regarding autopsies suspected to be fatal traumatic retropharyngeal haematomas were discussed. CONCLUSIONS Knowledge of the possibility of late onset and understanding of the features of imaging and autopsy findings of traumatic retropharyngeal haematoma is beneficial for forensic pathologists dealing with similar cases.
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Affiliation(s)
- Shuheng Wen
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kana Unuma
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Ryo Watanabe
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yohsuke Makino
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koichi Uemura
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Kitai Y, Sato R. Delayed retropharyngeal hematoma following a minor facial blunt trauma. Trauma Case Rep 2021; 32:100442. [PMID: 33665328 PMCID: PMC7907531 DOI: 10.1016/j.tcr.2021.100442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2021] [Indexed: 11/06/2022] Open
Abstract
We described the case of 75 years old male patient with an airway obstruction due to retropharyngeal hematoma that developed after a minor blunt trauma to the face. The patient was not taking any anticoagulants or antiplatelet agents and did not have any coagulopathy. This case report indicates that emergency physicians must be aware of the risk of delayed airway obstruction in elderly patients regardless of whether the patient is using anticoagulants or antiplatelet agents.
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Affiliation(s)
- Yuya Kitai
- Department of Emergency Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, United States of America
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Warken C, Rotter N, Maurer JT, Attenberger U, Lammert A. Retropharyngeal hematoma in the context of obstructive sleep apnea: a case report and review of the literature. J Med Case Rep 2019; 13:269. [PMID: 31443681 PMCID: PMC6708226 DOI: 10.1186/s13256-019-2202-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 07/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea is related to increased systemic inflammation and arterial hypertension. We present a case of retropharyngeal hematoma without trauma und hypothesize that this could be caused by untreated obstructive sleep apnea. CASE PRESENTATION A 47-year-old white woman with unilateral pharyngeal discomfort presented to our ear, nose, and throat clinic. She had no risk factors for the development of a spontaneous retropharyngeal hematoma, for example, hypertension or coagulation disorder. As she was overweight, the anamnesis included signs of obstructive sleep apnea such as snoring or breathing arrests during the night, which she denied. An endoscopic examination showed a submucosal hemorrhage of the posterior wall of her pharynx. Magnetic resonance imaging revealed a retropharyngeal hematoma without evidence of the injury of any blood vessel. A subsequent seven-channel polygraphy revealed a severe obstructive sleep apnea with an apnea-hypopnea index of 59.5 per hour. She was subsequently treated with auto-titrating continuous positive airway pressure resolving obstructive sleep apnea immediately. Two months after this episode she presented without any complaints. CONCLUSION In consequence of this case we are convinced that an untreated obstructive sleep apnea can lead to retropharyngeal hematoma.
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Affiliation(s)
- Christian Warken
- Department of Otolaryngology, Head and Neck Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nicole Rotter
- Department of Otolaryngology, Head and Neck Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Joachim Theodor Maurer
- Department of Otolaryngology, Head and Neck Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Ulrike Attenberger
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Anne Lammert
- Department of Otolaryngology, Head and Neck Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
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Tomita H, Yamashiro T, Ikeda H, Fujikawa A, Kurihara Y, Nakajima Y. Fluid collection in the retropharyngeal space: A wide spectrum of various emergency diseases. Eur J Radiol 2016; 85:1247-56. [PMID: 27235871 DOI: 10.1016/j.ejrad.2016.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 03/27/2016] [Accepted: 04/05/2016] [Indexed: 01/01/2023]
Abstract
Fluid collections in the retropharyngeal space (RPS) result from a wide spectrum of diseases, including retropharyngeal abscess, cervical osteomyelitis, and calcific tendinitis of the longus colli muscle. These conditions should be managed by different specialties; beginning with care in the emergency room, physicians from orthopedics, pediatrics, otolaryngology, and oncology are in charge of the treatment. Since these diseases demonstrate similar fluid collections in the RPS on computed tomography (CT) and magnetic resonance imaging (MRI), the radiologist's diagnosis based on the characteristic imaging findings is very important to identify the primary disease. Also, since some of the diseases require immediate surgical intervention to avoid life-threatening mediastinitis or airway obstruction, radiologists must distinguish these diseases correctly and provide recommendations for their management to physicians. Understanding clinical features and imaging findings of these fluid collections in the RPS is crucial for the best care.
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Affiliation(s)
- Hayato Tomita
- Department of Radiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan.
| | - Tsuneo Yamashiro
- Department of Radiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan; Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa 903-0215, Japan
| | - Hirotaka Ikeda
- Department of Radiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - Atsuko Fujikawa
- Department of Radiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - Yoshiko Kurihara
- Department of Radiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - Yasuo Nakajima
- Department of Radiology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
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Vieitez V, Martín-Cuervo M, López-Ramis V, Ezquerra LJ. Acute upper airway obstruction due to retropharyngeal hematoma in a dog with Anaplasma species: a case study. BMC Vet Res 2015; 11:257. [PMID: 26452479 PMCID: PMC4600258 DOI: 10.1186/s12917-015-0574-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 10/05/2015] [Indexed: 11/25/2022] Open
Abstract
Background Retropharyngeal hematoma is a rare condition that is difficult to diagnose and may progress rapidly to airway obstruction. The authors report the first known case of acute upper airway obstruction resulting from retropharyngeal hematoma in a dog. Documented causes in human medicine have included coagulopathic states, trauma, infection, parathyroid adenoma rupture, and foreign body ingestion. Vague symptoms in humans such as sore throat, shortness of breath, dysphonia, dysphagia, and neck swelling may precede lethal airway obstruction. Case presentation The authors report a case of an 18-month-old, intact female water spaniel with thrombocytopenia that developed a massive retropharyngeal hematoma and symptoms of airway compromise. The dog required tracheal intubation followed by surgical tracheostomy. Lateral cervical radiography and magnetic resonance imaging of the neck was consistent with a retropharyngeal hematoma compromising the airway. The retropharyngeal hematoma was managed conservatively. Conclusion Retropharyngeal hematoma should be considered in patients presenting with abrupt respiratory distress. Magnetic resonance imaging allowed specific diagnosis of a rare condition that is otherwise difficult to diagnose.
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Affiliation(s)
- Verónica Vieitez
- Veterinary Teaching Hospital, University of Extremadura, Avda, Universidad s/n, Cáceres, 10003, Spain.
| | - María Martín-Cuervo
- Veterinary Teaching Hospital, University of Extremadura, Avda, Universidad s/n, Cáceres, 10003, Spain.
| | - Víctor López-Ramis
- Veterinary Teaching Hospital, University of Extremadura, Avda, Universidad s/n, Cáceres, 10003, Spain.
| | - Luis Javier Ezquerra
- Veterinary Teaching Hospital, University of Extremadura, Avda, Universidad s/n, Cáceres, 10003, Spain.
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Udy A, Senthuran S, Lipman J. Airway obstruction due to a pre-vertebral haematoma following difficult central line insertion--implications for ultrasound guidance and review of the literature. Anaesth Intensive Care 2009; 37:309-13. [PMID: 19400499 DOI: 10.1177/0310057x0903700219] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We describe a case of airway obstruction secondary to a large pre-vertebral cervico-mediastinal haematoma following failed attempts at insertion of an internal jugular central venous line. The need for a high index of suspicion to diagnose this injury and early aggressive intervention to manage it are outlined. The role of ultrasound guidance in preventing such a complication is reviewed, as well as other possible mechanisms of haematoma development.
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Affiliation(s)
- A Udy
- Department of Intensive Care Medicine, Royal Brisbane and Womens Hospital, Brisbane, Queensland, Australia
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[Retropharyngeal hematoma secondary to neck trauma--case report]. Otolaryngol Pol 2009; 62:800-2. [PMID: 19205538 DOI: 10.1016/s0030-6657(08)70366-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Traumatic retropharyngeal hematoma is a rare but potentially fatal condition that requires early diagnosis and treatment. Obstruction of the airways may develop insidiously, several hours after the trauma. Thus hospital admission with close observation is essential. Intubation can be difficult due to distorted anatomy. Surgical airway management is often necessary. In most of cases the treatment is conservative, however large hematomas may require drainage. We present a case of 85-years old women with retropharyngeal hematoma after minor blunt trauma of the neck without cervical fracture. Since respiration was not impaired airway intervention was not necessary. After 5 days of close observation the patient was discharged in good condition. Further recovery was uneventful.
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Srivastava S, Solanki T. Retropharyngeal haematoma - an unusual bleeding site in an anticoagulated patient: a case report. CASES JOURNAL 2008; 1:294. [PMID: 18976502 PMCID: PMC2584089 DOI: 10.1186/1757-1626-1-294] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Accepted: 11/02/2008] [Indexed: 11/24/2022]
Abstract
Introduction Anticoagulation is used widely for the primary prevention of embolic events in patients with atrial fibrillation. Bleeding is the most common complication with oral anticoagulation. We describe the case of a patient who developed a massive retropharyngeal haematoma after a fall. Whilst the retropharyngeal space is an uncommon site for bleeding complications, it is clinically important as the development of upper airway obstruction may be life threatening. Case Presentation We present the case of an 85-year-old Caucasian woman on warfarin, who developed a massive retropharyngeal haematoma after a fall. She initially presented with pulmonary oedema and Type 2 respiratory failure. She was commenced on treatment for this with a good clinical response. She subsequently deteriorated, developing stridor and bruising to the neck. She was urgently intubated and ventilated. Computerized Tomography scan showed a massive retropharyngeal haematoma. The baseline International Normalized Ratio (INR) was 4.9. The patients was managed conservatively and treated with Vitamin K and Prothrombin Complex Concentrates (PCCs). The INR was rapidly corrected to 1.1 and the patient made a full recovery. Conclusion Retropharyngeal haematoma should be considered in anticoagulated patients presenting with abrupt respiratory distress after minor head trauma. It can develop after minor traumatic events, such as falls. It can result in upper airway obstruction, which can be life threatening. Patients should be urgently assessed for intubation and ventilation. Computerized Tomography imaging of the neck and mediastinum is diagnostic. Correction of the International Normalized Ratio with Vitamin K and Prothrombin Complex Concentrates is essential. Management is mainly supportive. However, in very large haematomas surgical drainage may be considered.
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Affiliation(s)
- Seema Srivastava
- Taunton and Somerset Foundation Trust, Musgrove Park, Hospital, Taunton, TA1 5DA, Somerset, UK.
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Affiliation(s)
- Tun-Yen Hsu
- Department of Otolaryngology, E-DA Hospital/I-Shou University, Kaohsiung County, Taiwan, Republic of China.
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Lin JY, Wang CH, Huang TW. Traumatic retropharyngeal hematoma: case report. Auris Nasus Larynx 2006; 34:423-5. [PMID: 17161928 DOI: 10.1016/j.anl.2006.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2006] [Revised: 10/12/2006] [Accepted: 10/13/2006] [Indexed: 11/23/2022]
Abstract
Traumatic retropharyngeal hematoma is a rare but potentially life-threatening condition that requires an early diagnosis. Isolated retropharyngeal hematoma without an associated cervical fracture is a relatively rare condition. The treatment of retropharyngeal hematoma is conservative in most cases, with close observation. The indications for surgical evacuation of hematomas are large size, difficult with mechanical ventilation and failure to improve with medical therapy. We present the case of a 50-year-old man with retropharyngeal hematoma with a compromised airway due to minor contusion of the neck, which required surgical intervention. The patient underwent emergent surgical debridement and tracheostomy. Postoperative course was uneventful. The patient was discharged 9 days later. Early surgical intervention can reduce the hospital stay, resulting in a rapid convalescence.
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Affiliation(s)
- Jiun-Yu Lin
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, 325, Cheng-Kung Road 2nd Section, Taipei 114, Taiwan, ROC
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