Retropharyngeal Hematoma Treatment & Management

Updated: May 13, 2019
  • Author: Neil Gildener-Leapman, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

Medical Therapy

Most authors advise that patients with small nonexpanding hematomas can be treated conservatively with repeated assessments of the size of the hematoma with nasolaryngoscopy, CT scanning, or MRI.

Admission is advised until the hematoma resolves. The prophylactic use of antibiotics is considered controversial.

Bleeding tendencies should be addressed on an urgent basis with input from a hematologist. A particularly difficult case to manage is that of a hemophilic patient with high levels of inhibiting antibodies to factor VIII. A recent case report has highlighted the successful use of recombinant activated factor VII in a life-threatening retropharyngeal hematoma. [12]

Endotracheal intubation with admission to intensive care is an option in more severe cases.

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Surgical Therapy

In the event of real or anticipated airway compromise, preparations for urgent tracheotomy should be made.

A tracheotomy under local anesthesia may be the only safe option. This is especially true if a very difficult intubation is anticipated. A senior anesthetist should be involved in the decision, and the procedure should be performed by an experienced surgeon.

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Preoperative Details

Ventilation and oxygenation are the primary concerns. Achieving these objectives is an anesthetic challenge because of the presence of lower tracheal obstruction, and patient care is best provided by a clinician experienced in difficult airway management. Immobilization of the cervical spine is an important consideration when trauma is involved.

As an interim measure, orotracheal intubation may be a feasible option, but each case should be considered on its own merits. Flexible nasolaryngoscopy should provide enough information for the clinician to decide whether an attempt at orotracheal intubation is worthwhile.

Other measures include use of positive end-expiratory pressure (PEEP) and posture changes, low-frequency jet ventilation, and administration of helium-oxygen mixtures. PEEP should be used with caution, as this may worsen airtrapping. A possible jet ventilation strategy is the use of 40-60 psi (275-413 kPa) at a rate of 12 L/minute with an inspiratory-expiratory ratio of 1:4. This method has been used successfully in ventilating adult patients with severe fixed narrowing of the trachea just above the carina due to retrosternal goiter.

Helium-oxygen mixtures are less dense than oxygen alone and work by reducing turbulence and improving laminar flow. Helium cylinders may contain oxygen, and helium-oxygen mixtures from a cylinder typically contain only 21% oxygen. Administration of supplemental oxygen via a t-piece or nasal prongs is advised.

Femorofemoral cardiopulmonary bypass before the induction of anesthesia has been described for tumors that obstruct the lower trachea.

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Intraoperative Details

For further details, please see the Medscape Reference article Tracheostomy. A cricothyroidotomy could be helpful depending on the level of obstruction. [13]

Because of the inferior extent of the hematoma, a longer-than-normal tracheostomy tube should be placed.

When the hematoma continues to expand or when ventilation is difficult despite the aforementioned measures, surgical evacuation of the hematoma is indicated. This may be done via an oral or transcervical approach. The oral approach avoids a scar but risks reaccumulation of the hematoma because no drain can be left. The transcervical approach is therefore favored. For this approach, an incision is made along the anterior border of the sternocleidomastoid muscle. The carotid sheath is located and retracted, and the retropharyngeal space is opened.

After the hematoma is evacuated and hemostasis is achieved, a large, closed-suction drainage system is inserted, and the wound is closed in layers.

In exceptional cases, thoracotomy may be necessary to alleviate airway compromise.

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Postoperative Details

The patient should be observed in a unit in which adequate tracheotomy care is available. The unit should offer immediate access to an on-site anesthetist should the patient's airway deteriorate.

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Follow-up

In cases in which a cause is identified, it should be addressed. To the authors' knowledge, recurrence has not been described.

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Complications

Complications of retropharyngeal hematoma occur as a result of mass effect, rupture, or infection.

The mass of the blood in the retropharyngeal space can compress the airway, which lies immediately anterior to it.

Rupture can lead to asphyxiation or aspiration pneumonia.

The hematoma is an ideal culture medium, and infection may supervene. Infection may spread laterally to the carotid sheath. The infection may spread posteriorly. Osteomyelitis of the vertebrae requires long-term antibiotic therapy. Subluxation at any level may follow. Inferior spread of infection may be life threatening. Mediastinitis, purulent pericarditis, pericardial tamponade, bronchial erosion, and mediastinal abscess may follow. The pus may spread to the pleural cavity, causing pleuritis, pyopneumothorax, or empyema. Necrotizing fasciitis requires extensive debridement. Generalized sepsis may follow.

Jugular vein thrombosis may cause tenderness over the anterior border of the sternocleidomastoid muscle, vocal cord paralysis, or sepsis. Aggressive antimicrobial therapy is indicated.

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Outcome and Prognosis

Once the initial airway insult is managed, an uncomplicated recovery should be the goal. However, among the patients with spontaneous onset reported in the literature, only a few have survived. This suggests an especially poor prognosis for this subgroup of patients.

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Future and Controversies

Several questions must still be addressed, as follows:

  • When can a hematoma be considered safe (ie, what size is small enough for observation alone and what other risk factors for surgical intervention can be identified)?

  • What is the best way to assess the size of the hematoma: nasoendoscopy, CT, and/or MRI? How often should the study be repeated?

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