Eur J Cardiothorac Surg 2002;21:117-118
© 2002 Elsevier Science NL
Retropharyngeal hematoma — a rare complication of anticoagulant therapy
Vinayak Nilkanth Bapat*,
Karen Brown,
Apostolos Nakas,
Fick Shabbo
Department of Cardiothoracic Surgery, 6th Floor, East Wing, St. Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK
Received 20 July 2001;
received in revised form 18 October 2001;
accepted 22 October 2001.
* Corresponding author. Tel.: +44-207-922-8005; fax: +44-207-928-5680
e-mail: vnbapat{at}yahoo.com
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Abstract
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Anticoagulation is routinely employed in cardiac surgery following mechanical valve replacement. Warfarin is the most common agent used for anticoagulation. Bleeding, internal or external, remains the major complication with anticoagulant therapy. The risk is known to be higher with INR levels above 4.5. We report a case of a retropharyngeal hematoma following trivial blunt trauma to a patient whose INR had shot up to 6.8 and also discuss its management.
Key Words: Retropharyngeal hematoma • Warfarin • Anticoagulation
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1. Clinical summary
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A 53-year-old woman had undergone aortic valve replacement with Carbomedics bileaflet mechanical valve in 1993. She was on warfarin since then with the INR being maintained between 2.5 and 3.0. While shopping, she tripped off a kerb, suffering trivial blunt trauma to the left shoulder and forehead which she initially ignored. She was alarmed later in the day by a change in her voice and increasing breathlessness and hence rushed to the local hospital. On arrival, she was stable and maintaining her oxygen saturations well. Clinical examination was unremarkable. A chest X-ray revealed a widened mediastinum. The possibility of aortic dissection was considered and a computerised tomography (CT) of the chest was performed. This revealed intact great vessels with no evidence of dissection of the aorta and a mediastinal hematoma extending from the root of the neck to the carina and was compressing the upper esophagus and the trachea (Fig. 1). The patient worsened progressively requiring endotracheal intubation. This was 36 h after her initial fall. She was then transferred to our hospital for further management. Her INR on admission was 6.9 requiring correction with fresh frozen plasma (FFP). Flexible bronchoscopy and esophagoscopy were performed, which confirmed an extrinsic compression of the esophagus and trachea. Evacuation of the hematoma was carried out under general anaesthesia via cervical approach. A 6 cm incision was taken anterior and parallel to the right sternocleidomastoid muscle. The carotid sheath was retracted laterally and the trachea and thyroid medially. The retropharyngeal space was opened with blunt and sharp dissection. At least 500 ml of blood and clots were removed with the help of suction and finger sweep. Ventilatory airway pressures fell down by 10 cm of water on evacuation of the hematoma. Tracheostomy was performed and a corrugated drain was then placed in the space before closing the incision. The patient recovered well after the surgery.
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Fig. 1. Computerised tomogram of the cervical region — arrow points to the large retropharyngeal hematoma. Trachea is delineated by the endotracheal tube.
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2. Discussion
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Anticoagulation is routinely employed in cardiac surgery following mechanical valve replacement and to prevent thromboembolism due to atrial fibrillation. Warfarin is the most common agent used for this purpose. Bleeding, internal or external, remains the major complication with anticoagulant therapy [1]. The reported incidence of bleeding events varies between 0.3 and 7.0 events per patient year [1]. The risk is known to be higher with INR levels above 4.5 [1]. Bleeding can occur spontaneously or following trivial trauma.
Retropharyngeal hematoma, although extremely uncommon is a well known complication of cervical trauma, surgery, retropharyngeal sepsis, carotid aneurysm and internal jugular vein puncture [2]. It has also been reported to occur spontaneously in patients with bleeding diatheses [3]. The retropharyngeal space is a potential space lying between the middle (buccopharyngeal) fascia and the deep (prevertebral) layers of deep fascia. It extends from the base of the skull to the level of 4th thoracic vertebra in the mediastinum where the two layers fuse. Thus blood entering this space can cause airway and esophageal obstruction at various levels. The commonest cause is closed cervical trauma with the bleeding occurring from the contused and lacerated tissues of the retropharyngeal space and tearing of vessels resulting in the formation of a hematoma [4]. A raised INR, such as in the reported case, can conceivably lead to the development of such a hematoma following trivial injury.
The patient may present with symptoms of vague neck pain, dysphagia, dyspnoea or change of voice and can present as late as 5 days after the injury [4]. A high index of suspicion is essential. The diagnosis may be delayed because of associated injuries. The diagnosis is aided by a lateral X-ray of the neck which shows a widening of the prevertebral space [2]. CT scan is a better investigation to confirm the diagnosis and to assess the extent of the hematoma and its relation to the neck structures [5]. Direct laryngoscopy, bronchoscopy and oesophagoscopy help in the diagnosis and subsequent assessments.
Patients with small, non-expanding hematomas can be treated conservatively with cervical spine immobilization and intravenous steroids [3–5]. In high retropharyngeal hematoma producing significant airway obstruction, tracheostomy may be required [3–5]. In cervico-mediastinal hematomas, tracheostomy with an extended tube is essential and helps in maintaining the airway after evacuation of the hematoma [3–5]. Correction of INR is essential as it prevents further bleeding. Surgical drainage is essential for large hematomas and in rapidly expanding hematomas [5]. The commonest approach is an anterior cervical approach with incision anterior to the sternocleidomastoid muscle [5]. It may be necessary to carry this out bilaterally. The patient may take a few days to benefit from the operation as most patients also have an element of tracheal edema, which responds well to systemic steroids.
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References
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Abstract
1. Clinical summary
