This article describes the case of a 61-year-old female who developed spontaneous retropharyngeal hematoma with widespread bruising in front of the neck and chest wall.
She presented with complaints of dysphagia with both solids and liquids. She also complained of mild dyspnea. She specified being a patient with hypertension and taking a combination of atenolol and chlortalidone. Her blood pressure was well controlled on this regimen, and she did not have any signs of hypertensive pathologies like hypertensive retinopathy or cardiac co-morbidities.
Examination and Investigations
The examination of the patient turned out normal except for widespread bruising in the front of her neck and chest. To investigate the cause, doctors advised a CT, which showed a mass in the oropharyngeal region. The mass extended from the retropharyngeal space downwards towards the level of bifurcation of the trachea. It was exerting pressure over the carina to cause both tracheal deviation and narrowing. This narrowing thus contributed to the presenting complaints of dyspnea.
Doctors also evaluated her coagulation profile for cutaneous bruising. Surprisingly, it turned out within the normal range. Other tests like an aortogram for a possible bleed from the descending aorta, also showed no pathologies.
Spontaneous Hematoma Resolves Spontaneously
Fortunately, the patient’s retropharyngeal swelling started regressing without any active intervention. Doctors performed another CT scan after 10 days which showed a significant decrease in the size of the hematoma. By this time, the bruising over the patient’s neck and chest had also gone. Additionally, a follow-up CT after three months also came out completely normal.
What is a retropharyngeal hematoma, and how does it develop?
The retropharyngeal space is located behind the nasopharynx, oropharynx, hypopharynx, and larynx. It is bounded anteriorly by the buccopharyngeal fascia which surrounds the pharynx, oesophagus, and trachea. Posteriorly, the space is limited by the alar fascia. It extends superiorly up to the base of the skull, while inferiorly, it extends into the mediastinum at the level of the bifurcation of the trachea. It is a potential space for the accumulation of any fluid or blood collection or the impaction of objects, causing symptoms of dysphagia and dyspnea due to the compression of the oesophagus and trachea, respectively.
A hematoma in the retropharyngeal space is not uncommon. Usually, it develops as a result of trauma, especially during central venous line insertion. Other causes can include bleeding disorders like haemophilia, vascular aneurysms neoplasia, etc. When it does not have a clear aetiology, we call it a spontaneous retropharyngeal hematoma.
Presentation of Retropharyngeal Hematoma and its Management
A retropharyngeal hematoma usually presents with symptoms of superior mediastinal compression and a bruise over the neck within 48 hours. The bruise first appears on the neck and then spreads laterally to the chest wall as well. Compression of the superior mediastinum manifests as difficulty breathing, which often requires airway management through a tracheostomy.
In most cases, the hematoma resolves spontaneously with conservative management. Doctors usually resist surgical intervention and only employ it in cases of significant respiratory symptoms. Surgical intervention involves the surgical evacuation of the hematoma. Overall, the prognosis of spontaneous retropharyngeal hematoma remains good, and most cases resolve with only conservative management.
