Volume 3, Issue 4 , Pages 151-154, December 2008
A rare case of spontaneous retropharyngeal heamatoma presenting as acute respiratory distress in a child
Article Outline
Summary
A rare case of spontaneous retropharyngeal haematoma in a 4-year-old child is presented hitherto unreported in the medical literature. The aetiology was spontaneous; clinically the child presented with acute respiratory distress and was successfully managed surgically after securing the airway.
Keywords: Retropharyngeal Haematoma, Paediatric
Introduction
Spontaneous retropharyngeal haematoma is an uncommon occurrence with most of the cases reported in adults [1], [2]. We present one such case in paediatric age group where aetiology, clinical presentation and management were found to be interesting. To the authors knowledge such a case has not been reported previously in the literature.
Case report
A 4-year child presented in the casualty department of Vardhman Mahavir Medical College & Safdarjung hospital, New Delhi (a tertiary care “Central Government” teaching institution) with the complaints of respiratory difficulty and fever for the last 2 days. Patient had also been suffering from dysphagia to solids for the past 2 months. In general there was a gradual deterioration in patient's symptoms over a period of time. On examination patient was febrile and stridor was present, rest of the vitals were normal. Oral examination revealed a bulge in the posterior pharyngeal wall. Child also had bilateral palpable jugulodigastric lymph nodes.
An X-ray soft tissue lateral neck (Fig. 1) and CT scan were done to confirm the retropharyngeal swelling. CT scan revealed a prevertebral collection from C1 vertebral body, extending to C4 level caudally and compromising the airway at the level of oropharynx and hypopharynx (Fig. 2, Fig. 3). The size of the swelling was 5
cm×3.4cm×4.3cm. A diagnosis of “acute retropharyngeal abscess” was made. After all other relevant investigations for general anesthesia, tracheostomy with incision and drainage was planned.
Fig. 1.
X-ray soft tissue lateral neck showing increased retropharyngeal space.
Fig. 2.
CT scan at the level of C3 and C4 showing large retropharyngeal mass.
Fig. 3.
Axial cuts of the CT scan image delineating the retropharyngeal mass.
Patient was intubated and tracheostomy was done. However, when needle aspiration was done from the swelling to confirm the presence of abscess: blood tinged fluid was aspirated with no pus. Hence the said treatment protocol was abandoned.
Subsequently patient was re-evaluated (no history or s/s of external trauma were recorded) and investigated for fever. The aspirated fluid was found to be sterile and negative for AFB. All other tests for TB were also negative. USG and Colour Doppler were also done to rule out lymphatic malformations, haemangioma and other variety of cysts in this region. Thus, finally a diagnosis of “spontaneous retropharyngeal haematoma” was made and the patient was conservatively managed for 4 weeks. Patients fever settled within a week and was found to be a part of generalized “upper respiratory tract infection” presumably viral in origin. However, there was no resolution of the oral swelling and neither was there any improvement in patient's dysphagia. A re-evaluation of the retropharyngeal swelling was done by CT scan again.
Finally “transoral incision and drainage” was done: approximately 30cc of blood tinged fluid was released from tension. Patient's dysphagia improved dramatically and was extubated on the fifth post-operative day (Fig. 4). Afterwards patient was discharged uneventfully on the seventh post-operative day. On follow up after 6 weeks the patient was normal.
Fig. 4.
Photograph of the patient on the first post-operative day.
Discussion
Spontaneous retropharyngeal haematoma is a rare entity. Besides being spontaneous it is also usually associated with trauma and anticoagulent therapy [1], [2]. Some other rare causes are: bleeding disorders, violent coughing, ruptured aneurysm, pharyngeal foreign bodies, bleeding into a tumour, internal jugular venous cannulation, arteriography and carotid sinus massage [1], [2], [3]. It usually runs a benign course presenting with hoarseness, odynophagia, dysphagia and is generally self-limiting. However, it can sometimes cause respiratory distress. Such cases then would require endotracheal intubation or tracheostomy. Review of literature suggests a waiting period of 4 weeks for spontaneous resolution of the said lesion prior to surgical intervention [1], [4].
This case merits discussion on many accounts. First, it is unclear that how the patient developed the retropharyngeal haematoma. The history of anticoagulant therapy was absent in this case. Regarding trauma it is pertinent to note that aetiopathogenesis of retropharyngeal haematoma is attributed to hyperextension of the spine causing damage to longus colli muscle and anterior ligament along with rupture of the anterior muscular and spinal branches of the vertebral arteries [3], [5]. As no history or signs of external trauma were recorded in this case, whether a minor hyperextension injury to the spine did happen while the child was playing with his siblings or friends (when parents were away) is difficult to contemplate and the issue is open to debate. Nevertheless it highlights the importance of adult/parental supervision in children and the hazard of leaving infants unattended. It thus becomes important for all health personnel's to propagate the concept of “child care” (i.e. care provided by an individual outside nuclear family or in a setting separate from child's home) as an important factor to prevent pediatric emergencies [6].
In addition the classical triad of clinical features (superior mediastinum obstruction, anterior displacement of trachea and bruising appearing on the neck within 48h and spreading onto the chest wall) as reported for spontaneous retropharyngeal haematoma in literature were not seen in this case [2]. The case presented as an “emergency–acute air way obstruction” along with fever and URTI, thus masquerading as retropharyngeal abscess. The needle aspiration however helped us to reach a correct diagnosis. It would thus be prudent for otorhinolaryngologists to rule out this rare lesion in cases of retropharyngeal abscess in best interest of patient care, for retropharyngeal abscess usually resolve spontaneously over a period of time.
Of the fewer than 35 cases mentioned in the world literature only five cases have reported a spontaneous etiology and that too in adults (one each by Epstein and Klassen [7], Sandor and Cooke [8], Hennessy and Martinez [9], and two by AL-Fallouji et al. [2]). A review of literature on retropharyngeal haematoma reveals this to be the only recorded case in the paediatric age group where no clear cause was found and clinically patient presented with respiratory distress. Hence, the unique nature of this clinical record, prompted us to share our professional experience with other members of our medical fraternity.
References
- . Retropharyngeal space swelling secondary to minor blunt head and neck trauma. J. Laryngol. Otol. 2004;118:465–467
- . Spontaneous retropharyngeal haematoma: two cases and review of the literature. J. Laryngol. Otol. 1993;107:649–650
- . Acute airway obstruction secondary to retropharyngeal hematoma. J. Anesth. 2003;17:46–48
- . Retropharyngeal haematoma secondary to minor blunt head and neck trauma. Ear Nose Throat J. 1994;73:41–43
- . Mechanical airway obstruction secondary to retropharyngeal hematoma. Eur. J. Emerg. Med. 1997;4:166–168
- . Child care and our youngest children. Future Child. 2001;11:35
- . Spontaneous superior mediastinal haemorrhage. J. Thorac. Cardiovasc. Surg. 1960;39:740–745
- . Spontaneous cervico-mediastinal haemtoma. Br. J. Surg. 1964;51:682–686
- . Spontaneous cervico-mediastinal haematoma. J. Ir. Med. Assoc. 1970;63:298
PII: S1871-4048(08)00019-1
doi:10.1016/j.pedex.2008.02.002
© 2008 Elsevier Ireland Ltd. All rights reserved.
Volume 3, Issue 4 , Pages 151-154, December 2008
