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87 Copyrights © 2014 The Korean Society of Radiology INTRODUCTION A retropharyngeal hematoma is an uncommon entity that may rapidly cause airway obstruction. e etiology of a retro- pharyngeal hematoma includes infections, cervical spine trau- ma, great vessel trauma, violent head movements, iatrogenic in- jury, parathyroid adenoma hemorrhage and a foreign body ingestion (1). e occurrence of a spontaneous retropharyngeal hematoma is rare and without any identifiable causes. In the majority of cases the diagnosis is delayed because of its rarity and absence of objective signs and diagnostic laboratory data. e author reports a case of spontaneous retropharyngeal he- matoma in a 56-year-old man. CASE REPORT A 56-year-old man without a history of pre-existing neck dis- ease presented to the emergency ward with sore throat, dyspho- nia and dyspnea. e symptoms were sudden in onset, severe in nature and rapidly progressive over two hours. e patient was a heavy alcoholics but had no prior cardiovascular, respiratory or gastrointestinal symptoms, no medical history or history of for- eign body ingestion and also no past or current medication. e neck was non-tender and no significant limitation of neck move- ment was present. The subject was not febrile and presented a normal blood pressure. e hematologic evaluation showed a he- matocrit of 47.9%, hemoglobin of 15.9 g/dL, white blood cell count with 13610/uL (neutrophil 73.7%, lymphocytes 15.7%, monocytes 8.2%), platelet count 251000/dL, erythrocyte sedi- mentation rate (ESR) 8 (0–10) mm/hr and C-reactive protein 25.3 (0–8) mg/L. Coagulation tests showed 96% prothrombin activity, a normal partial-thromboplastin time and a fibrinogen of 485 mg/dL. In the fiberoptic examination of the pharynx a significant anterior bulging of the posterior pharyngeal wall without ecchymosis was visible. The plain neck lateral view showed a markedly increased Case Report pISSN 1738-2637 / eISSN 2288-2928 J Korean Soc Radiol 2014;70(2):87-91 http://dx.doi.org/10.3348/jksr.2014.70.2.87 Received October 1, 2013; Accepted December 29, 2013 Corresponding author: Ji Hwa Ryu, MD Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, 875 Haeun-daero, Haeundae-gu, Busan 612-896, Korea. Tel. 82-51-797-0392 Fax. 82-51-797-0379 E-mail: [email protected] This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distri- bution, and reproduction in any medium, provided the original work is properly cited. A spontaneous retropharyngeal hematoma is a rare condition with a difficult diag- nostic. This disease may rapidly progress to an airway obstruction. The author re- ports about a case of a 56-year-old man with an acute onset of sore throat, dys- phonia and dyspnea. A retropharyngeal high attenuated soft tissue density could be seen on the neck CT. A rapid improvement of the retropharyngeal abnormality was seen on the 3 days follow-up MR imaging. Signal changes caused by blood prod- ucts which were visible on the MRI images suggested the diagnosis of retropharyn- geal hematoma. The patient was conservatively managed. Index terms Retropharyngeal Hematoma Airway Obstruction CT MRI Spontaneous Retropharyngeal Hematoma: A Case Report and Literature Overview 자발성 후인두 혈종: 증례 보고 및 문헌고찰 Ji Hwa Ryu, MD Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea

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87Copyrights © 2014 The Korean Society of Radiology

INTRODUCTION

A retropharyngeal hematoma is an uncommon entity that may rapidly cause airway obstruction. The etiology of a retro-pharyngeal hematoma includes infections, cervical spine trau-ma, great vessel trauma, violent head movements, iatrogenic in-jury, parathyroid adenoma hemorrhage and a foreign body ingestion (1). The occurrence of a spontaneous retropharyngeal hematoma is rare and without any identifiable causes. In the majority of cases the diagnosis is delayed because of its rarity and absence of objective signs and diagnostic laboratory data. The author reports a case of spontaneous retropharyngeal he-matoma in a 56-year-old man.

CASE REPORT

A 56-year-old man without a history of pre-existing neck dis-ease presented to the emergency ward with sore throat, dyspho-

nia and dyspnea. The symptoms were sudden in onset, severe in nature and rapidly progressive over two hours. The patient was a heavy alcoholics but had no prior cardiovascular, respiratory or gastrointestinal symptoms, no medical history or history of for-eign body ingestion and also no past or current medication. The neck was non-tender and no significant limitation of neck move-ment was present. The subject was not febrile and presented a normal blood pressure. The hematologic evaluation showed a he-matocrit of 47.9%, hemoglobin of 15.9 g/dL, white blood cell count with 13610/uL (neutrophil 73.7%, lymphocytes 15.7%, monocytes 8.2%), platelet count 251000/dL, erythrocyte sedi-mentation rate (ESR) 8 (0–10) mm/hr and C-reactive protein 25.3 (0–8) mg/L. Coagulation tests showed 96% prothrombin activity, a normal partial-thromboplastin time and a fibrinogen of 485 mg/dL. In the fiberoptic examination of the pharynx a significant anterior bulging of the posterior pharyngeal wall without ecchymosis was visible.

The plain neck lateral view showed a markedly increased

Case ReportpISSN 1738-2637 / eISSN 2288-2928J Korean Soc Radiol 2014;70(2):87-91http://dx.doi.org/10.3348/jksr.2014.70.2.87

Received October 1, 2013; Accepted December 29, 2013Corresponding author: Ji Hwa Ryu, MDDepartment of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, 875 Haeun-daero, Haeundae-gu, Busan 612-896, Korea.Tel. 82-51-797-0392 Fax. 82-51-797-0379E-mail: [email protected]

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distri-bution, and reproduction in any medium, provided the original work is properly cited.

A spontaneous retropharyngeal hematoma is a rare condition with a difficult diag-nostic. This disease may rapidly progress to an airway obstruction. The author re-ports about a case of a 56-year-old man with an acute onset of sore throat, dys-phonia and dyspnea. A retropharyngeal high attenuated soft tissue density could be seen on the neck CT. A rapid improvement of the retropharyngeal abnormality was seen on the 3 days follow-up MR imaging. Signal changes caused by blood prod-ucts which were visible on the MRI images suggested the diagnosis of retropharyn-geal hematoma. The patient was conservatively managed.

Index termsRetropharyngealHematomaAirway ObstructionCTMRI

Spontaneous Retropharyngeal Hematoma: A Case Report and Literature Overview자발성 후인두 혈종: 증례 보고 및 문헌고찰 Ji Hwa Ryu, MDDepartment of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea

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Spontaneous Retropharyngeal Hematoma

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T1 weighted spin echo images [repetition time (TR)/echo time (TE), 433.3/10.0] a diffuse homogeneous hyperintensity was shown within the lesion. The lesion showed a low signal intensi-ty on the fat suppressed T2 weighted images (TR/TE, 3500/47.9, short T1 inversion recovery). On the post-contrast T1 weighted fast spin echo images (TR/TE, 666.7/7.5) the lesion was not en-hanced. Above mentioned image sequences disclosed typical signal characteristics of a subacute hematoma and represented intracellular methemoglobin converted from deoxyhemoglobin (Fig. 3) (2). The thickness of retropharyngeal prevertebral soft tissue was decreased in the 3 days follow-up check of the plain neck lateral view (Fig. 4).

The diagnosis of spontaneous retropharyngeal hematoma was suggested on the basis of clinico-radiologic findings. The patient remained stable with no progressive airway compromise. Con-servative treatment was selected and a complete resolution of sore throat, dysphonia and dyspnea was reached. The patient was discharged within 5 days. The patient remained asymptom-atic during the follow-ups 1 week and 1 month later.

DISCUSSION

Retropharyngeal hematoma is a rare entity with a fatal out-come potential owing to progressive internal blood loss and air-way obstruction. The diagnosis can be difficult. In cases with no history of trauma, an early diagnosis in an outpatient depart-ment may be challenging because of non-specific-symptoms, such as neck pain or dysphagia, especially when a hematoma is limited to a retropharyngeal space. A patient may initially have only a sore throat without shortness of breath and may be mis-diagnosed with viral pharyngitis (2). If a retropharyngeal mass is identified, the patient may be misdiagnosed with retropha-ryngeal abscess also.

The classical manifestations of cervicomediastinal hematomas are referred to as “Capps triad” and consist of tracheal and esoph-ageal compression, anterior displacement of the trachea and sub-cutaneous bruising over the neck and anterior chest (2-6). The blood loss caused in a few cases a hypovolemic shock as a compli-cation. However, in cases of moderate retropharyngeal hemato-ma, clinical signs are related to airway compression and include dysphagia and upper respiratory failure without a subcutaneous bruising (2).

thickness of the retropharyngeal pre-vertebral soft tissue (Fig. 1). On pre-contrast CT, the lesion which occupied the retropha-ryngeal space showed a slightly high-attenuation if compared with the adjacent muscle. In the region of interest in CT the num-bers of lesions showed 75 Hounsfield unit (HU), which were higher than those of the adjacent muscle (55 HU). The post-con-trast enhanced CT showed an expansile soft tissue attenuation at the retropharyngeal space with a slightly peripheral enhance-ment that ventrally displaced the posterior pharyngo-laryngeal wall with narrowing the airway from occiput to C7 level (Fig. 2). Three days later, a MR imaging was performed. On pre-contrast

Fig. 1. Plain neck lateral view shows markedly increased thickness of retropharyngeal prevertebral soft tissue.

Fig. 2. Precontrast (A) neck computed tomography scan show an ex-pansile mass lesion with slightly high attenuation as compared with muscle (arrow). Postcontrast CT (B) shows the high attenuated lesion (arrow) with slight peripheral enhancement in retropharyngeal space with narrowing of airway from occiput to C7 level.

BA

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CT and MR offer the exact localization of the lesion. The MR al-lows more specific diagnosis about blood products in different stages of evolution, because of their paramagnetic signal proper-ties which change over the time depending on their dominant component (acute deoxyhemoglobins, subacute intra- or extra-cellular methemoglobins and chronic hemichromes) (2).

The differential diagnosis of retroperitoneal hematoma in-cludes retropharyngeal infection, acute calcific prevertebral ten-dinitis and retropharyngeal effusion. Clinical and laboratory findings such as fever and dysphagia, leukocytosis and elevated ESR are important for the correct diagnosis. CT and MR images show a contrast enhancing retropharyngeal soft tissue or a ring enhancing abscess pocket formation. A patient with an acute

The retropharyngeal hematoma is associated with a wide vari-ety of etiologies. These include infection, cervical spine trauma, great vessel trauma, violent head movement, iatrogenic injury, parathyroid adenoma hematoma, foreign body ingestion and sudden pressure changes (due to vomiting, coughing and sneez-ing). Anticoagulation or hemorrhagic diathesis predisposes an individual to develop a retropharyngeal hematoma (1-3). A spontaneous retropharyngeal hematoma is defined by the ab-sence of any clear etiology and any predisposing factor.

The retropharyngeal space is located immediately posterior to the naso-, oro- and hypopharynx, larynx and trachea. Its anteri-or border is formed by the buccopharyngeal fascia (surrounding the pharynx, trachea, esophagus and thyroid) and its posterior border is formed by the alar fascia. Laterally, it is bounded by the parapharyngeal space and the carotid sheaths (3-5, 7). The space consists of loose areolar tissue. A retropharyngeal hemato-ma is assumed to expand within this loose areolar tissue, which may delay symptoms for at least 2–3 hours and may possibly compromise the airway (3).

Plain radiography and CT and MRI are used to measure the prevertebral soft tissue thickness and to diagnose a retropharyn-geal hematoma. Keats and Sistrom (8) reported that upper nor-mal limits of normal range for thickness of prevertebral soft tis-sue in lateral cervical spine plain radiograph were 7 mm and 22 mm at C2 respective C6 levels. The upper normal limits on the multi detector CT were 6 mm at C2 and 18 mm at C6 and C7 lev-els (9). In the present case the prevertebral soft tissue thickness was increased to 38 mm at C3–C4 level on the neck CT. Using the multiplanar anatomic display and the tissue characterization

Fig. 4. On 3-days follow-up check of plain neck lateral view, retropha-ryngeal prevertebral soft tissue markedly decreased in thickness.

Fig. 3. Magnetic resonance imaging. Axial spin-echo T1-weighted image (A) shows heterogenously high signal intensity lesion (arrow) in retro-pharyngeal space. Gadolinium enhanced T1-weighted image (B) show non-enhancing retropharyngeal collection (arrow). The airway is moder-ately compromised. On axial T2-weighted image (C), the lesion (arrow) shows low signal intensity, suggestive of blood products such as subacute hematoma. Sagittal T2-weighted image (D) shows low signal intensity of retropharyngeal hematoma (arrow).

B C DA

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taneous retropharyngeal hematoma. J Emerg Med 2003;24:

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2. Muñoz A, Fischbein NJ, de Vergas J, Crespo J, Alvarez-Vin-

cent J. Spontaneous retropharyngeal hematoma: diagnosis

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calcified prevertebral tendinitis is less febrile and may have a normal white blood cell count. The CT of the such patient shows a calcific density in the site of the insertion of the longus colli muscle just anterior to the upper cervical spine. An effusion ex-tends into the retropharyngeal space from C1 down to the level of C5 or C6. The abnormality begins in the prevertebral space rather than in the retropharyngeal space and shows less dense fluid collection without any contrast enhancement (10).

The treatment of retropharyngeal hematoma is basically to se-cure the airway and remove the hematoma. A close airway mon-itoring with the ability for an active intervention by intubation or a surgical maintenance of airway is essential in cases where an infection, foreign bodies or a continuous hematoma expan-sion are highly suggestive (2). However surgical intervention should be avoided unless a treatable etiological factor is found or an airway compromise occurs. Most cases of small or moder-ate hematomas can be resolved with a conservative manage-ment. The spontaneous retropharyngeal hematoma is usually less severe also (4).

The author presents a rare case of spontaneous retropharyn-geal hematoma conservatively managed. A clinical diagnosis can be difficult for this potentially life-threatening condition. This case shows the possibility of an acute retropharyngeal swelling due to acute spontaneous hemorrhage. CT and MR imaging provide important informations for the correct diagnosis in this situation.

REFERENCES

1. Bloom DC, Haegen T, Keefe MA. Anticoagulation and spon-

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자발성 후인두 혈종: 증례 보고 및 문헌고찰

류지화

자발성 후인두 혈종은 드물게 발생하고 진단이 어려운 질환으로, 급속히 진행하여 기도 폐색을 초래할 수 있다. 저자는 갑

자기 발생한 인후통, 발음곤란과 호흡곤란의 증상으로 내원한 56세 남자에서 발생한 자발성 후인두 혈종을 보고하고자

한다. 경부 컴퓨터단층촬영에서 후인두에 연부조직음영의 고 이상음영이 관찰되었다. 그리고 3일 후에 시행한 자기공명영

상에서 후인두 병변은 빠른 호전을 보였고, 후인두 혈종으로 진단하여 고식적인 보존적 치료를 시행하였다.

인제대학교 의과대학 해운대백병원 영상의학과