N Engl J Med 2016; 374 January 21, 2016
Spontaneous Retropharyngeal Hematoma
Noah Ditkofsky, M.D., and Tarek Hanna, M.D.
- A 56-year-old man presented to the emergency department with a 5-hour history of throat swelling and pain and difficulty breathing that was exacerbated by supine positioning; he had not had any obvious antecedent trauma. His medical history included prostate cancer, hypertension, hyperlipidemia, deep-vein thrombosis, and stroke. Medications included warfarin (presumably for deep-vein thrombosis), antihypertensive agents, and a statin. He was afebrile, and the physical examination was notable for minor swelling of the posterior oropharynx. Laboratory studies revealed a normal white-cell count, an international normalized ratio of more than 11, a prothrombin time of more than 120 seconds, and an activated partial-thromboplastin time of 127 seconds. Radiography of the neck revealed marked soft-tissue swelling that was causing mass effect on the airway (Panel A); the findings on a subsequent computed tomographic scan of the neck were consistent with a retropharyngeal hematoma, which was probably caused by supratherapeutic anticoagulation (Panel B shows the sagittal view, and Panel C the axial view; the arrow in each panel indicates the hematoma). Transnasal laryngoscopy revealed a bulging posterior pharynx but a patent airway. The patient was administered 6 units of fresh-frozen plasma and was admitted to the intensive care unit for observation. His coagulopathy resolved, as did his symptoms, and he was discharged 4 days after admission.