Clinical communication
Anticoagulation and spontaneous retropharyngeal hematoma1,

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Abstract

A 57-year-old man treated with Coumadin for an episode of paroxysmal atrial fibrillation presented to the Emergency Department with progressive dysphagia and odynophagia. Physical examination revealed a large right-sided lateral and posterior pharyngeal wall mass. Laboratory studies were significant for an international normalized ratio (INR) of 5.4 with a white blood cell count of 11,600/muL and a hematocrit of 33.2%. A lateral soft tissue radiograph and computed tomography (CT) scan of the neck demonstrated a retropharyngeal hematoma compromising the airway. Rapid reversal of the coagulopathy was achieved with fresh frozen plasma and vitamin K. Patients with space-occupying retropharyngeal masses present a significant management dilemma. The choice between observation, intubation, or a surgical airway intervention must rely upon knowledge of the natural course and high rate of airway occlusion when faced with a patient who presents with a retropharyngeal hematoma. Once symptoms of airway compromise manifest, the airway must be expeditiously secured before complete obstruction occurs. This diagnosis should be sought when an anticoagulated patient presents with upper airway symptoms.

Introduction

A retropharyngeal hematoma is a rare entity that may rapidly cause airway obstruction. Etiologies of retropharyngeal hematoma include infection, cervical spine trauma, great vessel trauma, violent head movements, iatrogenic injury, parathyroid adenoma hemorrhage, and foreign body ingestion (1). Retropharyngeal hematomas classically present with the triad of tracheal and esophageal compression, ventral tracheal displacement on the lateral cervical radiograph, and subsequent appearance of subcutaneous bruising in the anterior neck and upper thorax (2). We present a case of spontaneous retropharyngeal hematoma after Coumadin anticoagulation, review the pertinent literature, and discuss the diagnosis and treatment of this entity.

Section snippets

Clinical data

A 57-year-old man presented to the Emergency Department (ED) complaining of a sore throat and difficulty swallowing. The symptoms began the day before presentation along with a cough and subsequent blocked sensation in his throat. His primary care physician prescribed Augmentin, 875 mg twice daily, and viscous Lidocaine. Two months before this presentation, the patient was started on Coumadin, 5 mg per day, for an episode of paroxysmal atrial fibrillation. He had a history of hypertension and

Discussion

This case demonstrates the potential for the formation of a retrophayrngeal hematoma secondary to the administration of Coumadin. Coumadin acts by blocking the vitamin K-dependent reducing enzymes that provide the carboxylase substrate needed for activation of coagulation factors II, VII, IX, and X. Coumadin’s half-life is 35 h with anticoagulant effects persisting for 3–5 days (3). Bleeding is the most frequent complication of oral anticoagulation therapy. The reported incidence per year of

Conclusion

Many common medical conditions and drugs increase the risk of bleeding in patients taking Coumadin and other anticoagulants. The initial benign clinical presentation of retropharyngeal space hematoma combined with the potential for rapid airway compromise make this diagnosis important to rule out in anticoagulated patients who present with odynophagia, dysphagia, cough, or hoarseness.

References (13)

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    Of the 20 cases reviewed, nine cases described spontaneous hematomas involving the epiglottis [1-3,6,7,11,15-17], four involved the retropharyngeal space [13,14,18,19], four involved the arytenoids [1,7,8,10]; three cases did not describe the specific upper airway structures involved [4,12,20], and one identified an intramural esophageal hematoma [5]. Twelve cases identified patients on warfarin; six of these patients received anticoagulant reversal therapy as part of their initial management [1-12]. Two cases were identified involving rivaroxaban, and one each for acenocoumarol and dual antiplatelet therapy [15,18].

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    Interaction with drugs like broad spectrum antibiotics, quinidine, salicylate, thyroxine, alcohol and diet often makes anticoagulation with warfarin a challenge. The overall incidence of bleeding in patients on warfarin is about 6.8% [4]. Retropharyngeal, submaxillary and epiglottic hematomas or bleeding has been described in patients on warfarin therapy, but they can be difficult to identify [3].

  • An unexpected complication of occipitocervical stabilization surgery: Retropharyngeal hematoma

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    The patient had stated at the 6-month follow-up that the dysphagia was then more tolerable and she is now stable at the 12-month follow-up. Most retropharyngeal hematomas described in the literature have involved complicating factors such as anticoagulant therapy, tumor, aneurysm, infection, or major cervical spine injury [1–7]. Retropharyngeal hematoma after cervical spinal surgery is a potentially fatal entity because of the possibility of acute airway obstruction.

  • Active retropharyngeal hemorrhage from an acute thyrocervical artery injury: A rare complication of hyperextension cervical spine injury

    2012, Journal of Emergency Medicine
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    For the emergency physician, early recognition of clinically significant retropharyngeal hemorrhage is important, as continued bleeding can lead to airway obstruction with potentially fatal consequences. The clinical presentation is variable and patients may present with stridor, hoarse voice, or dysphagia with bulging of the posterior pharyngeal wall on nasoendoscopy (4). In addition, there may be bruising and tenderness of the neck and, as demonstrated in the described case, large hematomas can result in clinically apparent anterior displacement of the larynx.

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Clinical Communications is coordinated by Ron Walls, md, of Brigham and Women’s Hospital and Harvard University Medical School, Boston, Massachusetts

1

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

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