Injury: the British Journal of Accident Surgery (1992) Vol. 23/No.6

424

Acute upper airway obstruction due to a ruptured vertebral artery caused by minor cervical trauma M. Ghurye, P. J. McQuillan, G. J. Madden, G. B. Smith and B. L. Taylor Intensive

Therapy Unit, Queen Alexandra

Hospital, Cosham, Portsmouth,

Case report

UK

woman presented to the accident and emergency department with acute strider. She had fallen forward from a high stool striking her forehead on another stool. There had been no loss of consciousness, subsequent pain or neurological symptoms; she had remained well for several hours. However, she gradually developed dyspnoea and stridor and she was admitted to hospital by ambulance. Clinical examination revealed a distressed, frail, elderly woman with marked inspiratory stridor. She was not cyanosed while breathing 33 per cent oxygen by mask, her pulse was 85 beats/mm and her blood pressure was 120/80mmHg. There was a mild diffuse swelling of her neck. She denied a personal or family

history of bleeding problems; she was taking no medication. Impending acute total airway obstruction required immediate intervention. After induction of anaesthesia, using an inhalational technique (oxygen and halothane), the patient was intubated with considerable difficulty, maintaining manual axial cervical spine traction and stabilization at all times. At laryngoscopy the larynx was compressed and deviated anteriorly and to the right. A lateral cervical spine radiograph (Figure I 1,taken after securing the airway, demonstrated a compression fracture of the body of the fifth cervical vertebra with posterior displacement. At the level of the fourth and fifth cervical vertebrae, there were fractures of anterior osteophytes and the spinous processes; there was marked retropharyngeal swelling. The chest radiograph (FigureZ) revealed a

showing a compression Figure 1. Cervical spine radiograph fracture of the body of the fifth cervical vertebra with posterior displacement, fractures of anterior osteophytes associated with the fourth and fifth cervical vertebrae, and fractures of the spinous processes of the same vertebrae.

Figure2. Chest radiograph demonstrating a widened upper mediastinum and swelling of the soft tissues of both supraclavicular regions.

Anbl-year-old

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Case reports

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wide upper mediastinurn and swelling of the soft tissues of both supraclavicular regions. Coagulation studies and platelet count were normal; the haemoglobin concentration was 11.7 g/dl. The patient was admitted to the intensive therapy unit, sedated with propofol and allowed to breathe spontaneously through the endotracheal tube. Over the subsequent 3 h she became hypotensive, her neck became massively swollen and bruised (Figure3) and the haemoglobin level fell to 8.7 g/dl. Surgical exploration of the neck revealed a ruptured right vertebral artery, ruptured anterior cervical ligaments and a massive retropharyngeal haematoma, A total of 6 units of blood, 3 litres of colloid and 3 litres of crystalloid was transfused in the first 24 h. The patient was extubated 4 days later and there was no neurological deficit. However, on the 6th postoperative day she developed ventricular fibrillation and resuscitation was unsuccessful. At post-mortem the cervical spinal cord was intact and there was severe coronary artery disease.

Discussion Retropharyngeal haematomas have been reported in association with a variety of medical and surgical conditions. Sandor and Cooke (1964) reported spontaneous bleeding from aberrant arteries at the thoracic inlet. More commonly, spontaneous retropharyngeal haematomas have been reported in association with hereditary and acquired disorders of coagulation such as haemophilia (Bray and Nugent, 1986), thrombocytopenia, polycythaemia rubra Vera (Mackenzie and Jellicoe, 1986) and during anticoagulant therapy (Reussi et al., 1969; Thatcher and George, 1987). Retropharyngeal haemorrhage has also occurred from aneurysms (true, dissecting and mycotic) of the carotid arteries and aorta (Thomson and Mar-son, 1955; Lindsay et aI., 1989) haemorrhagic tumours (Owens et al., 1975) and as a result of deep infections and abscesses (Carmody and Wergowske, 1983). However, retropharyngeal haemorrhage is most commonly caused by major blunt injury; it does not occur frequently following minor trauma, except in the elderly. The prevertebral haematoma often noted on cervical spine radiographs is a useful and common sign of cervical fracture. In an extensive radiological review, Penning (1981) noted that most haematomas occur anterior to the upper four cervical vertebrae. Small haematomas tend to occur with odontoid and compression fractures, whereas larger haematomas were associated with disruptive hyperextension injury, as occurred in our patient. Retropharyngeal haematomas, of whatever cause, rarely ‘precipitate airway compromise. Therefore, no specific airway assistance is required. However, if the patient’s airway is at risk patency must be secured as rapidly as possible, taking into account the potential for associated cervical spine injury. Ideally, if time and the condition of the patient permit, a cervical spine radiograph should be taken in the accident and emergency department before endotracheal intubation. Once airway patency has been assured, even most large retropharyngeal haematomas usually require only general supportive measures. Our case report is remarkable in that, in a patient with normal coagulation, the severity of the bleeding into the neck and upper mediastinum following minor trauma was sufficient to produce hypotension and massive neck marked hypovolaemia, swelling. Under such circumstances, urgent surgical exploration must be considered. Although Logan and Doby (1962) reported an extensive retropharyngeal haematoma in a patient with a fracture of the fifth cervical vertebra and postulated vertebral artery

patient immediately prior to surgical exploration of her neck

injury, we are unaware of any other report of retropharyngeal haematoma requiring surgical exploration and none in which vertebral artery rupture was confirmed.

References Bray G. and Nugent D. (1986) Haemomhage involving the upper airway in haemophilia. Clin. Pediafr. 25,346. Carmody T. J. and Wergowske G. L. (1983) Retropharyngeal abscess and hematoma in an elderly woman following esophagoscopy and endotracheal intubation. j. Am. Geriuf, Sac. 31, 499. Lindsay D. C., Smith C. F., McQuillan P. J. et al. (1989) Laryngeal compression and stridor as the presenting feature of ruptured thoracic aortic aneurysm. J Cardiovasc Surg. 30,864. Logan, G. E. C. and Doby T. (1962) Retropharyngeal hematoma caused by vertebral fracture. J, h/iaine Med. Assuc. 53,114. Mackenzie J. W. and Jellicoe J. A. (1986) Acute upper airway obstruction. Spontaneous retropharyngeal haematoma in a patient with polycythaemia rubra Vera. Anaesfksiu 41,57. Owens D. E., Calcaterra T. C. and Aarstad R. A. (1975) Retropharyngeal hematoma: a complication of therapy with anticoagulants. Arch. ofo~ryngol. 101,565. Penning L. (1981) Prevertebral hematoma in cervical spine injury: Incidence and etiological significance. AjR 136,553. Reussi C., Schiavi J. E., Akman R. et aI. (1969) Unusual compkations in the course of anticoagulant therapy. Am. 1. Med. 46,

460. Sandor F. and Cooke R. T. (1964) Spontaneous cervico-mediastinal haematoma. Br. J Surg. 51,682. Thatcher, J. and George D. (1987) Retrophaqmgeal hematoma as a new cause of acute upper airway obstruction in rheumatoid arthritis. J. Rheumafol.14, 1172. Thomson A. P. and Marson P. G. W. (1955) Dissecting aneurysm of the aorta. hcef 268,482.

Paper accepted 4 November

1991.

Requests for reprinfsshouldbe achi~essed to: Dr G. 8. Smith, Intensive Therapy Unit, Queen Alexandra Hospital, Cosham, Portsmouth, Ikunpshire PO6 3LY, UK.

Acute upper airway obstruction due to a ruptured vertebral artery caused by minor cervical trauma.

Injury: the British Journal of Accident Surgery (1992) Vol. 23/No.6 424 Acute upper airway obstruction due to a ruptured vertebral artery caused by...
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