Anaesthesia, 1975, Volume 30, pages 50-53 CASE R E P O R T
Cervico-mediastinal haematoma following sneezing
R O S E M A R Y G. M A C D O N A L D
AND
J. KELLY
Spontaneous cervico-mediastinal haematoma was first reported by Capps‘ in 1934. Although uncommon it should be considered in any patient presenting with dyspnoea, dysphagia or dysphonia following exertion,2 s n e e ~ i n g coughing ,~ or ~ o m i t i n gTwo .~ cases have been reported in which there was no apparent precipitating Anaesthetists may find themselves called to the Emergency Room to deal with respiratory obstruction in these cases. Case report
A female aged 58 years was admitted with laryngeal stridor, a harsh ‘bovine’ cough, dysphagia, dyspnoea and dysphonia. Respiratory arrest occurred ; this necessitated immediate endotracheal intubation and intermittent positive pressure ventilation (IPPV). Adequate spontaneous respiration was resumed after a few minutes and the patient extubated herself. The airway was adequate provided she was quiet, but talking, coughing or anxiety led to further stridor and respiratory difficulty. Subsequent enquiries revealed that a bout of sneezing 60 hours prior to admission had been followed almost immediately by stabbing pain in the left side of her neck. This pain radiated retro-sternally. It was intermittent at first but it worsened to become continuous during the ensuing 16 hours. She also started to feel breathless. These symptoms continued until approximately 18 hours prior to admission when she developed dysphagia, vomiting, orthopnoea and a ‘barking’ cough. Further deterioration took place during the evening of admission until she felt that she was choking and unable to breath.
Physical examination The patient had dysphonia and a harsh bovine cough, suggestive of vocal cord paralysis when she was examined after the emergency and the anterior aspect of the neck was Rosemary G. Macdonald, MB, FFARCS, Lecturer, Department of Anaesthesia, University of Leeds and J. Kelly, FRCS, Surgical Registrar, Leeds (St James’s) University Hospital.
50
Spontaneous cervico-mediastinal haematoma
51
swollen and bruised, The trachea was deviated to the right and the apex beat was to the right of the mid-clavicular line, but the lung fields were normal to percussion and auscultation. There was no marked circulatory failure. Special investigations Radiological examination. The plain X-ray (Fig. 1) showed considerable widening of the mediastinum especially on the right. The trachea was deviated to the right in the lower cervical region and narrowed laterally. Lateral views showed forward displacement of the trachea at the thoracic inlet, the increased soft shadow extending to C1. The lung fields appeared normal otherwise.
Fig. 1. Plain X-ray soon after admission (see text).
Bronchoscopy demonstrated that the right vocal cord was immobile. The trachea was narrowed and appeared pushed forward by a soft, non-pulsatile mass extending to the carina. The lumen of the right main bronchus was narrowed. Oesophagoscopy was normal. Aortography (Fig. 2) showed the mediastinum to be wider than on admission but no aortic aneurysm was demonstrated. The innominate artery was compressed downwards and laterally, and the left common carotid splayed outwards suggesting a spaceoccupying lesion in this region. The venogram obtained after simultaneous injection of 60% ‘Conray’ into both median cubital veins confirmed this. Gastrografin instilled via a naso-gastric tube established that the oesophagus was also displaced antero-laterally and to the right.
52
Rosemary G . Macdonald and J. Kelly
Surgery Exploration of the retro-sternal space revealed no abnormality but at thoracotomy a large haematoma was found to occupy the posterior mediastinum from the thoracic inlet to the diaphragm. The full length of the oesophagus, the lower half of the trachea and the right main bronchus were compressed and pushed forward by this haematoma, which was removed with resultant decompression of these structures. No obvious bleeding point could be found. It was noted at extubation that the right vocal cord moved normally. The patient made satisfactory progress post-operatively.
Fig. 2. Aortography. The mediastinum is wider than in Fig. 1 (see text).
Discussion The possible lesions which can be complicated by haemorrhage leading to mediastinal haematoma are bronchial neoplasm, retro-sternal goitre, parathyroid adenomata,’ aortic aneurysm and mediastinal cyst. These lesions must be excluded in order to establish the diagnosis of ‘spontaneous’ cervico-mediastinal haematoma. Antero-posterior and lateral chest and neck X-rays are mandatory. These, repeated following a barium swallow or after instillation of gastro-grafin via a nasogastric tube as was done in this case, will clarify further the extent of the displacement of the oesophagus and trachea. Marion et aL6 state that aortography and venous angiography are the most helpful investigations and will site the haematoma. Many of these patients will recover with conservative treatment3-’ but progressive symptoms of mediastinal compression and difficulty in maintaining an adequate airway indicate the need for surgical intervention.
Spontaneous cervico-mediast haI haematoma
53
Sandor & Cooke3 postulated that the bleeding in spontaneous cervico-mediastinal haematoma arises from an aberrant retro-oesophageal artery. No active bleeding point was found in the case described above and aortography failed to reveal any abnormal circulation. It was concluded that the haematoma must have arisen from a ruptured para-oesophageal vein secondary to a sudden increase in intra-thoracic pressure during the bout of sneezing. Summary A case of spontaneous cervico-mediastinal haematoma is described. This is the ninth case recorded and is unusual in that the haematoma seems to have resulted from rupture of a para-oesophageal vein. The differential diagnosis and methods of investigation are discussed.
Acknowledgments
The authors are grateful to Mr Z . J. Rozycki for permission to publish this case, to Drs G. Dyson and S. D. Clayton for clinical advice and assistance with the management; and to Mrs s. Barlow for secretarial assistance. Dr J. Glanville, Consultant Radiologist, Leeds (St James’s) University Hospital carried out and reported on the various radiographic procedures. References 1. CAPPS,R.B. (1934) Multiple parathyroid tumours with massive mediastinal and sub-cutaneous haemorrhage:case report. American Journal of Medical Sciences, 188,800. S., CARRATU, M. & Rossr, F. (1958) Un caso-di emorragia mediastinica 2. BENEDETTI-VALENTIN, non-traumatica. Minerva Chirurgica, 13, 647. 3. SANDOR, F. & COOKE, R.T. (1964) Spontaneous cervico-mediastinalhaematoma. British Journal of Surgery, 51,682. 4. EPSTEIN, A.M. & KLASSEN, K.P. (1960) Spontaneous superior mediastinal haemorrhage.Journal of Thoracic and Cardiovascular Surgery, 39,740. 5. HENNESSY, T.P. & MARTINEZ, J.A. (1970) Spontaneous cervico-mediastinalhaematoma. Journal of the Irish Medical Association, 63,298. 6. MARION, P., MIKAELOFF, PH., ESTANOVE, S. & GALLET, M. (1968) Hematome spontane du mediastin. Lyon Chirurgical, 64, 705.
Cervico-mediastinal haematoma following sneezing
R O S E M A R Y G. M A C D O N A L D
AND
J. KELLY
Spontaneous cervico-mediastinal haematoma was first reported by Capps‘ in 1934. Although uncommon it should be considered in any patient presenting with dyspnoea, dysphagia or dysphonia following exertion,2 s n e e ~ i n g coughing ,~ or ~ o m i t i n gTwo .~ cases have been reported in which there was no apparent precipitating Anaesthetists may find themselves called to the Emergency Room to deal with respiratory obstruction in these cases. Case report
A female aged 58 years was admitted with laryngeal stridor, a harsh ‘bovine’ cough, dysphagia, dyspnoea and dysphonia. Respiratory arrest occurred ; this necessitated immediate endotracheal intubation and intermittent positive pressure ventilation (IPPV). Adequate spontaneous respiration was resumed after a few minutes and the patient extubated herself. The airway was adequate provided she was quiet, but talking, coughing or anxiety led to further stridor and respiratory difficulty. Subsequent enquiries revealed that a bout of sneezing 60 hours prior to admission had been followed almost immediately by stabbing pain in the left side of her neck. This pain radiated retro-sternally. It was intermittent at first but it worsened to become continuous during the ensuing 16 hours. She also started to feel breathless. These symptoms continued until approximately 18 hours prior to admission when she developed dysphagia, vomiting, orthopnoea and a ‘barking’ cough. Further deterioration took place during the evening of admission until she felt that she was choking and unable to breath.
Physical examination The patient had dysphonia and a harsh bovine cough, suggestive of vocal cord paralysis when she was examined after the emergency and the anterior aspect of the neck was Rosemary G. Macdonald, MB, FFARCS, Lecturer, Department of Anaesthesia, University of Leeds and J. Kelly, FRCS, Surgical Registrar, Leeds (St James’s) University Hospital.
50
Spontaneous cervico-mediastinal haematoma
51
swollen and bruised, The trachea was deviated to the right and the apex beat was to the right of the mid-clavicular line, but the lung fields were normal to percussion and auscultation. There was no marked circulatory failure. Special investigations Radiological examination. The plain X-ray (Fig. 1) showed considerable widening of the mediastinum especially on the right. The trachea was deviated to the right in the lower cervical region and narrowed laterally. Lateral views showed forward displacement of the trachea at the thoracic inlet, the increased soft shadow extending to C1. The lung fields appeared normal otherwise.
Fig. 1. Plain X-ray soon after admission (see text).
Bronchoscopy demonstrated that the right vocal cord was immobile. The trachea was narrowed and appeared pushed forward by a soft, non-pulsatile mass extending to the carina. The lumen of the right main bronchus was narrowed. Oesophagoscopy was normal. Aortography (Fig. 2) showed the mediastinum to be wider than on admission but no aortic aneurysm was demonstrated. The innominate artery was compressed downwards and laterally, and the left common carotid splayed outwards suggesting a spaceoccupying lesion in this region. The venogram obtained after simultaneous injection of 60% ‘Conray’ into both median cubital veins confirmed this. Gastrografin instilled via a naso-gastric tube established that the oesophagus was also displaced antero-laterally and to the right.
52
Rosemary G . Macdonald and J. Kelly
Surgery Exploration of the retro-sternal space revealed no abnormality but at thoracotomy a large haematoma was found to occupy the posterior mediastinum from the thoracic inlet to the diaphragm. The full length of the oesophagus, the lower half of the trachea and the right main bronchus were compressed and pushed forward by this haematoma, which was removed with resultant decompression of these structures. No obvious bleeding point could be found. It was noted at extubation that the right vocal cord moved normally. The patient made satisfactory progress post-operatively.
Fig. 2. Aortography. The mediastinum is wider than in Fig. 1 (see text).
Discussion The possible lesions which can be complicated by haemorrhage leading to mediastinal haematoma are bronchial neoplasm, retro-sternal goitre, parathyroid adenomata,’ aortic aneurysm and mediastinal cyst. These lesions must be excluded in order to establish the diagnosis of ‘spontaneous’ cervico-mediastinal haematoma. Antero-posterior and lateral chest and neck X-rays are mandatory. These, repeated following a barium swallow or after instillation of gastro-grafin via a nasogastric tube as was done in this case, will clarify further the extent of the displacement of the oesophagus and trachea. Marion et aL6 state that aortography and venous angiography are the most helpful investigations and will site the haematoma. Many of these patients will recover with conservative treatment3-’ but progressive symptoms of mediastinal compression and difficulty in maintaining an adequate airway indicate the need for surgical intervention.
Spontaneous cervico-mediast haI haematoma
53
Sandor & Cooke3 postulated that the bleeding in spontaneous cervico-mediastinal haematoma arises from an aberrant retro-oesophageal artery. No active bleeding point was found in the case described above and aortography failed to reveal any abnormal circulation. It was concluded that the haematoma must have arisen from a ruptured para-oesophageal vein secondary to a sudden increase in intra-thoracic pressure during the bout of sneezing. Summary A case of spontaneous cervico-mediastinal haematoma is described. This is the ninth case recorded and is unusual in that the haematoma seems to have resulted from rupture of a para-oesophageal vein. The differential diagnosis and methods of investigation are discussed.
Acknowledgments
The authors are grateful to Mr Z . J. Rozycki for permission to publish this case, to Drs G. Dyson and S. D. Clayton for clinical advice and assistance with the management; and to Mrs s. Barlow for secretarial assistance. Dr J. Glanville, Consultant Radiologist, Leeds (St James’s) University Hospital carried out and reported on the various radiographic procedures. References 1. CAPPS,R.B. (1934) Multiple parathyroid tumours with massive mediastinal and sub-cutaneous haemorrhage:case report. American Journal of Medical Sciences, 188,800. S., CARRATU, M. & Rossr, F. (1958) Un caso-di emorragia mediastinica 2. BENEDETTI-VALENTIN, non-traumatica. Minerva Chirurgica, 13, 647. 3. SANDOR, F. & COOKE, R.T. (1964) Spontaneous cervico-mediastinalhaematoma. British Journal of Surgery, 51,682. 4. EPSTEIN, A.M. & KLASSEN, K.P. (1960) Spontaneous superior mediastinal haemorrhage.Journal of Thoracic and Cardiovascular Surgery, 39,740. 5. HENNESSY, T.P. & MARTINEZ, J.A. (1970) Spontaneous cervico-mediastinalhaematoma. Journal of the Irish Medical Association, 63,298. 6. MARION, P., MIKAELOFF, PH., ESTANOVE, S. & GALLET, M. (1968) Hematome spontane du mediastin. Lyon Chirurgical, 64, 705.
