Retropharyngeal haematoma – an unusual bleeding site in an anticoagulated patient: a case report

INTRODUCTION: Anticoagulation is used widely for the primary prevention of embolic events in patients with atrial fibrillation. Bleeding is the most common complication with oral anticoagulation. We describe the case of a patient who developed a massive retropharyngeal haematoma after a fall. Whilst the retropharyngeal space is an uncommon site for bleeding complications, it is clinically important as the development of upper airway obstruction may be life threatening. CASE PRESENTATION: We present the case of an 85-year-old Caucasian woman on warfarin, who developed a massive retropharyngeal haematoma after a fall. She initially presented with pulmonary oedema and Type 2 respiratory failure. She was commenced on treatment for this with a good clinical response. She subsequently deteriorated, developing stridor and bruising to the neck. She was urgently intubated and ventilated. Computerized Tomography scan showed a massive retropharyngeal haematoma. The baseline International Normalized Ratio (INR) was 4.9. The patients was managed conservatively and treated with Vitamin K and Prothrombin Complex Concentrates (PCCs). The INR was rapidly corrected to 1.1 and the patient made a full recovery. CONCLUSION: Retropharyngeal haematoma should be considered in anticoagulated patients presenting with abrupt respiratory distress after minor head trauma. It can develop after minor traumatic events, such as falls. It can result in upper airway obstruction, which can be life threatening. Patients should be urgently assessed for intubation and ventilation. Computerized Tomography imaging of the neck and mediastinum is diagnostic. Correction of the International Normalized Ratio with Vitamin K and Prothrombin Complex Concentrates is essential. Management is mainly supportive. However, in very large haematomas surgical drainage may be considered.