Retropharyngeal Hematoma in the Context of Obstructive Sleep Apnea

A Case Report and Review of the Literature

Christian Warken; Nicole Rotter; Joachim Theodor Maurer; Ulrike Attenberger; Anne Lammert


J Med Case Reports. 2019;13(269) 

In This Article

Discussion and Conclusions

Today we know that there are many causes of retropharyngeal hematoma, including retropharyngeal abscess, trauma, sudden pressure changes (due to vomiting, coughing and sneezing), foreign body ingestion, surgery, central venous cannulation and carotid aneurysm, portal hypertension, the presence of tumors, and an aberrant artery at the thoracic inlet. Also, spontaneous bleedings in association with anticoagulant therapy or bleeding diatheses are possible causes.[6–8]

The retropharyngeal space is an area of loose connective tissue. The buccopharyngeal fascia which surrounds the pharynx, trachea, esophagus, and thyroid forms the anterior border of the retropharyngeal space. Bounded posteriorly by the alar fascia, the retropharyngeal space is limited laterally by the carotid sheaths and parapharyngeal spaces. The pretracheal, parapharyngeal, and retropharyngeal spaces communicate with each other. These spaces communicate with the subcutaneous spaces of the neck via the submandibular space and the mediastinal space. Because of these connections, infections or blood can track these spaces and a retropharyngeal hematoma can manifest itself as subcutaneous bruising. "Capp's triad" describes the classical manifestation including compression of the trachea and esophagus, displacement of the trachea anteriorly, and subcutaneous bruising over the neck.[9]

In the emergency of a spontaneous retropharyngeal hematoma it is crucial to decide which interventions are necessary. Symptoms may include dyspnea, dysphagia, or hoarseness. However, patients with early retropharyngeal hematoma can be seen with a sore throat without shortness of breath and may be misdiagnosed with a harmless viral pharyngitis. The protection of the airway has highest priority to maintain a sufficient respiration. In this context it is important to know if the size of the retropharyngeal hematoma is stable or progressive, because that information is important to assess the obstruction of the upper airway. Deaths can occur due to rapid development of respiratory distress from upper airway obstruction or great vessel compression caused by sublingual, retropharyngeal, and parapharyngeal hemorrhages.[8] Often the evacuation of the hematoma is not necessary to treat such patients successfully as the natural absorption of the hematoma is mostly sufficient. No need to say that continuous monitoring of vital parameters is obligatory. If respiration is insufficient even under a therapy with oxygen, then intubation or tracheostomy should be considered. It should also be considered that a transoral intubation could possibly lance the hematoma and cause severe bleedings. Obviously, parameters such as hemostasis and blood pressure should be optimized.

We hypothesize that an untreated OSA can cause spontaneous retropharyngeal hematoma. This could be due to the accompanying hypertension, the vibrations of the pharyngeal mucosa, or tissue alterations due to a chronic edema and inflammation of the subepithelial layers in upper airway tissues and the highly negative inspiratory pharyngeal pressures of down to − 100 cm H2O during obstructive apneas.[10,11] Woodson et al. showed that histologic differences occur in snorers and in patients with OSA compared with non-snorers, visible as focal atrophy of muscle fibers, disrupted adjacent muscle bundles by infiltrating mucous glands, and extensive edema of the lamina propria with vascular congestion and dilatation.[12] Sometimes first clinical symptoms occur several hours after the precipitating event of such a hematoma. This may be the explanation of why our patient reported her first complaints several hours after getting up from bed.

Different studies showed that OSA can lead to several tissue alterations both in mucosa and subepithelial layers. Inflammation and edema of the subepithelial layers can lead to a loss of substance and damage to small vessels.[10–12] A blood vessel could tear at the junction of the mobile and the fixed parts of arteries or veins. This could lead to a spontaneous hemorrhage in the retropharyngeal space. It has already been shown that moderate to severe OSA can be one of the independent predictors of cerebral microbleeds which are considered a surrogate marker of overt stroke.[13] It is likely that OSA is also a predictor for bleedings in other compartments of the body.

If other causes for a spontaneous retropharyngeal hematoma are unlikely, an untreated or not sufficiently treated OSA should be considered. As far as we know, this is the first case report describing retropharyngeal hematoma caused by the adverse effects of OSA.