Retropharyngeal haematoma is a rare entity with multiple aetiological factors. This is an alarming condition and although associated with life-threatening complications, often the condition resolves without event [1].

Individuals with hemophilia and those taking anticoagulants such as warfarin appear to be at an increased risk of retropharyngeal hematomas. In cases with no history of trauma, an early diagnosis in an outpatient department may be challenging because of non-specific-symptoms, such as neck pain or dysphagia, especially when a hematoma is limited to a retropharyngeal space. Conservative management has been successfully utilized with an understanding that this may entail a period of extended observation of up to three weeks until a complete resolution of the symptoms and underlying hematoma occurs [2,3].

We describe a case of retropharyngeal haematoma which demonstrates the clinical presentation and emphasises the need for a conservative approach.

A 14-year-old male child was brought to ENT OPD with bluish discolouration of throat and nasal bleeding from past 3 days. There was no history of trauma or antiplatelet drug intake. Patient had mild dyspnoea and dysphagia.

During examination, patient had normal oxygen saturation and there was no stridor. Intra oral examination revealed bluish discolouration of the posterior pharyngeal wall. On detailed examination, right knee was found to be swollen. There was no bruising in any other part of the body. Nasal and nasopharyngeal examination also did not reveal any mass causing epistaxis.

Lateral view of X-ray neck revealed widening of the retropharyngeal space, indicating collection.

Further enquiry about patient’s medical history revealed that he was Haemophilic. So, retropharyngeal hematoma and hemarthrosis was primarily due to Haemophilia. In addition, paediatric opinion was sought and factor viii administration was advised. Since factor viii was out of stock that time in our medical college, patient was referred to another institute for its administration and further management (Figure 1).

Retropharyngeal hematoma is a rare condition that can progress to airway blockage and is challenging to detect early. A wide range of aetiologies are linked to retropharyngeal haemorrhages. There are also neoplasia, Epstein-Barr virus, vascular aneurysms, parathyroid lesions, haematological problems (anticoagulation, Polycythaemia Rubravera, haemophilia) and trauma (central venous cannulation, fishbone impaction) [1,2].

Figure 1: Retropharyngeal hematoma and hemarthrosis in male child

A possible space between the nasopharynx, oropharynx, hypopharynx, larynx and trachea is known as the retropharyngeal space. The pharynx, trachea, oesophagus and thyroid are all surrounded by the buccopharyngeal fascia, which also serves as the anterior border of the retropharyngeal area. The parapharyngeal spaces and carotid sheaths limit the retropharyngeal space laterally, which is bounded posteriorly by the alar fascia. At the level of the tracheal bifurcation, it continues inferiorly to the mediastinum and superiorly to the base of the cranium. Via the connected deep neck spaces, infections or blood can track into the mediastinum, neck and anterior chest wall [1,3].

Clinically, retropharyngeal haemorrhage can manifest as a trio of symptoms, including superior mediastinal obstruction, anterior tracheal displacement and neck bruise that spreads to the chest wall within 48 hours. Significant superior mediastinal compression may be followed by airway blockage, necessitating airway intervention such as tracheostomy or intubation. Depending on how much bleeding is there, the latter may be challenging [1,4].

Understanding the aetiology and potential consequences of retropharyngeal haematoma is essential to its management. With the option for active intervention by intubation or a surgical airway, close airway monitoring is crucial. Only a small percentage of times do patients need to have the haematoma surgically removed because it usually resolves on its own within a few weeks. However, a mortality rate of up to 20% has been documented [1,5].

Different medical specialties, such as thoracic surgeons and otorhinolaryngologists, may be consulted for retropharyngeal haemorrhage. It is crucial to be knowledgeable about this particular illness and its unique appearance. It is advised to do a thorough evaluation that includes fiberoptic upper aerodigestive tract visualisation. Unless an airway compromise occurs or a curable aetiological reason is identified, surgical intervention should be avoided. The majority of instances can be handled conservatively.

1. Singh, A. et al. “Spontaneous Retropharyngeal Haematoma: A Case Report.” Journal of Medical Case Reports, vol. 2, 2008, pp. 8.

2. Kang, S.S. et al. “Spontaneous Retropharyngeal Hematoma: A Case Report.” Korean Journal of Pain, vol. 23, no. 3, September 2010, pp. 211-214.

3. Lin, M. and C. Sinclair. “Retropharyngeal Haematoma: An Unusual Cause of Airway Obstruction.” Journal of Surgical Case Reports, vol. 2011, no. 10, October 2011, pp. 5.

4. Lakhdar, Y. et al. “The Spontaneous Retropharyngeal Space Hematoma: How to Manage?” European Journal of Medical and Health Sciences, vol. 3, no. 2, 2021, pp. 16-18.

5. Ryu, JiHwa. “Spontaneous Retropharyngeal Hematoma: A Case Report and Literature Overview.” Journal of the Korean Society of Radiology, vol. 70, no. 2, February 2014, pp. 87-91.