An Evolving Difficult Airway.

Dear Editor,

Retropharyngeal hematoma causing airway obstruction following blunt trauma is a rare but life-threatening condition.[1234] We report the case of a 55-year-old moderately built male who developed upper airway obstruction due to retropharyngeal hematoma following a motor vehicle accident. On reaching the emergency department (ED), the patient was restless, agitated, and intoxicated with ethanol. The primary survey was unremarkable with normal vital signs and a negative extended focused assessment with sonography in trauma. A computed tomography (CT) head and C-spine were ordered but could not be done as he developed respiratory distress while in the radiology department. He was rapidly desaturating and required rapid sequence intubation. However, on laryngoscopy, the vocal cords could not be visualized. A bougie-assisted intubation and even bag mask ventilation failed. A surgical cricothyroidotomy was done for adequate ventilation. X-ray cervical spine lateral film showed increased soft-tissue density anterior to the vertebral column completely obstructing the upper airway suggestive of a retropharyngeal hematoma [Figure 1]. CT head and cervical spine showed no intracranial injury, but a retropharyngeal hematoma extending from C2 to C6 vertebra without any fractures in vertebral bodies [Figure 2]. The patient developed no further complications and was discharged on day 6 from the hospital. A study by Nørskov et al. has shown that difficult airways cannot be always predicted.[5] It is safer to assume that every airway in ED is going to be challenging and be prepared with multiple backup plans. Preparation is the key for the success of any emergency procedure. Surgical cricothyroidotomy is a lifesaving emergency procedure which every clinician should be proficient in.

Figure 1

X-ray cervical spine lateral film showing increased soft-tissue density anterior to the vertebral column suggestive of a retropharyngeal hematoma completely obliterating the upper airway

Figure 2

Computed tomography cervical spine showing retropharyngeal hematoma measuring 3 cm × 5.1 cm × 6 cm extending to paravertebral space, superiorly to C2 vertebra and inferiorly to C6 vertebra, displacing the Ryles tube anteriorly and without any obvious fractures, subluxation, or dislocations in the vertebral bodies

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