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Upper airway obstruction due to retropharyngeal haematoma after posterior cervical spine surgery.

Mechanical airway obstruction secondary to retropharyngeal haematoma is a life-threatening emergency that should be anticipated in all patients with cervical spine injuries, regardless of the severity of trauma or surgery. We report the case of a woman with rheumatoid arthritis who developed a retropharyngeal haematoma that caused acute airway compromise after posterior cervical spine surgery.

A 44-year-old woman with a 20 year history of rheumatoid arthritis presented to our neurosurgery department with generalised weakness and walking disability. Her neurological examination revealed 2/5 power in her upper limbs and 4/5 power in lower limbs. She had significant limitation of neck extension, but there was no tenderness. Cervical X-rays showed basilar invagination consistent with the superior part of the odontoid proces being displaced into the foramen magnum. Interim cervical traction was applied and her neurological examination improved to 4/5 power in upper limbs. Surgical stabilisation of C1-C6 using a posterior approach in the prone position was planned.

The patient was anaesthetised in the supine position using propofol. Suxamethonium was used for muscle relaxation. The Cormack & Lehane classification was grade 3 and a 7.0 mm internal diameter endotracheal tube was inserted. The patient was then turned prone. Surgery and anaesthesia proceed uneventfully. At the end of the procedure, the remifentanil and sevoflurane were ceased and she was turned supine for extubation. Residual cisatracurium was reversed with neostigmine with atropine. Once her ventilation and conscious state were satisfactory, she was extubated. However, she immediately developed airway obstruction with inspiratory stridor and became cyanosed. A difficult intubation was anticipated, so a laryngeal mask airway was inserted. During ongoing laryngeal mask ventilation, chest and cardiovascular examination was normal, with no elevated airway pressures or wheeze. This elimintaed the possibility of postextubation bronchospasm or laryngospasm for her respiratory distress. She had no obvious neurological impairment. She was sedated with fentanyl and midazolam and transported to the intensive care unit for further management. In the intensive care unit she was was allowed to breathe spontaneously in bilevel positive airway pressure mode with mild pressure support and positive end-expiratory pressure 5 mmHg. A computed tomography scan demonstrated a parapharyngeal haematoma which displaced the posterior pharyngeal wall ventrally. A carotid angiogram showed normal vascular anatomy with normal blushing of the thyroid. No surgical intervention or re-exploration was required. However, as flexible laryngoscopy showed an almost totally obstructed pharyngeal passage, a surgical tracheostomy was performed. On the fifth day postoperatively a repeat computed tomography showed that the retropharyngeal haematoma had completely resorbed. After closure of the tracheostomy the patient was discharged to neurosurgery department on the seventh postoperative day.

The retropharyngeal space is a potential space that lies posterior to the buccopharyngeal fascia, anterior to the prevertebral fascia of the cervical and thoracic spine and extends laterally to the carotid sheaths. It begins at the base of the skull and terminates in the superior mediastinum (1,2). It is found posterior to the nasopharynx, oropharynx, hypopharynx, larynx and trachea. A haematoma in the space may push forward and occlude the airway at any of these levels. The mechanisms triggering haemorrhage into the retropharyngeal space are thought to be due to injury to the longus colli muscles on the anterior surface of the vertebral bodies, the anterior longitudinal ligament or the anterior muscular and spinal branches of the vertebral artery (3).

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Anaesthetists should have a high degree of suspicion about the possibility of a retropharyngeal haematoma in patients with acute airway compromise post-extubation after cervical spine surgery.

References

(1.) Emery SE, Smith MD, Bohlman HH. Upper-airway obstruction after multilevel cervical corpectomy for myelopathy. J Bone Joint Surg Am 1991; 73:544-551.

(2.) Sandooram D, Chandramohan AR, Radcliffe G. Retropharyngeal haematoma causing airway obstruction: a multidisciplinary challenge. J Laryngol Otol 2000; 114:706-708.

(3.) Heywood AW, Learmonth ID, Thomas M. Cervical spine instability in rheumatoid arthritis. J Bone Joint Surg Br 1988; 70:702-707.

E. Ozyuvaci

O. Akyol

D. V. Erden

S. D. Vatansever

G. D. Yilmaz

N. Toprak

Istanbul, Turkey
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Title Annotation:Correspondence
Author:Ozyuvaci, E.; Akyol, O.; Erden, D.V.; Vatansever, S.D.; Yilmaz, G.D.; Toprak, N.
Publication:Anaesthesia and Intensive Care
Article Type:Letter to the editor
Date:Jul 1, 2011
Words:668
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