A 90-year-old woman with chronic obstructive pulmonary disease; hypertension; chronic kidney disease; diastolic dysfunction; severe tricuspid regurgitation; and atrial fibrillation (AF), for which she was taking rivaroxaban, presented to the ED for evaluation of injuries she sustained during a fall. The patient’s family stated that she fell while walking with the assistance of a walker and landed on her face. There was no reported loss of consciousness. Upon arrival at the ED, the patient’s vital signs were: blood pressure, 188/105 mm Hg; heart rate, 91 beats/min; respiratory rate, 20 breaths/min; and temperature, 97.88°F (36.6°C). Oxygen (O2) saturation was 90% on room air, but increased to 98% after the patient received 10 L/min of O2 through a non-rebreather mask.
On physical examination, the patient was awake, alert, and oriented to person, place, and time, with a Glasgow Coma Scale score of 15. She was able to move all four extremities and had 4/5 motor strength in the upper extremities bilaterally, and 3/5 motor strength in the bilateral lower limbs, which her family reported was the same as her baseline. On pulmonary examination, the lungs were clear to auscultation bilaterally and had no stridor. On auscultation she had a regular rate, with no murmurs or rubs.
The patient had nasal bone tenderness with epistaxis that resolved spontaneously and did not require packing; she had no other facial tenderness. The oropharynx was clear. There was mild posterior midline tenderness over C5 and C6, but no skin ecchymosis or neck swelling. Along with the non-rebreather mask, the patient was placed in a neck collar while she awaited transport to radiology for computed tomography (CT) studies.
The CT scan of the cervical spine demonstrated a minimally displaced fracture of the right anterior arch, both sides of the posterior arch of C1, and a comminuted minimally displaced fracture involving the posterior arch and spinous process of C5, with mild retrolisthesis of C5 over C6.In addition, a retropharyngeal hematoma extending from C1 to C7 measuring 9.6 x 2.2 cm in the superior inferior and anteroposterior diameter was present, causing a mass effect on the oropharynx and hypopharynx (Figure).
Based on the CT findings, the patient was taken to the operating room (OR) where she underwent awake fiberoptic laryngoscopy. During transfer to the OR, the patient’s O2 dropped to 87%; however, after successful intubation without complication, O2 saturation improved to 95%. After intubation, the patient was admitted to the intensive care unit for observation, and rivaroxaban therapy was discontinued.
A CT scan of the neck postintubation showed a mild interval decrease in the retropharyngeal hematoma, but an increase in the anterior disc space at C5-C6 with mild retrolisthesis, which raised suspicion for an anterior longitudinal ligamentous injury. A repeat CT scan on hospital day 4 revealed a new bleed within the old retropharyngeal hematoma, with no increase in thickness or size of the initial hematoma. The head and neck surgical team kept the patient intubated while awaiting resolution of the hematoma, with no plan of surgery.
On hospital day 6, the patient was transferred to another facility for continued long-term care. She was transitioned to a tracheostomy 4 days later. Follow-up approximately 2 weeks after presentation confirmed complete resolution of the hematoma, and no surgical intervention was required.
Retropharyngeal hematomas are infrequent, but potentially life-threatening complications of cervical fractures, foreign body trauma, infection, violent coughing, and anticoagulation therapy.1 Although retropharyngeal hematomas associated with warfarin have been well described, to our knowledge, there are no reported cases associated with a direct oral anticoagulant (DOAC).2
Though multiple studies have supported the effectiveness and safety of DOACs for prevention of stroke and systemic embolism in patients with AF, the risk of hemorrhage still exists.3 Postmarketing surveillance studies of DOACs report an overall risk of bleeding comparable to warfarin. Gastrointestinal bleeding was found to be slightly higher in patients taking a DOAC compared to those on warfarin, but the risk of intracranial bleeding from DOACs was notably lower.3 With limited effective reversal agents, DOACs present a tremendous challenge in managing acute life-threatening hemorrhage.4
Signs and Symptoms
Patients with retropharyngeal hematomas can present with dyspnea, sore throat, dysphagia, or odynophagia. Neck tenderness and swelling can suggest a retropharyngeal hematoma.5 The diagnosis of a retropharyngeal hemorrhage is of clinical importance because of the possible threat of airway obstruction—which may not be initially detectable clinically, and depends on how quickly the blood fills the retropharyngeal space.1,6
Computed tomography with intravenous contrast is the imaging study of choice for diagnosing retropharyngeal hematomas in the emergent care setting, and can detect the presence of any associated vertebral facture.5,7,8 Lateral neck X-ray imaging can detect prevertebral swelling, but is not as sensitive as CT and may underestimate the extent of spinal injury; moreover, lesions or early bleeding may be missed.9 In the absence of vertebral fracture on CT imaging, magnetic resonance imaging should be considered to evaluate for possible associated ligamentous injury.9
Treatment and Management
Airway Management. Given the risk of progression to complete airway obstruction, the first step in managing retropharyngeal hematomas is to secure the patient’s airway. Even though the published literature recommends either endotracheal intubation or tracheostomy, the latter should only be considered as a last resort for patients on DOACs because of the increased risk of bleeding.
The fiberoptic approach to endotracheal intubation minimizes the risk of further trauma and rupture of the hematoma.1,10 Once the patient’s airway is secure, the hematoma can be managed conservatively with spinal immobilization and observation for resolution, which may take 2 to 3 weeks.6,11
Surgical Intervention. Some clinicians believe early surgical intervention leads to early recovery and a shorter hospitalization.12 Surgical intervention using a transoral or anterior cervical approach is recommended for large hematomas that fail to regress.6 Surgical intervention may be considered for patients taking warfarin after successful anticoagulation reversal is achieved using fresh frozen plasma (FFP) and vitamin K. However, due to the increased bleeding potential and limited reversal options, there is an increased risk of surgical complications in patients on DOACs.5
Direct Oral Anticoagulation Reversal
The anticoagulation effect of DOACs resolves after five half-lives from the last administered dose, which in the case of rivaroxaban, is between 1 to 2 days.13 Therefore, when emergent surgical intervention is required for a retropharyngeal hematoma, understanding the options and limitations of reversal agents is necessary.
Idarucizumab. Currently the only DOAC anticoagulation reversal agent approved by the US Food and Drug Administration, idarucizumab is only effective for reversing the anticoagulation effects of dabigatran.4,14
Prothrombin Complex Concentrate. Also referred to as factor IX complex, prothrombin complex concentrate (PCC) has been shown to correct prolonged prothrombin time in experimental models of bleeding. Although there is no clinical evidence for its use in DOAC-associated bleeding, PCC should be considered in life-threatening cases, including large or expanding prevertebral hematoma, or other cases in which the potential benefit outweighs the potential risk of thrombosis associated with PCC.4
Fresh Frozen Plasma. In the absence of PCC, FFP may be considered, though there are no data supporting its use as a reversal agent for rivaroxaban.15
Although a rare entity, retropharyngeal hematoma should be suspected in patients with cervical fractures or trauma, especially in the setting of anticoagulation. Early airway management should be considered in a patient with a retropharyngeal hematoma, as symptoms of airway obstruction may be insidious. In patients on DOACs, the potential benefit of earlier resolution with surgical intervention must be strongly weighed against the increased risk of bleeding.