Because of the uncertain cause of the mass and the history of recent (last dose unclear) clopidogrel ingestion, rather than performing surgery emergently and during the off hours as originally envisioned, a discussion involving radiologists, otolaryngologists, cardiologists, and anesthesiologists as to the proper timing for surgery was held. The issue of clopidogrel inhibiting platelet function and potentially placing him at risk for excessive intraoral bleeding (without a clear diagnosis of either tumor, infection, or hematoma) during tracheal intubation or surgery (and the potential need for rapid surgical airway or blood, blood products, or platelets) was balanced with the concern for progressive loss of airway patency and possible stent thrombosis. However, since the condition of the airway appeared stable, he was admitted to the intensive care unit for observation, steroid administration, and a clopidogrel washout. Because of the issue of possible stent thrombosis, he was seen by the cardiology service for their assessment of this risk. Given the 8-year interval since placement of the drug-eluting stent, his excellent exercise capacity, and the low- to intermediate-risk surgical procedure, they felt it acceptable to withhold clopidogrel for a “short” period of time. After 48 hours (an admitted arbitrary decision made by the otolaryngology team, 5–7 days is suggested),4 he was brought to the operating room, and after awake fiberoptic tracheal intubation (using dexmedetomidine for sedation and aerosolized lidocaine for topical anesthesia followed by propofol, rocuronium, fentanyl, and sevoflurane) surgery (approached through a submandibular incision) revealed a 4 cm × 4 cm firm organized hematoma in the retropharyngeal space. This was evacuated, and a large osteophyte directly underneath the hematoma was removed with rongeurs. Bleeding was minimal and easily controlled, and after tracheal extubation the following day, complete resolution of his dysphonia and dysphagia had occurred.
He was discharged home on the second postoperative day and resumed taking aspirin and clopidogrel.
Spontaneous retropharyngeal hematomas are a rare cause of upper airway compression. Patients may present with the classic triad described as tracheal and esophageal compressive symptoms, ventral tracheal displacement detected on lateral cervical radiograph, and bruising in the anterior neck and upper chest regions.6 The most common cause of acute retropharyngeal hematoma is cervical trauma7 and is frequently associated with cervical spine fracture. However, retropharyngeal hematomas may also follow infection, cervical spine surgery, injury to the great vessels, traumatic endoscopy, and foreign body ingestion.8 Additionally, factors such as anticoagulation or an intrinsic bleeding disorder may increase the likelihood of a retropharyngeal hematoma.8
The most common complication associated with oral anticoagulants is untoward bleeding, with the upper aerodigestive tract being an uncommon site of involvement.9 Nine cases of warfarin-associated retropharyngeal hematoma have been documented, with 3 of these cases progressing to airway compromise requiring urgent tracheotomy.10
The retropharyngeal space is located between the middle and deep layers of the deep cervical fascia that extends from the skull base to the upper mediastinum.11 The differential diagnosis of a retropharyngeal mass identified by CT imaging includes reactive adenopathy, nodal metastasis from head and neck cancers (melanoma, thyroid carcinoma), lymphoma, leukemia, direct invasion of squamous cell carcinoma, benign tumors (lipoma or hemangioma), retropharyngeal abscess, cellulitis, and edema.11
Management of retropharyngeal hematoma depends on the severity and cause of the symptoms. Some studies suggest early airway intervention, while others advocate close observation of patients in the intensive care unit with airway intervention only if necessary. However, there appears to be no consensus regarding passive management versus aggressive early airway intervention.12–14
In addition, because upper airway hematomas may be due to localized infection,15 some suggest a role for antibiotics in the treatment of retropharyngeal hematomas.16
Since spontaneous retropharyngeal hematomas are a rare cause of upper airway obstruction, patients at risk for hemorrhage (secondary to a preexisting medical condition or medication) with preexisting cervical spine pathology should be viewed with greater concern and may require emergent intervention to secure the airway. In the setting of altered hemostasis, waiting for in vitro laboratory tests to return to normal (either through the use of reversal agents/blood products) must be balanced with the constant possibility of acute airway compromise. In the face of recent clopidogrel ingestion, waiting for the ideal time to operate may be a challenge even though there are commercially available tests of the P2Y12 receptor blockade. These include VerifyNow® (Accriva Diagnostics, Piscataway, NJ), or thromboelastography/thromboelastometry (TEG®, Hema scope, Skokie, IL), or ROTEM (Tem International GmbH, Munich, Germany). However, acceptance of these testing modalities demonstrating return of normal platelet aggregation function has not gained enough widespread popularity to represent “standard of practice” to assist in clinical decision making. Therefore, 5 to 7 days are needed for new platelets to be formed and properly function (this timeframe may need to be extended if the patient had ingested ticlopidine)3; if clinical circumstances dictate the need for earlier surgery with a low risk of thrombosis, the waiting period may, as was the case with our patient, be shortened. The risk of coronary artery stent thrombosis is greatest within the first year of stent placement especially for a drug-eluting stent. Treatment with dual antiplatelet therapy decreases this risk. If such a patient is to undergo a procedure where there is a high risk of bleeding, bridging therapy may need to be considered.3 Ideally, patients receiving clopidogrel will have their platelet function tested perioperatively4 to reduce the risk of procedural (neuraxial) and intraoperative bleeding. This may assist in minimizing the exposure time for stent closure due to thrombosis and determine normal platelet activity to obviate the unnecessary exposure to allogenic platelets (and the risks associated with such transfusions) in the treatment of intraoperative bleeding.
The authors thank Dr. Roman Schumann for his thoughtful comments during manuscript preparation.
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© 2014 International Anesthesia Research Society
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