The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Lindsey R. Baden, M.D., Editor

Spontaneous Retropharyngeal Hematoma

A B C

A
56-year-old man presented to the emergency department with Noah Ditkofsky, M.D.
a 5-hour history of throat swelling and pain and difficulty breathing that University of Toronto
was exacerbated by supine positioning; he had not had any obvious ante- Toronto, ON, Canada
cedent trauma. His medical history included prostate cancer, hypertension, hyper- noah.ditkofsky@sunnybrook.ca
lipidemia, deep-vein thrombosis, and stroke. Medications included warfarin (pre- Tarek Hanna, M.D.
sumably for deep-vein thrombosis), antihypertensive agents, and a statin. He was
Emory University
afebrile, and the physical examination was notable for minor swelling of the Atlanta, Georgia
posterior oropharynx. Laboratory studies revealed a normal white-cell count, an
international normalized ratio of more than 11, a prothrombin time of more than
120 seconds, and an activated partial-thromboplastin time of 127 seconds. Radiog-
raphy of the neck revealed marked soft-tissue swelling that was causing mass ef-
fect on the airway (Panel A); the findings on a subsequent computed tomographic
scan of the neck were consistent with a retropharyngeal hematoma, which was
probably caused by supratherapeutic anticoagulation (Panel B shows the sagittal
view, and Panel C the axial view; the arrow in each panel indicates the hematoma).
Transnasal laryngoscopy revealed a bulging posterior pharynx but a patent airway.
The patient was administered 6 units of fresh-frozen plasma and was admitted to
the intensive care unit for observation. His coagulopathy resolved, as did his symp-
toms, and he was discharged 4 days after admission.
DOI: 10.1056/NEJMicm1505596
Copyright 2016 Massachusetts Medical Society.

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