Mind the gap: life-threatening retropharyngeal haematoma resulting in acute airway obstruction following blunt trauma by closing train carriage doors

Abstract

Delayed life-threatening airway obstruction due to venous injury following blunt, non-penetrative trauma to the neck. A rare case of rapid force, blunt trauma by closing train carriage doors, leading to injury to the left internal jugular vein, subsequent retropharyngeal haematoma and airway obstruction. There was a significant delay of a few hours between injury and acute deterioration. Initial dual phase CT (unenhanced and arterial) studies identified the large retropharyngeal haematoma but the assessment of the source was inconclusive likely due to the venous injury becoming compressed by the swelling/haematoma at the time of investigation. Subsequent triple phase (unenhanced, arterial and venous) studies were performed identifying a flap in the left internal jugular vein as the likely site of vascular injury. A venous origin of haemorrhage supported the patients delayed onset of symptoms following the injury. We suggest with blunt force trauma to the neck, in the context of suspicion of haematoma and airway compromise, the radiologist should consider protocolling a triple phase (unenhanced, arterial and venous) angiographic study.

Figure 1.

Extensive retropharyngeal haematoma effacing the larynx and supraglottic airway anteriorly.

Figure 2.

Inferior extension of the haematoma, extending down the ‘danger’ space into the mediastinum.

Figure 3.

Luminal irregularity of the left IJV.

Figure 4.

(a, b) Luminal disruption again noted at the left internal jugular vein.

Figure 5.

Significant reduction in size of the retropharyngeal haematoma, with new rim enhancement suggestive of infection.