Retropharyngeal haematoma with subtotal upper airway obstruction after puncture attempt: a case report

Abstract

Mechanical complications during central catheterisation occur in approximately 15% of cases. This report describes a potentially fatal yet avoidable complication and highlights the typical radiological features of a retropharyngeal haematoma.

A patient with acute myeloid leukaemia was admitted to the intensive care unit with respiratory distress immediately after an attempt to insert a subclavian catheter without ultrasound guidance. A computed tomography scan revealed nearly complete obstruction of the upper airway by a retropharyngeal haematoma, with a blush of contrast agent. There was also a mass effect on the trachea and mediastinal structures. The haematoma was caused by accidental puncture of the thyrocervical artery. The patient’s condition improved following orotracheal intubation, transfusion of platelets and fresh frozen plasma, arterial radio-embolisation, and clinical monitoring of haematoma resorption, which restored airway patency.

A retropharyngeal haematoma is a potentially lethal complication, and its treatment carries significant risks. Therefore, central catheter insertion should likely not be attempted without ultrasound guidance to avoid serious complications for patients.

Introduction

Mechanical complications during central catheter placement occur in approximately 15% of cases.^1,2 Although these complications are more frequent with subclavian punctures, subclavian access is associated with a lower risk of infection. The most common complications include pneumothorax and haemorrhagic events, such as haematomas or arterial punctures, which can sometimes result in retropharyngeal haematomas (RHs).

In this report, we describe a case involving a 62-year-old patient who developed respiratory distress due to airway compression by an RH following the placement of a central subclavian catheter. It is important to note that subclavian puncture is contraindicated in patients with severe coagulation disorders. Although RHs are rare, they are potentially fatal because they can lead to compression of cervical structures, necessitating urgent treatment. The diagnosis is clinical and is confirmed by imaging studies. We present this case because to our knowledge, it is the first in the literature to describe subclavian catheter placement complicated by an RH. Furthermore, although it is a rare complication and potentially fatal, early identification and treatment can lead to favourable outcomes.

Case report

The patient was a 62-year-old woman who was not on long-term treatment and was fully independent at home. Her medical history began with a progressively worsening anaemia syndrome, which prompted her to consult her general practitioner on 20 March. Laboratory tests revealed hyperleucocytosis of 79 g/L with 80% blasts, leading to a diagnosis of acute myeloblastic leukaemia with disseminated intravascular coagulation. The patient provided verbal informed consent prior to the initiation of treatment after receiving full information about the treatment, risks of adverse events, and risks if treatment was not performed.

She was admitted to the haematology ward, where a central subclavian catheter was to be inserted under the cover of an intravenous infusion of fresh frozen plasma (on that day, her platelet count was 61 g/L, haemoglobin was 7.5 g/dL, and prothrombin time was 60%). However, the catheter placement was attempted without ultrasound guidance and was unsuccessful, resulting in the development of a right cervical haematoma that caused decubitus dyspnoea, dysphagia, and a nasal-like dysphonia. Immediate management included transfusion of platelet concentrate and fresh frozen plasma. Cervicothoracic computed tomography (CT) angiography (Figure 1) revealed a large haematoma in the right subclavicular and supraclavicular soft tissues, measuring 10 × 5 cm in the axial plane and exhibiting contrast medium extravasation during the arterial phase. There was significant haematic infiltration extending into the upper mediastinum, right axilla, right jugulocarotid region, and notably the retropharyngeal space. This resulted in a mass effect that reduced the calibre of the pharyngolaryngeal tract and oropharynx and caused leftward deviation of the trachea, oesophagus, and thyroid parenchyma. The right internal jugular, subclavian, and axillary veins were not opacified due to the mass effect exerted by the haematoma. The thoracic CT scan ruled out haemothorax, pneumothorax, and haemopericardium. There was no indication of air embolism based on the patient’s history.

Figure 1.

Cervicothoracic computed tomography scan with contrast agent. Label A illustrates the sagittal view showing near-total obstruction of the pharyngolaryngeal tract and oropharynx caused by the retropharyngeal haematoma. Label B highlights the contrast agent blush within the haematoma during the arterial phase of injection, indicating active bleeding. Label C demonstrates the mass effect exerted by the haematoma, resulting in mediastinal lateral deviation to the left.

Upon admission to the intensive care unit (ICU), the patient developed respiratory distress in the decubitus position and dysphonia. Management included intubation under videolaryngoscopy, transfusion of red blood cells, and vasopressor support with noradrenaline for 48 hours. The patient was then transferred to the interventional radiology suite, where catheterisation of the right subclavian artery was performed. No contrast extravasation was observed; however, catheterisation and embolisation of the distal branch of the thyrocervical artery with resorbable gelatine were carried out. Probabilistic antibiotic therapy was initiated because of a fever of 39.6°C. However, the therapy was discontinued 72 hours later because the patient remained asymptomatic and microbiological samples were sterile. The fever was attributed to the haematoma.

Mechanical ventilation was continued for 6 days because the initial leak test results were unfavourable. However, the patient’s condition improved, and extubation was successfully achieved with the use of corticosteroid aerosols to prevent laryngeal dyspnoea. No follow-up imaging was conducted because of the positive clinical evolution. The patient was discharged from the ICU and returned to the haematology ward on 9 April. Written informed consent was obtained from the patient for the publication of this case report. The reporting of this study adheres to the CARE guidelines.

Discussion

We have herein described a life-threatening complication of central venous catheterisation characterised by typical radiological features. The risk of arterial puncture during the placement of a central venous catheter is estimated at 4.7%, with a haematoma risk of 0.8%. ²

This case illustrates that despite the use of ultrasound guidance, mechanical complications remain inherent risks of these procedures. ³ We believe that while ultrasound guidance, as is now recommended, ⁴ could have mitigated some risks in the present case, the chosen insertion site was suboptimal because of the patient’s haemostasis disorders and the inability to compress the area in the event of an arterial puncture. Unfortunately, this led to the worst-case scenario: the development of an RH causing airway obstruction, necessitating transfer to the ICU.

RHs are rare and most often result from trauma. ⁵ Other causes include infections, ingestion of foreign bodies, cervical surgery, and anticoagulant therapy. Cases of spontaneous RHs have also been reported.^6–8 When RHs occur after catheterisation attempts, accidental arterial puncture should be suspected because it may not be immediately apparent. ⁹

Although several cases of RHs following internal jugular venous puncture have been described,^10,11 a compressive haematoma after subclavian puncture has not been previously reported in the literature.

This condition is particularly dangerous because the pharyngeal muscles are not resistant to haematoma expansion due to their anatomical attachments. Haematoma expansion can lead to compression of cervical structures, resulting in dysphagia, dysphonia, dyspnoea, respiratory distress, cardiorespiratory arrest, and death. ¹¹ Diagnosis is initially clinical and is then confirmed by imaging (X-ray, ⁹ ultrasound, ¹¹ Doppler ultrasound, ¹⁰ CT scan, or CT angiography). Management typically involves interventional radiology ¹⁰ or surgery ⁹ and tracheal intubation to maintain airway patency.

Follow-up relies on visual assessment, leak tests in patients undergoing mechanical ventilation, and sometimes radiological evaluation. ¹⁰

This complication might have been prevented in our case by placing subclavian catheters under ultrasound guidance ⁴ and adhering to contraindications for this approach, such as severe haemostasis disorders (platelet count of <50 g/L or prothrombin time of <30%). ⁴ Indeed, central catheter placement under ultrasound guidance reduces the risk of failure and complications. ³

Our strengths in managing this case were consistent with literature recommendations, involving both symptomatic (mechanical ventilation) and etiological (interventional radiology) treatments, which led to rapid recovery. However, optimal management would have included radiological follow-up in addition to clinical monitoring.

In conclusion, the occurrence of this RH necessitated invasive care, which carried a high risk of iatrogenic complications including exposure to antibiotics, risky ventilation and intubation, general anaesthesia, and vasopressor administration. These treatments pose significant risks in addition to the life-threatening nature of the RH itself.