What is the management for a hematoma just above the arytenoids on the posterior pharyngeal wall?

Management of Hematoma Above the Arytenoids on Posterior Pharyngeal Wall

For a hematoma just above the arytenoids on the posterior pharyngeal wall, immediate airway assessment and management is critical, with evacuation of the hematoma if there are any signs of airway compromise. 1

Initial Assessment and Management

• Immediately administer supplemental oxygen if there are concerns about the hematoma 1
• Position patient in head-up position to optimize airway patency 1, 2
• Assess for signs of airway compromise using the DESATS approach: Difficulty swallowing/discomfort; increase in Early warning score; Swelling; Anxiety; Tachypnea/difficulty breathing; and Stridor 2
• If signs of airway compromise (arterial oxygen desaturation, difficulty breathing, stridor, tachypnea) are present, immediately call for help and proceed to hematoma evacuation 1

Urgent Management

• Arrange immediate senior surgical review (ENT specialist/consultant); if not immediately available, arrange senior anesthetic review 1, 2
• Perform flexible endoscopic laryngeal assessment by an experienced operator to evaluate the extent of the hematoma and airway patency 1
• Consider intravenous dexamethasone to reduce upper airway edema and tranexamic acid to reduce bleeding 1, 2
• Increase frequency of observations if there are ongoing concerns about potential hemorrhage 1, 2

Hematoma Evacuation

• If the patient shows signs of airway compromise due to the hematoma, a systematic approach should be taken to evacuate the hematoma 1
• For retropharyngeal hematomas specifically, surgical drainage may be required if the hematoma is large or fails to reabsorb 3
• The SCOOP approach (developed for thyroid surgery but applicable to neck hematomas) includes: Skin exposure; Cut sutures; Open skin; Open muscles; Pack wound 1
• Local anesthetic infiltration is not required when opening the wound in emergency situations 1

Airway Management

• If evacuation fails to stabilize the patient with ongoing airway compromise, emergency tracheal intubation must be considered 1
• Consider videolaryngoscopy at the first attempt of tracheal intubation 1
• In time-critical settings with imminent life-threatening airway compromise, attempt tracheal intubation after evacuation of the hematoma 1
• Use a smaller tracheal tube and/or adjuncts such as a bougie to facilitate intubation 1
• Confirm successful intubation with capnography 1
• Multiple attempts at intubation may exacerbate laryngeal edema - consider early progression to front-of-neck airway if difficulties arise 1

Critical Considerations

• Stridor may be a late sign of airway compromise and warrants immediate management 2
• Retropharyngeal hematomas are clinically important due to their proximity to the upper airway - any swelling can cause the posterior pharyngeal wall to bulge anteriorly into the airway 3
• In cases of poor direct visualization of the glottis, decompression of the airway by opening the surgical incision may facilitate intubation 4
• Smaller hematomas without airway compromise may be observed with close monitoring, while larger hematomas require drainage 3
• Emergency front-of-neck airway equipment, including a scalpel (number 10 blade), bougie and tracheal tube must be immediately available 1
• In a cannot intubate, cannot oxygenate situation, scalpel cricothyroidotomy or emergency tracheostomy are preferred to cannula cricothyroidotomy 1, 5

Monitoring and Follow-up

• Monitor vital signs and airway patency closely, with frequent observations tailored to the patient's condition 1, 2
• Ensure patients are nursed in a bed where they can easily attract attention of nursing staff 2
• Monitor for subtle signs of complications including agitation, anxiety, difficulty in breathing, and discomfort 2
• Consider transfer to operating theater, post-anesthesia care unit (PACU) or ICU for close observation if the patient is stable but there are ongoing concerns 1