Background: Cervical trauma can be associated with C-spine injury and the airway may be compromised by disruption, edema or hematoma. It can cause life-threatening airway obstruction, but sometimes the clinical onset may be delayed for days.
Case Report:77 years old man with ankylosing spondylitis, hypertension, CPOD, on anti-platelet therapy, was admitted on hospital due to neck pain 4 days after a fall. At arrival he had GCS 15, respiratory distress, dysphonia and dysphagia. He had a cervical collar, limited mouth opening, Mallampati IV and an exuberante cervical and periorbital hematomas. We called ENT and Neurosurgery teams. Cervical CT scan revealed a C4 fracture and a C3-C6 prevertebral soft tissue mass compressing the airway. The multidisciplinary team decided to perform an urgent tracheotomy under monitored anesthesia care, with spontaneous breathing and bimanual in-line stabilization of cervical spine. A following videolaryngoscopy showed an extremely
narrowed supraglottic opening. 3 days later a posterior C2-C6 cervical fixation was performed. He stayed in the ICU 3 weeks under ventilatory support for hematoma’s reabsortion, transferred to the neurosurgical ward and 2 months later he was discharged with reestablished airway and respiratory functions and mild neurologic deficits.
Discussion: Retropharyngeal space hemorrhage is commonly associated with blunt cervical trauma and anticoagulant therapy and can cause airway obstruction. The choice between primary surgical airway, awake intubation, rapid sequence induction and watchful waiting without intubation is a clinical decision that depends on patient’s condition, material and human resources. Awake fiberoptic intubation is usually the first strategy, however, without the anesthesiologist expertise and with severe glottic stenosis, the risk of hematoma’s dislodge was too high. In teamwork we decided surgical airway was the best approach.
Learning points:
· Cervical hematoma may rapidly progress to lethal airway obstruction.
· Be aware of associated spinal injuries.
· The first step is establishing definitive airway control.
· A multidisciplinary approach privileging patient’s security is the key for success.
References:
1. Lazzot L et al. Severe upper airway obstruction due to delayed retropharyngeal hematoma formation following blunt cervical trauma. BMC Anesthesiology. 2007; 
2. Levy J. Management of the Traumatized Airway. Anesthesiology. 2016 Jan; 124

07 / Dyspnea and neck pain 4 days after a fall – should we hurry? – A case report