Internal Jugular Vein Injury and Retropharyngeal Hematoma: A Critical Insight into Blunt Neck Trauma

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Keywords: Internal Jugular Vein Injury, Retropharyngeal Hematoma, Blunt Neck Trauma, Airway Compromise, Pharyngeal Space

The management of blunt neck trauma presents a formidable challenge in emergency medicine and trauma surgery. While arterial injuries receive considerable attention due to their immediate and catastrophic potential, venous injuries, particularly to the internal jugular vein (IJV), are often under-recognized and can lead to delayed, yet equally life-threatening complications, such as a rapidly expanding retropharyngeal hematoma. This column delves into a compelling case study, offering a world-class expert perspective on the pathophysiology, clinical features, imaging characteristics, and management strategies for this rare and critical condition, drawing upon the latest global literature.

Case Study: Delayed Airway Compromise Following Blunt Neck Trauma

The provided case study illustrates the insidious and dramatic progression of an Internal Jugular Vein Injury with subsequent Retropharyngeal Hematoma in an 83-year-old male.

Patient Presentation and Clinical Course

An 83-year-old male, with a history of Type 2 Diabetes Mellitus and controlled hypertension, presented to the emergency department (ED) with progressive difficulty breathing and swallowing (dysphagia). This followed an accidental neck trauma two hours prior, where his neck was caught in the closing doors of a subway car.

Initially, he only reported mild left neck pain, proportionate to the injury, and continued his journey. However, approximately 60 minutes later, the neck pain worsened. Crucially, 90 minutes post-injury, en route to the ED, he developed progressive inability to swallow his saliva (sialorrhea).

Upon arrival, he exhibited dysphagia, repetitive expectoration, and mild stridor. Within 10 minutes of ED arrival, signs of acute airway compromise rapidly progressed, including:

  • Rapidly developing bilateral neck swelling
  • Marked stridor
  • Voice changes (dysphonia)
  • Respiratory distress
  • Acute agitation

This rapid deterioration mandated immediate transfer to the resuscitation bay, with urgent requests for Anesthesia and Ear, Nose, and Throat (ENT) support. Immediate measures included high-flow oxygen via a non-rebreather mask and placement of a nasopharyngeal airway. The patient remained conscious but maintained an oxygen saturation ($SpO_2$) below 96% throughout. Given the urgency and complexity, the patient was intubated using an awake fiberoptic technique and rapid sequence induction, following a combined ENT and Anesthesia review. Direct visualization of the upper aerodigestive tract revealed extensive mucosal edema and copious secretions, but no visible hemorrhage or mucosal laceration.

Imaging Findings

Initial contrast-enhanced dual-phase computed tomography (CT) of the head and neck was performed to assess the extent of the injury.

The CT demonstrated diffuse opacification (average 65 Hounsfield Units [HU]) of the entire retropharyngeal ("danger") tissue space, extending from the skull base to the mediastinum. This resulted in a significant mass effect, obliterating the nasopharynx and supraglottic larynx anteriorly.

[Figure 1] (Axial CT) Extensive retropharyngeal hematoma(Red Star)

 


[Figure 2] (Axial CT) Inferior extension of the hematoma (Red Star)

 


[Figure 3] (Axial CT) Extensive retropharyngeal hematoma (Red Star) obliterating the larynx and supraglottic airway anteriorly.

 

[Figure 4] (Axial CT) Inferior extension of the hematoma along the "danger" space into the mediastinum.

No contrast extravasation or evidence of penetrating injury or acute fracture was identified. However, the initial arterial-phase imaging showed partial opacification of both internal jugular veins. A focal luminal irregularity, consistent with the injury site, was identified within the left Internal Jugular Vein (IJV). 

[Figure 5] (Axial CT) Luminal irregularity in the left Internal Jugular Vein (Red Arrow).

A repeat tri-phasic (non-enhanced, arterial, and venous phase) CT of the neck, performed approximately 5 hours later after stabilization in the ICU , again demonstrated the luminal irregularity in the left IJV, now deemed consistent with acute venous intimal tear.

 


[Figure 6] (Axial CT, A and B) Recurrent luminal collapse in the left Internal Jugular Vein (Red Arrow in A)

Diagnosis

The final diagnosis was Internal Jugular Vein Injury with subsequent Retropharyngeal Hematoma. The differential diagnosis included acute venous injury and arterial injury with hemorrhage.

Clinical Progression and Management

The patient required intubation and mechanical ventilation for 11 days for airway security. No immediate or delayed surgical intervention was required. A follow-up CT on day 3 showed persistent swelling, with the retropharyngeal hematoma maturing and persistent left IJV luminal injury. Importantly, the arterial branches remained intact.

On day 7, the patient developed a low-grade fever (37.5o C), with purulent discharge observed orally and a significant increase in C-reactive protein (CRP) from 6 mg/L to 137 mg/L. Delayed venous-phase CT of the neck and chest showed an overall reduction in the volume of the retropharyngeal hematoma, but the collection now demonstrated heterogeneous attenuation and focal rim enhancement, consistent with an infected hematoma. 

[Figure 7] (Axial CT) Significantly reduced size of the retropharyngeal hematoma (Blue Oval) with new rim enhancement (Red Arrow) suggesting infection.

Broad-spectrum antibiotics were initiated. The patient was discharged after a full recovery and followed up in the ENT outpatient clinic two weeks later.

Pathophysiology of Internal Jugular Vein Injury and Retropharyngeal Hematoma

The key to understanding this rare presentation lies in the unique anatomy of the venous system and the neck fascial planes.

I. Venous System Characteristics

The internal jugular vein (IJV) is a low-pressure system, possessing little to no elastic recoil in its intimal layer. Unlike the high-pressure arterial system, a breach in the venous wall may lead to a slower, more protracted blood loss. This explains the delayed onset of significant symptoms in the presented case.

II. The Retropharyngeal Space ("Danger Space")

The retropharyngeal space is a well-defined potential space, located between the thick prevertebral fascia (posteriorly) and the buccopharyngeal (visceral) fascia (anteriorly).

  • It extends superiorly to the skull base.
  • It extends inferiorly to the posterior mediastinum.
  • It is sometimes referred to as the "danger space" because it provides a direct path for infection or hemorrhage to disseminate from the neck into the chest.

Because it is a potential space, it can accommodate a large volume of fluid, such as blood from a venous tear, before the increased extravascular pressure compresses the bleeding point and causes the mass effect to manifest clinically. The location of the IJV, nestled within the carotid sheath lateral to the pharynx, means that bleeding from an IJV injury can readily track into the nearby retropharyngeal space.

The combination of slow venous bleeding and the capacity of the retropharyngeal space to contain a large hematoma explains the initial mild symptoms followed by the rapid, catastrophic onset of airway obstruction once the hematoma volume exceeds the accommodation capacity and begins to cause significant mass effect on the pharynx and larynx.

Epidemiology

Blunt neck trauma resulting in secondary venous injury is rare. The majority of acute airway compromise cases secondary to vascular injury in the neck are associated with arterial injuries following penetrating trauma. Isolated IJV injury due to blunt trauma, especially from a "transient" compression mechanism like a subway door, is exceedingly uncommon, with only a few cases described in the literature, typically involving sustained, significant compressive forces from motor vehicle accidents.

Clinical Presentation

The classic presentation of a massive retropharyngeal hematoma, regardless of etiology (arterial or venous), involves signs of acute upper aerodigestive tract compromise:

  • Dysphagia/Odynophagia: Difficulty or pain upon swallowing, often rapidly progressing to sialorrhea (inability to swallow saliva).
  • Airway Symptoms: Stridor (a harsh, high-pitched sound on inspiration) and dyspnea (shortness of breath).
  • Voice Changes: Hoarseness (dysphonia).
  • Neck Signs: Swelling and pain, which can rapidly expand.

The critical difference in venous injuries is the delayed onset of severe symptoms, as demonstrated by the 90-minute lag time in this case. Given the life-threatening nature of the potential airway obstruction, these symptoms mandate immediate attention and securing of the airway.

Imaging Features and CT Protocol

Imaging Protocol

In the context of blunt neck trauma, especially with acute upper aerodigestive tract signs or symptoms, a Tri-phasic (non-enhanced, arterial phase, and venous phase) CT angiography study is the recommended best practice.

  • Non-enhanced: To assess for acute fractures, air, and the initial density of the hematoma.
  • Arterial Phase: To evaluate for active arterial extravasation, dissections, or pseudoaneurysms.
  • Venous Phase: Crucial for identifying venous injuries, which may only show up as subtle luminal irregularities or partial opacification in the earlier phases.

Imaging Findings

  • Retropharyngeal Hematoma: The CT will show opacification (density typically around 50–70 HU) of the retropharyngeal space, often extending to the mediastinum. The key feature is the mass effect—anterior displacement and obliteration of the pharyngeal and laryngeal airspaces.
  • IJV Injury: May present as an intimal tear (focal luminal irregularity), thrombus, or a significant lack of opacification. Active venous extravasation is rare due to the spontaneous compression (tamponade) effect of the surrounding structures and the hematoma itself.
  • Complications: Subsequent imaging (as seen in the case study) may reveal features of an infected hematoma/abscess, which includes a reduction in overall volume but the presence of heterogeneous attenuation and rim enhancement.

Differential Diagnosis (DDx)

The primary differential diagnoses for a patient presenting with an acute, expanding neck mass and impending airway compromise following blunt trauma include:

  • Acute Venous Injury and Hemorrhage (Diagnosis in this case)
  • Acute Arterial Injury and Hemorrhage (e.g., Carotid or Vertebral Artery dissection/rupture). This is more common, particularly with penetrating trauma, and often presents more rapidly.
  • Fractures/Skeletal Injury (e.g., Cervical spine fracture with prevertebral hematoma).
  • Infection/Abscess (e.g., Acute retropharyngeal abscess), though this is less common in the immediate post-trauma setting but is a critical complication, as seen on Day 7.

Diagnosis

The diagnosis of Internal Jugular Vein Injury with subsequent Retropharyngeal Hematoma is based on the constellation of clinical presentation (blunt trauma, delayed and progressive airway compromise) and the characteristic findings on advanced imaging (CT) that confirm both the hematoma's location/extent and the underlying venous tear.

Treatment

The management of this condition is multi-disciplinary and follows two critical axes: Airway Management and Hemorrhage/Hematoma Management.

1. Airway Control (The Priority)

  • Definitive Airway: Establishing a definitive airway is paramount. Given the laryngeal mass effect and potential for edema, an awake fiberoptic intubation is often the safest approach, as performed in this case.
  • C-Spine Management: Minimal neck movement and manipulation are recommended to preserve cervical alignment and reduce the risk of further hemorrhage/spinal complications.

2. Hemorrhage and Hematoma Management

  • Conservative (Expectant) Management: In the absence of active contrast extravasation on CT, conservative management (e.g., observation, ventilation support) is often favored, as the hematoma itself often tamponades the bleeding (self-compression).
  • Surgical/Interventional Management: This remains controversial and is typically reserved for:
    • Failure of the hematoma to resolve.
    • Massive or rapidly expanding hematomas.
    • Infected hematomas (abscess formation).
    • Infected collections often require percutaneous or surgical drainage, though the trans-oral approach carries a higher risk of infection. In the case presented, the patient was successfully managed with broad-spectrum antibiotics for the infected collection.

Prognosis

The prognosis largely depends on the promptness and success of airway management. If the airway is secured effectively, the patient can often be managed conservatively, as the venous injury often self-tamponades. Despite the high morbidity associated with the prolonged intubation and the complication of an infected hematoma, the patient in this case made a full recovery demonstrating a good long-term prognosis when aggressive, multi-disciplinary management is instituted promptly.

Quiz

Question 1. What is the most common and immediate life-threatening complication associated with an expanding retropharyngeal hematoma following blunt neck trauma?

A. Hypovolemic shock

B. Acute arterial dissection

C. Acute airway obstruction

D. Spinal cord ischemia

E. Acute infectious spondylitis

Answer and Explanation:

C. Acute airway obstruction. The retropharyngeal space lies immediately posterior to the pharynx and larynx. As a hematoma expands within this space, the mass effect rapidly compresses the upper airway anteriorly, leading to stridor and acute respiratory failure, which is the immediate, life-threatening concern.

Question 2. Which of the following statements correctly describes the Retropharyngeal Space, also known as the "Danger Space"?

A. It is a "true" space that is always patent.

B. It is separated from the carotid sheath by the alar fascia.

C. It is bounded inferiorly by the level of the diaphragm.

D. It is a "potential" space that extends superiorly to the skull base and inferiorly to the posterior mediastinum.

E. It is located anterior to the visceral fascia.

Answer and Explanation:

D. It is a "potential" space that extends superiorly to the skull base and inferiorly to the posterior mediastinum. The retropharyngeal space is a potential space (A is incorrect) that only becomes visible when distended by fluid or pus. It extends from the skull base superiorly to the posterior mediastinum (T1-T6 level or as low as the tracheal bifurcation) inferiorly.

Question 3. A patient presents with delayed signs of upper airway compromise following blunt neck trauma. Which CT angiography protocol is most strongly recommended for evaluating potential vascular injury in this setting?

A. Non-enhanced CT only

B. Dual-phase study (Non-enhanced + Arterial Phase)

C. Dual-phase study (Non-enhanced + Venous Phase)

D. Tri-phasic study (Non-enhanced + Arterial Phase + Venous Phase)

E. Ultrasound with Doppler

Answer and Explanation:

D. Tri-phasic study (Non-enhanced + Arterial Phase + Venous Phase). For blunt neck trauma, especially with aerodigestive signs, a tri-phasic study is recommended. While the arterial phase is crucial for arterial injuries, the venous phase is essential to accurately identify subtle venous tears, which may be missed in the arterial phase.

References

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