Case report: mediastinal hematoma secondary to hypertension, presenting as a retropharyngeal space abscess

The majority of retropharyngeal hematomas described in the literature have been associated with anticoagulation therapy, tumors, aneurysm, infection or cervical spine injury. We present a case of a 55-year-old African American female with acute chest pain, sore throat, and dysphagia. Her past medical history was significant for uncontrolled hypertension and cervical spine arthritis. Physical exam was significant for posterior pharyngeal edema and her labs indicated mild leukocytosis. Contrast-enhanced CT scan of the neck demonstrated an extensive retropharyngeal fluid collection with mediastinal extension, concerning for an abscess. A trans-oral and trans-cervical incision and drainage of the presumed abscess revealed clotted blood and venous ooze. Penrose drains were placed in the retropharyngeal space to allow for spontaneous drainage over the next two days. The patient was kept intubated for 8 days to ensure a secure airway while venous ooze was allowed to self-tamponade. Antihypertensive medications were utilized to control her labile blood pressures. To our knowledge this is the first case report of uncontrolled chronic hypertension as the etiology of a spontaneous mediastinal venous hematoma with presentation as a retropharyngeal space fluid collection. When evaluating retropharyngeal space occupying lesion with mediastinal extension, consideration should be given to mediastinal venous plexus bleeding. Treatment involves securing the airway, drainage, and control of blood pressure.