中華放射醫誌　Chin J Radiol 2005; 30: 283-287 283

The neck connects the head with the trunk, and iseasily injuried due to trauma. Herein we reported acase with diffuse neck swelling after car accident.She suffered from progressive dyspnea and cyanosis3 hours after the accident and needed airway main-tenance with tracheostomy. A plain lateral radi-ograph and computed tomography scan of the neckshowed diffuse edema at deep neck spaces. Wereviewed the medical literature on this subject, dis-cussed the possible causes and management of theneck swelling.

Key words: Angioedema, Cervical Injury,Lymphedema, Neck Swelling, Whiplash Injury

The neck serves as the communication betweenthe head and body, and contains important vital struc-tures. The retropharyngeal space is a compact spacelocated dorsally to the pharynx. Any cause of swellingin the retropharyngeal space may cause compressionon the airway. Up to date, approximately 50 cases ofthe traumatic airway obstruction due to retropharyn-geal hematoma have been reported in the literature [1];however, most of them did not have diffuse edema atthe soft tissue and third space (interstitial/potentialspace). Herein we presented a patient with remarkableneck swelling after accident and discussed the possiblecauses and the management of such neck swelling.

CASE REPORT

A 49-year-old woman dropped accidentally ontothe improperly positioned platform in a mechanicalparking garage, which was about three-story lowerthan ground. Three hours later she was rescued andsent to our Emergency Room (ER). At presentation shewas alert and oriented and did not complain ofdyspnea, dysphagia or hoarseness. Mild swelling atanterior neck was present but there was neitherobvious skin bruise nor petechia over the neck.Neurological examination revealed sensory abnormali-ties and decreased muscle power in the upper extremi-ties, worse in the distal forearms.

She was brought to the Radiology Department forplain radiographs of her cervical spine; however, shedeveloped dyspnea progressively and then cyanosisduring waiting. Oral endotracheal intubation wasdifficult due to deep neck swelling, and she underwenttracheostomy. A plain lateral radiograph (Fig. 1) andcomputed tomography (CT) scan (5 mm slicethickness) (Fig. 2) of the neck showed diffuse edema atdeep neck spaces, especially the retropharyngeal space.The airway was obliterated from the level of thesecond cervical vertebra to the cervicothoracicjunction. There was neither cervical bone fracture norextravasation. Magnetic resonance (MR) images of thecervical spine showed subtle abnormal signal intensityat the cervical cord around C5-6, high signal intensityon T2 weighted image (T2WI) and low signal intensity

Reprint requests to: Dr. Kou-Mou HuangDepartment of Medical Imaging, National TaiwanUniversity Hospital.No. 7, Chung Shan S. Road, Taipei 100, Taiwan, R.O.C.

Diffuse Neck Swelling after Car AccidentHUAN-WU CHEN

1 SHENG-CHAU HUANG1 HUAN-WEN CHEN

2 KOU-MOU HUANG1

Departments of Medical Imaging1, National Taiwan University HospitalDepartment of Internal Medicine2, Lo-Tung Poh Ai Hospital

on T1WI, consistent with spinal cord edema. Directlaryngoscopy revealed a symmetrical pharyngeal wallswelling and normal vocal cords.

She was admitted to the intensive care unit andmanaged with intravenous corticosteroid. Because ofearly improvement of neck swelling and neurologicaldeficits, the corticosteroid was tapered and tra-cheostomy tube was removed on the seventh andeighth day respectively. She was discharged on theseventeenth day in good condition.

DISCUSSION

The neck contains important vital organs,including trachea, esophagus, major blood vessels,peripheral nerves and the spinal cord, which connectthe head and the body. The retropharyngeal space ismore important than other spaces in the neck becausethis compact space is located dorsally to the airway.Regardless the causes of swelling in this space, it mayresult in airway obstruction.

After a thorough search of the medical literature,there are five major etiologic categories of neckswelling: (1) angioedema [2-4], (2) vascular lesion [1,5-8], (3) infection [9], (4) denervation [10], (5) lym-phedema [5, 11]. This patient developed dyspnea andcyanosis three hours after the accident. She could notrecollect the details about the accident; thus, we didnot know the mechanism of the trauma. Due to traumahistory and without evidences of infection symptomand sign, only three categories should be considered:angioedema, hematoma or lymphedema.

This patient in the car fell down from a three-

story height to the basement floor. In this kind ofcollision, the safety belt fixed the body and the patientunderwent flexion of the cervical spine, which wasfollowed by hyperextension, so-called “whiplashinjury” [12]. The forceful motion of head and neckleads to contusion and laceration of the soft tissues [6]

Diffuse neck swelling284

Figure 1. Lateral cervical spine radiograph showedmarked widening of the retropharyngeal soft tissue andextensive hypopharyngeal airway compression.Endotracheal tube was intubated via tracheostomy. Therewas a partial block vertebra of C5-C6

Figure 2. Contrast enhanced axial CT scan (5mm slice) at the C2 vertebral level a. and C3 vertebral level b. showeddiffuse edema with the airway obscuration at the retropharyngeal, parapharygeal and bilateral carotid spaces. Visceralspace was spared.

2a 2b

and tear the vessels [8] or the microcirculations,including lymphatic or capillary destructions [1, 7,13], which induce the fluid or blood accumulations inthe third space. Hematoma is commonly first consid-ered when an upper airway obstruction after traumaticinjury is encountered [1, 5-8]. However, on her arrivalat our ER, there was no common sign of directcontusion, such as skin bruise and petechia over theneck. There was neither hyperdense fluid collectionnor contrast extravasations on the CT imaging. As aresult, hematoma was not likely.

In this patient, CT scanning showed low densityat the neck outside the muscle and major vascularstructures, compatible with fluid collection. However,airway obstruction due to simple soft tissue edema isuncommon following trauma because the amount oflocal tissue is too small to cause significant edematousswelling [14]. Acute lymphedema may be anotheretiology, and it can occur soon or several hours afterneck injury or post-operation of radical neck lymphnode dissections [5, 11]. It may be caused by distur-bance of lymphatic flow due to trauma or operation.Usually, management of the lymphedema itself is notnecessary and it could take several weeks to developcollateral venous and lymphatic drainage to relievespontaneously [5, 6]. In this patient, the neck swellingreduced in one week; perhaps, the lymph microcircu-lation was partially torn and could recover faster thanthat in the cases of radical neck lymph node dissec-tions.

Angioedema (or angioneurotic edema) is a hered-itary or acquired disorder predisposing the patient todiffuse submucosal and/or subcutaneous swelling. It istypically manifested in the head and neck, resulting ina significant risk in airway compromise. There arethree main etiologic categories: allergic reaction tofood or drugs, hereditary, and idiopathic [3, 15].Allergic reaction is the most common cause forangioedema, but about 25% of patients have no clearcause [3]. Although this patient has had no furtherincidents of angioedema and did not take any medica-tion or food before driving, mechanical trauma oremotional stress is another precipitating factor [2, 16].However, swelling of the tongue and visceral space isperhaps the most clinical obvious sign distinguishingangioedema from other categories [2], which is notseen in this patient.

The diagnosis of retropharyngeal swelling relieson clinical examination and radiographs. Except forhematoma, increased index of suspicion of the possi-bility of airway obstruction secondary to massive lym-phedema or angioedema after neck injury is needed.When the patient with suspicious neck injury arrive

the ER, no matter respiratory distress or not, the pha-ryngeal mucosa should be examined first beforehe/she undergoes imaging study, which was alsosuggested by Brown and Millar after radical neck dis-section [13]. If the mucosa appears edematous orswelling, there may be a higher risk of developing anairway obstruction. The prudent treatment is necessaryto eliminate occurrence of airway obstruction, such asclose observation and monitoring at the intensive careunit, endotracheal intubation or tracheostomy [13]. Ingeneral, the retropharyngeal soft tissue shouldmeasure no more than one third to one half of thewidth of the cervical vertebra [7]. An increased widthof the soft tissue in retropharyngeal space on lateralradiographs would also suggest an abnormal finding.In addition, CT scan is a powerful modality whichdetects the retropharyngeal pathology more accurately.

The most important management of acute-onsetneck swelling is to secure the airway. Generally, thefirst choice is oral endotracheal intubation [1], but itmay be difficult due to anatomic distortion caused byneck swelling, such as for this patient. Tracheostomyis advocated if oral endotracheal intubation is impos-sible [8, 17]. If there is no experienced physician fororal intubation or tracheostomy, needle cricothyroido-tomy is another safe and quick method to reestablishthe airway [17]. Management of the lymphatic micro-circulation tearing or small hematoma themselves isnot necessary, and the patient could receive observa-tion until it relieves spontaneously over a 2 to 3-weekperiod of time [5, 6]. Large hematoma requiressurgical intervention for drainage [6].

CONCLUSION

If a patient comes from the scene of the trafficaccidence, a high index of suspicion of airwayobstruction is crucial. Before imaging study, goodevaluation and proper management including protec-tion of the airway are suggested. We believe thatclinician and radiologist should consider this poten-tially life-threatening condition in any patient withneck injury and familiarize themselves with thetechnique of airway protection, especially the needlecricothyroidotomy. ◆

REFERENCES

1. Suzuki T, Imai H, Uchino M, et al. Fatal retropharyn-geal haematoma secondary to blunt trauma. Injury2004; 35: 1059-1063

2. Krnacik MJ, Heggeness MH. Severe angioedema caus-ing airway obstruction after anterior cervical surgery.Spine 1997; 22: 2188-2190

Diffuse neck swelling 285

3. Zirkle M, Bhattacharyya N. Predictors of airway inter-vention in angioedema of the head and neck.Otolaryngol Head Neck Surg 2000; 123: 240-245

4. Kaneaster SK, Kim JC, Amedee RG. Angioedema ofthe head and neck. J La State Med Soc 2001; 153: 446-450

5. Daniello NJ, Goldstein SI. Retropharyngeal hematomasecondary to minor blunt head and neck trauma. EarNose Throat J 1994; 73: 41-43

6. O’Neill JV, Toomey JM, Synyder GG. Retropharyngealhematoma secondary to minor blunt trauma in the elder-ly patient. J otolaryngol 1977; 6: 43-47

7. Kochilas X, Ali A, Montague ML, Kelleher RJ.Retropharyngeal space swelling secondary to minorblunt head and neck trauma. J Laryngol Otol 2004; 118:465-467

8. Van Velde R, Sars PR, Olsman JG, Van De Hoeven H.Traumatic retropharyngeal haematoma treated byembolization of the thyrocervical trunk. Eur J EmergMed 2002; 9: 159-161

9. Brook I. The swollen neck. Cervical lymphadenitis,parotitis, thyroiditis, and infected cysts. Infect Dis ClinNorth Am 1988; 2: 221-236

10. Ho TL, Lee KW, Lee HJ. Subacute mandibular andhypoglossal nerve denervation causing oedema of themasticator space and tongue. Neuroradiology 2003; 45:262-266

11. Takara I, Takechi A, Sugahara K. A case of pharyngola-ryngeal edema after posterior occipito-cervical opera-tion. Masui 2004; 53: 1173-1176

12. Svensson MY, Bostrom O, Davidsson J, et al. Neckinjuries in car collisions-a review covering a possibleinjury mechanism and the development of a new rear-impact dummy. Accid Anal Prev 2000; 32: 167-175

13. Brown AM, Millar BG. Acute upper airway obstructionfollowing “staged” bilateral radical neck dissectionsin previously irradiated patients. Br J Oral MaxillofacSurg 1990; 28: 272-274

14. Penning L. Prevertebral hematoma in cervical spineinjury: incidence and etiologic significance. AJR Am JRoentgenol 1981; 136: 553-561

15. Haddad A, Frenkiel S, Small P. Angioedema of the headand neck. J Otolaryngol 1985; 14: 14-16

16. Farnam J. Grant JA. Angioedema. Dermatologic Clinics1985; 3: 85-95

17. McLauchlan CA, Pidsley R, Vandenberk PJ. Minortrauma--major problem. Neck injuries, retropharyngealhaematoma and emergency airway management. ArchEmerg Med 1991; 8: 135-139

Diffuse neck swelling286

Diffuse neck swelling 287

車禍後頸脡廣泛異常腫大之罕見病例報告

陳煥武1 腐聖超1 陳煥文2 腐國茂1

國立台灣大學附設醫院　影像醫學脡1

羅東博愛醫院　內科脡2

頸部是聯繫頭和身體的重要構造芴內含許多重要的器官芴容易在加速度下受到傷害。一但

有任何傷害芴可能影響呼吸造成死亡。一位中年女性誤入尚未升起之機械式停袛位芴而直接跌

落三層樓高的地下室。病患三小時候後被救出芴送至本院急診時意識清楚芴僅抱怨手麻、無力

和頸部疼痛。在攝影室前等候影像檢查時芴呼吸越來越困難芴終至發紺。經緊急實施氣管切開

術併氣管內插管芴病人恢復意識芴轉入加護病房。我們報導此一鏒見的袛禍現象芴並且探討造

成此鏒見頸部腫大的原因以及第一線醫療人員及放射線科醫謢人員該如何早期發現瀕臨呼吸道

阻塞之徵兆與緊急處治之方式。

關鍵詞睥血管神經性水腫芴頸部傷害芴淋巴水腫芴頸部腫脹芴馬鞭式創傷