Dysphagia as a Presentation of Spontaneous Mediastinal Hematoma With Life-Threatening Airway Obstruction

Abstract

SESSION TITLE: Disorders of the Mediastinum 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Spontaneous atraumatic mediastinal hematomas are rare. Considering the infrequency with which it is encountered, the clinical identification and management of them can prove to be challenging. We report a case of spontaneous mediastinal hematoma in a patient presenting with dysphagia. CASE PRESENTATION: An otherwise healthy 67-year-old female presented to the emergency department with a 4 day history of worsening dysphagia to both solids and liquids, chest pain radiating to the upper back, and anterior chest bruising. The patient denied history of trauma, vomiting, cough or other constitutional symptoms. She had no reports of antiplatelet or anticoagulant use and no known personal or family history of bleeding problems. Physical examination was only significant for ecchymosis on the anterior chest. Initial blood work was unremarkable with a hemoglobin level of 13.0 g/dl, normal platelet count and coagulation profile. Over the next 48 hours, her hemoglobin dropped to 9.4 g/dl. Initial plain chest radiograph demonstrated widening of the superior and middle mediastinum. An emergent CT chest revealed a large retrotracheal mass extending from the oropharynx to the level of the subcarinal region, with mass effect and anterior displacement on the trachea consistent with a mediastinal hematoma. A conservative approach was initiated. The patient remained stable under intensive care monitoring. Repeat CT Chest 3-days following admission confirmed a decreasing size of the mediastinal hematoma. The patient's remaining hospital course was uncomplicated and she was discharged 10 days later. Hematologic work up for a bleeding diathesis was unrevealing. DISCUSSION: Less than two dozen cases of spontaneous atraumatic mediastinal hematomas have been reported to date. Mediastinal hematomas are commonly provoked by thoracic trauma, iatrogenic procedures, sustained hypertension, hematologic conditions and transient increase in intra thoracic pressure. Although rare, spontaneous mediastinal hematomas must be recognized as a potential cause for mediastinal widening. Dysphagia as a presenting symptom of spontaneous mediastinal hematoma is infrequently reported in the literature. CONCLUSIONS: Spontaneous mediastinal hematomas pose a life-threatening risk. Timely recognition and awareness of atypical presentations is vital to appropriate treatment and management. Although the primary etiology of the hemorrhage may remain unidentified, awareness of the phenomenon is crucial to the differential diagnosis. Reference #1: Li X, Liu L, Cao D, Sun Y. Spontaneous Hematoma of Posterior Mediastinum with an Uncommon Cause: A Case Report and Review of the Literature. Clinics and Practice. 2016;6(1):838. doi:10.4081/cp.2016.838. Reference #2: Iskander M, Siddique K, Kaul A. Spontaneous Atraumatic Mediastinal Hemorrhage: Challenging Management of a Life-Threatening Condition and Literature Review. Journal of Investigative Medicine High Impact Case Reports. 2013;1(2):2324709613484451. doi:10.1177/2324709613484451 DISCLOSURE: The following authors have nothing to disclose: Phyllis Suen, Abdul Siddiqui, Paul Catella, Shimshon Wiesel, Michel Chalhoub No Product/Research Disclosure Information