Case report
Large retropharyngeal haematoma. Airway management with Airtraq® laryngoscope
Gran hematoma retrofaríngeo: manejo de la vía aérea con laringoscopio óptico Airtraq®
M.D. Mira
, M.I. Valldeperas, A. Socias, H. Sarasíbar, J.L. Aguilar Sánchez
Corresponding author
Departamento de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Son Llàtzer (HSLL), Palma de Mallorca, Spain
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Airway management with Airtraq® laryngoscope" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 951 "Ancho" => 950 "Tamanyo" => 119808 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">TAC cervical: Reconstrucción parasagital en ventana de partes blandas en la que se observa un gran hematoma/masa orocervical en el espacio mucoso faríngeo, retrofaríngeo con desplazamiento anterior de la laringe y la tráquea.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.D. Mira, M.I. Valldeperas, A. Socias, H. Sarasíbar, J.L. 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Airway management with Airtraq<span class="elsevierStyleSup">®</span> laryngoscope" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "229" "paginaFinal" => "233" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M.D. Mira, M.I. Valldeperas, A. Socias, H. Sarasíbar, J.L. Aguilar Sánchez" "autores" => array:5 [ 0 => array:4 [ "nombre" => "M.D." "apellidos" => "Mira" "email" => array:1 [ 0 => "mdmira@hsll.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.I." "apellidos" => "Valldeperas" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Socias" ] 3 => array:2 [ "nombre" => "H." "apellidos" => "Sarasíbar" ] 4 => array:2 [ "nombre" => "J.L." "apellidos" => "Aguilar Sánchez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Son Llàtzer (HSLL), Palma de Mallorca, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Gran hematoma retrofaríngeo: manejo de la vía aérea con laringoscopio óptico Airtraq<span class="elsevierStyleSup">®</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 951 "Ancho" => 950 "Tamanyo" => 83118 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Cervical spine CT scan: Sagittal bone window showing the fracture line parallel to the end plate of C6 that ruptures the osteophyte on the anterior vertebral ligament.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The development of a retropharyngeal haematoma after minor trauma is an uncommon clinical situation.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Any delay in diagnosis or treatment can lead to life-threatening asphyxia due to the proximity of the upper airway. The clinical signs of retropharyngeal haematoma will depend on the rate of development and extension of the lesion. It will usually manifest with dysphagia, odynophagia, or dyspnoea secondary to anterior compression of the larynx, trachea, pharynx and oesophagus, subcutaneous bruising can appear in the neck and upper thorax. Diagnosis is made on the basis of clinical manifestations and radiological findings.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of late diagnosis of a large retropharyngeal haematoma secondary to minor cervical spine trauma. We review the literature and discuss the main treatment in these cases, including airway management with the disposable Airtraq<span class="elsevierStyleSup">®</span> (Prodol Meditec, Vizcaya, Spain) optical laryngoscope.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">An 80-year-old man presented in the emergency room (ER) of our hospital due to facial trauma after falling forward after falling asleep in a chair. Upon arrival, the patient presented with a wound in the supraciliar region, nasal contusion, thickening of prevertebral soft tissues and mild dysphagia. He reported no drug allergies, but had a history of dyslipidaemia, epilepsy since childhood with no recent crises, and antiplatelet therapy with acetylsalicylic acid (100<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h) following ischaemic left abducens nerve palsy 8 years previously. On physical examination, the patient presented a Glasgow score of 15 with fair general status. He reported no previous history of dizziness, syncope or other accompanying neurological symptoms. Vital signs measured in the ER were within normal ranges. The complete blood count showed no abnormalities or coagulopathy. A 12-lead electrocardiogram showed sinus rhythm with a first-degree atrioventricular block: PR >300<span class="elsevierStyleHsp" style=""></span>ms. This had already been described in a previous electrocardiogram. Brain computed tomography (CT) showed: absence of intracerebral haemorrhage and cortical atrophy. The X-ray of the nose showed fracture of nasal bones, and the chest X-ray findings were normal.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was kept under observation for a few hours, during which time the initial symptoms of dysphagia worsened, with the appearance of dyspnoea when lying flat and an enlargement of the prevertebral oedema. This prompted us to perform lateral cervical spine X-ray (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) that showed a significant increase in prevertebral soft tissue causing anterior displacement of the laryngeal structures. There was no clear evidence of bone fracture, but ankylosis was observed between C4 and C5 with calcification of the intervertebral disc and calcification of the prevertebral soft tissue anterior to the C5–C6 disc and the body of C6. We immediately consulted the duty ears nose and throat (ENT) specialist, who performed nasal endoscopy in the ER and observed an airway obstruction at the supraglottic level due to protrusion of the posterior wall of the hypopharynx. There were traces of blood in the airway, but no evidence of active bleeding. Given these findings, the ENT specialist ordered emergency airway management with intubation instead of tracheotomy. The duty anaesthesiologist was called and patient was transferred to the operating room to secure the airway before performing a cervical spine CT scan.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">On arrival in the operating room, the patient showed slight distress, dysphagia and dyspnoea when lying flat, so he was placed in an upright (90°) sitting position. His vital signs were monitored and found to be within normal ranges. The initial approach to airway management was oral fibreoptic intubation and a VAMA<span class="elsevierStyleSup">®</span> cannula, since despite the situation, the patient's blood oxygen (SpO<span class="elsevierStyleInf">2</span>) levels were normal in the sitting position. After checking for leaks in the respirator and preparing the tracheotomy set, ranitidine (50<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mg atropine for saliva management) in 50<span class="elsevierStyleHsp" style=""></span>ml physiological saline was administered together with 2% lidocaine spray and instillation of lidocaine spray (Xilonibsa<span class="elsevierStyleSup">®</span>) at the base of the tongue and pharynx. Following this, we administered anaesthesia for intubation under conscious sedation: intravenous ketamine (0.2<span class="elsevierStyleHsp" style=""></span>mg/kg), intravenous fentanyl (0.5<span class="elsevierStyleHsp" style=""></span>mcg/kg) and an intravenous bolus of 2<span class="elsevierStyleHsp" style=""></span>mg diazepam, maintaining a SpO<span class="elsevierStyleInf">2</span> of >94% under spontaneous ventilation. The procedure was well tolerated by the patient, who remained cooperative at all times. After an unsuccessful attempt at oral fibreoptic intubation, we decided to change the airway management strategy. Given that the patient could not tolerate the decubitus position and could not extend his neck, he was tilted backwards 25° from his upright sitting position and an Airtraq<span class="elsevierStyleSup">®</span> number 3 optical laryngoscope was inserted. After placement, the epiglottis, posterior part of the glottis and arytenoid cartilages were visualised and a number 7 wire-reinforced trachael tube was inserted without incident. Following this, a rigid cervical collar was placed and the patient was transferred, under monitoring, to the radiology suite under continuous mandatory ventilation and sedation with intravenous profolol (1.5<span class="elsevierStyleHsp" style=""></span>mg/kg per hour).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Contrast-enhanced cervial spine CT revealed a large haematoma in the form of a mass (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>) in the retropharyngeal space that extended down the back of the trachea as far as the aortic arch and the origin of the supra-aortic vessels, causing anterior displacement and collapse of the airway. A horizontal anterior to posterior fracture in the body of C6, just below the endplate, with fracture of the anterior bony ridge was also noted.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">We decided to take a conservative approach and the patient was admitted to the intensive care unit for monitored surveillance, where he stayed for 17 days. After 72<span class="elsevierStyleHsp" style=""></span>h, endotrachael tube exchange was performed and the patient was extubated on the seventh day, after verifying subsidence of the retropharyngeal haematoma in the cervical spine CT scan (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The patient remained stable, and was discharged to the orthopaedic ward with a cervical collar and a nasogastric tube for enteral feeding due to persistent dysphagia.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">The development of a retropharyngeal haematoma secondary to minor cervical spine trauma is an uncommon clinical situation<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a>; only around 60 cases have been reported in the English language literature since 1966.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> The retropharyngeal space is formed between the middle and deep layers of the deep cervical fascia and extends from the base of the skull to the superior mediastinum at the level of the second thoracic vertebra. It is more important than other spaces in the neck (carotid and prevertebral) because of its location posterior to the airway. It contains fat and lymph nodes, and is divided into an anterior and posterior compartment by the alar fascia. The posterior compartment is also known as the “danger space” because it provides a pathway for infection to spread from the head and neck to the posterior mediastinum. Any space-occupying lesion at that level can be life-threatening due its potential to obstruct the airway, and requires rapid diagnosis and prompt treatment. The retropharyngeal space is the route used in cervical spinal surgery, and retropharyngeal haematoma is an occasional postoperative complication in these cases.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Retropharyngeal haematoma is also associated with anticoagulant therapy, iatrogenic injury, cervical spine infection, ingestion of foreign bodies, vascular lesions, and other causal factors such as sudden head movements, sneezing or violent coughing.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4,5</span></a> It has been described in the context of major neck trauma with cervical fracture, but the appearance of a large retropharyngeal haematoma after minor cervical trauma or secondary to injury of the anterior cervical vertebral ligament with no cervical fracture is far less common. The clinical presentation of the haematoma can differ, depending on its rate of formation and size. Symptoms are usually related to the compression of adjacent anatomical structures, and include dysphagia, odynophagia or dyspnoea, as well as the appearance of subcutaneous bruising in the neck and upper thorax. Diagnosis is made on the basis of clinical manifestations and radiological findings. Lateral cervical spine X-ray is particularly useful; generally speaking, the thickness of the prevertebral soft tissue should not exceed half or a third of the size of the adjacent cervical spine vertebra. An increase in soft tissue at that level is an abnormal finding that should be confirmed with cervical spine CT. The best treatment is unclear: the first step is to secure the airway by means of intubation or urgent tracheotomy, as required. Intubation is usually difficult in these patients, above all in the presence of an underlying cervical fracture that limits cervical extension. Tracheotomy is performed either to avoid damaging the pharynx during intubation, or when blood oxygen cannot be maintained above 90%. Once the airway has been secured, the haematoma is usually treated conservatively and is reabsorbed in 2–4 weeks. Surgical evacuation is performed in particularly large haematomas that prevent mechanical ventilation or in those that do not improve with conservative treatment.</p><p id="par0045" class="elsevierStylePara elsevierViewall">With regard to our case, the patient had suffered minor cervical trauma, but on arrival in the ER he already presented cervical oedema. However, diagnosis was delayed for several hours, since the lateral cervical spine X-ray was performed almost 5<span class="elsevierStyleHsp" style=""></span>h later, when the patient's symptoms had already worsened. Furthermore, the possibility of a cervical fracture was not taken into account, and a cervical collar was not placed in the ER A diagnosis was ultimately achieved after exploratory nasal endoscopy. The patient required urgent airway management, and because we anticipated a difficult airway, he was intubated under mild conscious sedation and spontaneous ventilation, according to the algorithm of the American Society of Anesthesiology.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> We did not consider the use of nasal fibreoptic bronchoscopy (FOB), since the ENT specialist had already performed nasal endoscopy in the ER and we did not wish to further worsen glottic visualisation during intubation. The initial strategy of oral FOB was ruled out in favour of video laryngoscopy because the anaesthesiologist was more accustomed to performing FOB from behind the patient's head, and not in a sitting position. The fact that the patient tolerated the VAMA<span class="elsevierStyleSup">®</span> cannula prompted the anaesthesiologist to use video laryngoscopy, which can be inserted with the patient tilted backwards at an angle of 25°. Since it was first marketed in 2005, the Airtraq<span class="elsevierStyleSup">®</span> optical laryngoscope has been shown to be superior to the conventional Macintosh laryngoscope in patients with anticipated difficult airway: fewer attempts are needed, there is less likelihood of oral trauma and haemodynamic changes, and intubation is achieved in less time.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> Video laryngoscopy has been used outside the operating room; it can be inserted in the sitting position, and does not require cervical extension, two factors that were key to successful intubation in our patient. In a prospective randomised study<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> comparing conventional laryngoscopy vs the Airtraq<span class="elsevierStyleSup">®</span> in patients with cervical spine immobilisation, intubation was easier and caused fewer haemodynamic changes with the latter, although the authors were unable to rule out bias, since the anaesthesiologist could not be “blinded”. We were unable to find any studies comparing FOB and the Airtraq<span class="elsevierStyleSup">®</span> in awake intubation, although the use of the Aitraq<span class="elsevierStyleSup">®</span> in awake intubation in patients with anticipated difficult airway has been described.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> In a randomised clinical trial comparing the McGrath<span class="elsevierStyleSup">®</span> videolaryngoscope to FOB, Rosenstock et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> found no significant differences in intubation time between these devices.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In our case, it seems that the combination of a small fracture in C6, the rupture of the osteophyte on the anterior vertebral ligament combined with previous antiplatelet therapy caused bleeding in the retropharyngeal space. The patient was intubated in the operating room, given the high likelihood of tracheotomy if intubation failed. In the case of anticipated difficult airway, the American Society of Anesthesiology recommends having a well-defined action strategy that takes into account not only the urgency of the procedure but also the patient's status and the skill or preferences of the attending anaesthesiologist. It is advisable to gain experience in performing fibreoptic intubation both from behind and facing the patient. In this regard, we agree with Fitgerald et al. who observed that, despite the obvious advantages of the latest generation video laryngoscopes in awake intubation with anticipated difficult airway, no single device will satisfy all clinical situations, and anaesthesiologists must be trained in all available techniques and choose the best approach in each situation.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> In our case, the use of the Airtraq<span class="elsevierStyleSup">®</span> laryngoscope was an effective technique for awake intubation in a patient in a semi-seated position, with an anticipated difficult airway and limited cervical extension.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1018450" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec976820" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1018449" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec976821" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-06-01" "fechaAceptado" => "2017-11-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec976820" "palabras" => array:4 [ 0 => "Retropharyngeal haematoma" 1 => "Retropharyngeal space" 2 => "Optic laryngoscope" 3 => "Difficult airway" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec976821" "palabras" => array:4 [ 0 => "Hematoma retrofaríngeo" 1 => "Espacio retrofaríngeo" 2 => "Laringoscopio óptico" 3 => "Vía aérea difícil" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Retropharyngeal haematoma is a life-threatening clinical situation that can lead to a potential obstruction of the upper airway and requires rapid diagnosis. Clinically, it can be presented in different ways, depending on its size and growing speed. The first measure is to protect and manage the airway: in most cases this is a difficult airway situation. A retropharyngeal haematoma can be formed due to a previous traumatic history, with or without associated cervical fracture. Treatment of the haematoma is conservative in most cases, with close monitoring until it is reabsorbed in 3–4 weeks, although they can sometimes require surgical evacuation. We present the case of a patient who developed a large retropharyngeal haematoma after minor cervical trauma and describe an approach of the airway using the Airtraq<span class="elsevierStyleSup">®</span> disposable optical laryngoscope.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Un hematoma retrofaríngeo es una situación clínica que puede poner en peligro la vida por la potencial obstrucción de la vía aérea superior y que requiere un rápido diagnóstico. Puede presentarse clínicamente de diferentes formas, según el tamaño y la velocidad en su desarrollo. La primera medida que tener en cuenta es la protección y el manejo de la vía aérea que, en la mayoría de las veces, es una situación de vía aérea difícil. En la aparición de un hematoma retrofaríngeo puede existir un antecedente traumático previo, con o sin fractura cervical asociada. El tratamiento del hematoma en la mayoría de los casos es conservador, con una estrecha vigilancia hasta su reabsorción en 3-4 semanas, aunque en ocasiones precisa de evacuación quirúrgica. Presentamos el caso clínico de un paciente que desarrolló un gran hematoma retrofaríngeo tras traumatismo cervical menor y describimos el abordaje de la vía aérea mediante el uso del laringoscopio óptico desechable Airtraq<span class="elsevierStyleSup">®</span>.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Mira MD, Valldeperas MI, Socias A, Sarasíbar H, Aguilar Sánchez JL. Gran hematoma retrofaríngeo: manejo de la vía aérea con laringoscopio óptico Airtraq<span class="elsevierStyleSup">®</span>. Rev Esp Anestesiol Reanim. 2018;65:229–233.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1197 "Ancho" => 950 "Tamanyo" => 69667 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Lateral cervical spine radiograph. The white arrow indicates an important increase in prevertebral soft tissue causing anterior displacement of laryngeal structures.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 951 "Ancho" => 950 "Tamanyo" => 83118 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Cervical spine CT scan: Sagittal bone window showing the fracture line parallel to the end plate of C6 that ruptures the osteophyte on the anterior vertebral ligament.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 951 "Ancho" => 950 "Tamanyo" => 119808 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cervical spine CT scan: Sagittal soft tissue window showing a large cervical haematoma/mass in the retropharyngeal space causing anterior displacement of the larynx and trachea.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 115977 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Follow-up cervical spine CT scan: Sagittal soft tissue window clearly showing shrinkage of the retropharyngeal haematoma in the anteroposterior axis at C4 (0.8<span class="elsevierStyleHsp" style=""></span>cm from the previous 1.8<span class="elsevierStyleHsp" style=""></span>cm) and in the craniocaudal axis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Retropharyngeal hematoma secondary to minor blunt neck trauma: case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.C. 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