|Retropharyngeal hematoma after stellate ganglion block: analysis of 27 patients reported in the literature
|Higa K, Hirata K, Hirota K, Nitahara K, Shono S
The authors concluded that retropharyngeal haematoma after stellate ganglion block necessitates emergency airway management. Since airway obstruction cannot be predicted by initial symptoms, emergency airway management tools should be at hand and the openness of the airway should be continuously evaluated. There were limitations to this review but, overall, the authors’ conclusions appear to reflect the limitations of the evidence presented.
To determine symptoms, signs and urgency of airway management of retropharyngeal haematoma (RPH) after stellate ganglion block (SGB).
MEDLINE (1966 to 2006) and Japana Centra Revuo Medicina (1983 to 2006) were searched; the keywords were reported. The reference lists in identified studies were screened.
Study designs of evaluations included in the review
Inclusion criteria were not specified in terms of the study design. The included studies were case reports.
Specific interventions included in the review
Reports of patients who developed RPH after SGB were eligible for inclusion. Ten patients were receiving drugs that could affect haemostasis: aspirin, ticlopidine, dextran, urokinase, batroxobin, loxoprofen, trapidil and non-steroidal anti-inflammatory drugs.
Participants included in the review
Reports of patients who developed RPH after SGB were eligible for inclusion. Patients varied widely with respect to the disease for which SGB was administered: such diseases included facial palsy, sudden deafness, neck and/or shoulder pain, allergic rhinitis, retinal vein thrombosis, headache, whiplash injury, central post stroke pain, trigeminal herpetic pain and upper limb pain. Concurrent diseases among participants included chronic renal failure, chronic renal failure on haemodialysis, diabetes mellitus, hypertension, ischaemic heart disease, obesity, hyperthyroidism, cerebral infarction and idiopathic thrombocytopenic purpura. Some patients had no concurrent diseases. The mean age was 54.5 (+/- 14.6) years (range: 26 to 76) and both male and female patients were included. Most of the included studies (83%) were reported in Japanese language journals.
Outcomes assessed in the review
Reports of RPH subsequent to SGB were eligible for inclusion. The review reported, time of onset of initial signs and symptoms, initial signs and symptoms, results of imaging tests of the neck and/or mediastinum, timing and method of emergency airway management, and surgical findings on evacuation of the haematoma or autopsy, as well as a number of variables which may be associated with the development of RPH.
How were decisions on the relevance of primary studies made?
The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.
Assessment of study quality
The authors did not state that they assessed validity.
The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction. For each study, extracted data included details of concurrent diseases, characteristics of the neck, coagulation studies and use of drugs that could influence coagulation, as well as RPH-related outcomes.
Methods of synthesis
How were the studies combined?
The studies were combined in a narrative. Each study was described in the text and additional descriptive information was tabulated. Any statistical comparisons were performed using an unpaired t-test or chi-squared test with Yates correction.
How were differences between studies investigated?
Differences between the studies were discussed with respect to the characteristics of the patients.
Results of the review
Twenty-seven case reports (n=27) were included.
Initial symptoms and signs.
The included studies reported neck pain (n=10), dyspnoea (n=10), neck swelling (n=8), hoarseness (n=5), sore throat (n=4), pressure sensation in the neck (n=3), back pain (n=3), chest pain (n=3), ecchymosis in the neck (n=3), feeling of suffocation (n=2), dysphagia (n=2), abnormal sensation in the neck (n=1), chest oppression (n=1) and occipital pain (n=1). Symptoms occurred 2 hours or more after SGB in 14 patients (52%).
Method of airway management.
Emergency airway management was needed in 21 patients (78%) because of airway obstruction. There were no statistically significant predictors of later emergency airway management. Among these 21 patients, orotracheal intubation was attempted first in 17 patients, nasotracheal intubation with a bronchofibrescope in 1 patient and tracheostomy in 3 patients. Orotracheal intubation was successful in 12 of the 17 patients in whom it was attempted, but extremely difficult in the remaining 5 patients. The technique failed in 5 patients, despite multiple attempts, and these patients received an emergency tracheostomy. Failed airway management caused one death. There were no statistically significant predictors of later emergency airway management amongst the initial signs and symptoms reported, and there was no significant difference in the time of onset of symptoms between those who later needed emergency management and those who did not. The speed with which airway compromise worsened was unpredictable and varied greatly among patients.
RPH after SGB necessitates emergency airway management. Since airway obstruction cannot be predicted by initial symptoms or signs, emergency airway management tools should be at hand, and the patency of the airway should be continuously evaluated after onset of RPH after SGB.
The review question was clear in terms of the intervention, outcomes, participants and study design. Only two databases were searched and, although no language restrictions were specified, it appears that only studies in English and Japanese were included; it is therefore possible that cases from other geographic locations might have been missed. The methods used to select studies and extract the data were not described, so it is not known whether any efforts were made to reduce error and bias. The included studies were case series which do not provide robust evidence. Given the heterogeneity of the disease state of the population and the small number of case reports available, a narrative synthesis was appropriate. There were limitations to this review but, overall, the authors’ conclusions appear to reflect the limitations of the evidence presented.
Implications of the review for practice and research
Practice: The authors stated that RPH after SGB necessitates emergency airway management. Emergency airway management tools should be at hand since airway obstruction cannot be predicted by initial symptoms or signs, and the patency of the airway should be continuously evaluated after onset of RPH after SGB.
Research: The authors did not state any implications for further research.
Institutional and/or departmental sources.
Higa K, Hirata K, Hirota K, Nitahara K, Shono S. Retropharyngeal hematoma after stellate ganglion block: analysis of 27 patients reported in the literature. Anesthesiology 2006; 105(6): 1238-1245
Subject indexing assigned by NLM
Adult; Aged; Airway Obstruction /diagnosis /etiology /pathology; Autopsy; Blood Coagulation /drug effects; Drug Interactions; Dyspnea /etiology; Female; Hematoma /diagnosis /etiology /pathology; Hoarseness /etiology; Humans; Intraoperative Complications /diagnosis /etiology /pathology; Magnetic Resonance Imaging; Male; Middle Aged; Neck Pain /etiology; Nerve Block /adverse effects; Pharyngeal Diseases /diagnosis /etiology /pathology; Pharyngitis /etiology; Respiration, Artificial; Retrospective Studies; Stellate Ganglion; Tomography, X-Ray Computed
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.