Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 92711

AbstractCase ReportDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : OR01 - OR03 Full Version

Acute Upper Airway Obstruction as Atypical Manifestation of Uncommon Aetiologies- A Case Series


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/56507.16312
Manju Mathew, Anjana Mary Reynolds, Sunil Mathew, Reena Thomas

1. Assistant Professor, Department of Critical Care, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India. 2. Assistant Professor, Department of Otorhinolaryngology, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India. 3. Associate Professor, Department of General Medicine, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India. 4. Professor, Department of Nephrology, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India.

Correspondence Address :
Dr. Manju mathew,
Assistant Professor, Department of Critical Care, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India.
E-mail: dr.tresamaria@gmail.com

Abstract

Acute upper airway obstruction, an emergent situation, can sometimes put the clinician in a dilemma with no positive history or clinical findings to aid in the diagnosis. A myriad of conditions causes upper airway obstruction. Priority is to secure the airway and then seek out the underlying cause. Computed tomography scan is an important imaging modality for reaching a definitive diagnosis and might at times, reveal unexpected findings. In this case series, authors report three cases of acute upper airway obstruction which were atypical manifestation of diseases. Case 1 is about Lemierre’s syndrome with compromised airway in the absence of abscess formation. Case 2 depicts an atypical presentation of Boerhaave syndrome as retropharyngeal accumulation of air and pneumomediastinum. Case 3 is about retropharyngeal haematoma in a patient with anticoagulant therapy without any definite history of trauma. Treatment with reversal of anticoagulation was successful in the case 3. It is important for the clinician to be aware of the unusual reasons for airway compromise, as early suspicion can translate into better patient survival. Airway should be secured by either intubation or tracheostomy. Many a time, radiological and blood investigations help to arrive at a definite diagnosis.

Keywords

Anticoagulants, Boerhaave syndrome, Esophageal perforation, Haematoma, Lemierre’s syndrome, Venous thrombosis

Airway emergencies must be recognized and dealt with promptly. Common causes of acute airway obstruction in adults include anaphylaxis, angioneurotic oedema, trauma, infections, inhalational injury, vocal cord paralysis (1). Intubation is anticipated to be difficult. Occasionally prompt, disease specific management can avert intubation such as adrenaline shots in anaphylaxis. Treatment of the primary cause such as antibiotics in infections and abscess drainage is essential. While knowledge about the common reasons for acute airway obstruction is essential, awareness about the rare, atypical manifestations would increase the chances of patient survival. Authors report three cases of acute upper airway obstruction requiring intensive care, which are atypical manifestations of diseases. These conditions, Lemierre’s and Boerhaave syndrome, itself are uncommon and require specific interventions. Authors aim to bring the spotlight on these to instil a high index of suspicion.

Case Report

Case 1

A 82-year-old male with no co-morbidities presented with fever, sore throat, cough for four days, swelling, pain in the left side of the neck and odynophagia for two days. His symptoms quickly progressed to dysphagia with pooling of secretions and airway compromise requiring intubation. Laboratory results were unremarkable except for total White Blood Cells (WBC) count of 18000/mm3 (polymorphs 86% with toxic granules, lymphocyte 16%) and raised C-reactive Protein (CRP). Coagulation studies were normal. Blood cultures were negative. Contrast Enhanced Computed Tomography (CECT) scan neck showed left Internal Jugular Vein (IJV) thrombosis with surrounding oedema and mass effect with deviation of trachea. Thrombus extended into the left subclavian and axillary veins. Cervical and mediastinal lymphadenopathy was present (Table/Fig 1). Other causes for IJV thrombosis like history of IJV cannulation, trauma, malignancy, or other systemic disorders could not be elucidated during further evaluation. Computed Tomography (CT) scan of brain, neck, thorax, abdomen, and tumor biomarkers, all were negative. No metastatic focus of infection was identified.

Patient was diagnosed as atypical manifestation of Lemierre’s syndrome, septic thrombophlebitis of left IJV. Broad spectrum antibiotic for gram negative and anaerobic organisms was given for six weeks along with therapeutic anticoagulation. The 2D echocardiography was negative for clot or vegetations. Weaning from ventilator was prolonged. He was tracheostomized and decannulated one month later. On follow-up, he was healthy.

Case 2

A 47-year-old male with history of alcoholism, diabetes mellitus, hypertension, Chronic Kidney Disease (CKD) presented with throat discomfort, oliguria and breathlessness. He was dialysed for acute on CKD. He rapidly developed stridor and desaturation and was intubated. On examination, breath sounds were normal bilaterally. No obvious swelling of the throat was noticed. Laryngoscopy showed bulging of the posterior wall of oropharynx without oedema of vocal cords or epiglottis. Chest X-ray (CXR) was normal. The CECT neck and thorax was done to rule out possible deep space abscess. It showed extensive air involving the retropharyngeal space extending from the level of clivus to D3 vertebra along with pneumomediastinum but no pneumothorax or pleural effusion (Table/Fig 2),(Table/Fig 3). No contrast leaked into mediastinum or lungs, given through a nasogastric tube retracted to the level of carina. No abscess was found in the retropharyngeal or prevertebral regions. No foreign body or tumors were found. An upper gastrointestinal fluoroscopy was done subsequently, which also did not reveal contrast leak.

On further enquiry, history of retching and vomiting following episodes of alcohol binges was obtained. He had chest discomfort two days before admission with progressive breathlessness. There was no history of trauma or medical interventions. A diagnosis of spontaneous oesophageal rupture, Boerhaave syndrome was made based on history of vomiting, chest pain and pneumomediastinum. Investigations revealed total WBC 23800/mm3 (polymorphs 90%, lymphocyte 7%) with raised CRP. Conservative treatment with nil per mouth, broad-spectrum antibiotic piperacillin-tazobactam was given as per gastrosurgery advice with intensive monitoring for sepsis deterioration. On day 13 of admission, he was transferred to another hospital as per family request and lost follow-up.

Case 3

A 67-year-old male, presented with vague pain in the throat and breathing difficulty which started an hour after taking a vegetarian meal. He was diabetic and was on anticoagulants for mitral valve replacement. There was no history of trauma, foreign body ingestion, fever, or neck pain. On examination, SpO2 was 93%, pulse rate was 88/minute and blood pressure was 150/90 mmHg. He was in stridor and had laboured breathing. Throat examination showed a uniform bulge in the posterior pharyngeal wall with haemorrhagic mucosa. Laryngeal crepitus was absent. Flexible laryngoscopy showed bulging posterior pharyngeal wall with narrowing of glottic space.

A diagnosis of retropharyngeal haematoma, possibly triggered by coarse food matter ingested on the backdrop of anticoagulation therapy was made. Investigations showed haemoglobin 8 gm/dL, International Normalised Ratio (INR) was 8 (prothrombin time test 96 sec, control 12 sec) with normal white cell count, platelet count, liver, and renal function tests.

The CECT neck showed a well defined, hyperdense, non enhancing collection in the retropharyngeal space measuring 2×5 cm and extending craniocaudally from C2 to D4 vertebral level (Table/Fig 4). As intubation had the risk of triggering further bleed and patient’s blood gases were in acceptable range, he was admitted for close observation. Anticoagulation was withheld until INR reached the target range. He improved with conservative management. Videolaryngoscopy performed after a week showed resolution of the haematoma.

Discussion

Acute airway obstruction may, at times, be atypical manifestation of diseases. Many a times, imaging studies are ordered to rule out deep space infections of the neck which then subsequently, reveal unexpected aetiological findings as was the case in this series. All three cases reported were uncommon diagnoses and manifested in an atypical fashion with acute airway obstruction. In the first case, once the CECT scan clinched the diagnosis of IJV thrombosis, patient required prolonged antibiotics and mechanical ventilation, resulting in significant morbidity. Initial history and symptoms need not reveal the aetiology as in the second case. The history of chest pain and vomiting came to light only on further directed questions after the diagnosis was suspected based on retropharyngeal air in the CECT. Initial clinical examination and CXR also missed signs of oesophageal perforation. It is therefore important to maintain a high index of suspicion and be aware of the atypical presentations of Boerhaave disease. Third case was difficult in that coagulopathy made any intervention risky. While the first two required emergency intubation, retropharyngeal hematoma could safely be managed with reversal of anticoagulation.

Most common causes of IJV thrombosis are malignancy and central venous catheterisation, less common causes being local infections, trauma, surgery, or hypercoagulable states (2). IJV thrombosis in the setting of recent oropharyngeal infection, with anaerobic bacteraemia caused primarily by F. necrophorum is diagnosed as Lemierre’s syndrome (3). Upper respiratory tract is the most common primary site of infection, although skin, gastrointestinal and genitourinary infections can also predispose to this condition. Metastatic infections occur in 63-100% of patients, most commonly in the lung followed by the major joints. Life-endangering complications such as pulmonary embolism, airway swelling, cortical venous thrombosis, septic emboli can occur (4). Early antibiotic therapy in this case possibly prevented progression of thrombosis to metastatic sites. The full spectrum of Lemierre’s syndrome is seldom seen in the present era of advanced diagnostics and antibiotics.

Oesophageal perforation is potentially life-threatening with 13% mortality rate. It may be iatrogenic (46.5%), spontaneous (38%) or due to foreign body (6%) (5). Boerhaave syndrome, is a spontaneous perforation of the oesophagus that results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure such as that associated with vomiting (6). Although rare, if unrecognised, it can be fatal. Majority of perforations are thoracic (70%). The classic triad of acute epigastric and substernal chest pain, subcutaneous emphysema, and vomiting may not always be present. Atypical presentations of Boerhaave syndrome include hoarse voice, back pain, hematemesis, lung abscess, pericarditis (7). Patient may appear well with hardly any signs of inflammation before they suddenly decompensate, in cases where the perforation is sealed. The variable clinical presentations may contribute to a delayed diagnosis and poor outcome. The CT with oral contrast and presence of salivary amylase in the pleural fluid may be diagnostic. Treatment may be conservative, endoscopic, and surgical intervention depending on the severity of the perforation and clinical progression to sepsis (8). If the perforation occurs beyond 24 hours, and the leakage is contained without systemic signs of infection, then conservative treatment is usually advocated.

Haematoma in the retropharyngeal space has the potential risk for airway obstruction. Retropharyngeal haematomas occur most commonly following road traffic accidents, neck trauma and following sharp foreign body ingestion (9). Anticoagulant with uncontrolled bleeding parameters can trigger bleeding in the retropharyngeal space even with trivial injuries as in the present case series (10). At times, cervical angiography and emergent transcatheter arterial embolization of the bleeding vessels might be helpful (11). Along with discontinuation of the anticoagulant, vitamin K and fresh frozen plasma might be required. Blood dyscrasias can also cause spontaneous retropharyngeal haematoma (12). The CECT or Magnetic resonance imaging can reveal the extent of bleed. Intubation can potentially aggravate bleeding and may be impossible in the presence of posterior pharyngeal swelling (11). Often, tracheostomy is advocated to secure airway which again, can be hazardous in patients with deranged bleeding parameters. If saturation is maintained, a wait and watch policy may be resorted to, with plans for a surgical airway, when required. Management of retropharyngeal hematoma with fibreoptic intubation has been reported (10). Drainage of hematoma was attempted, obviating the need for intubation in another case report of aspirin induced hematoma showing persistent symptoms (13).

Conclusion

Awareness about the rare causes of acute airway obstruction and early suspicion is imperative for a positive outcome. The CECT may be diagnostic when clinical symptoms are nonspecific, and history is not forthcoming.

References

1.
Eskander A, de Almeida JR, Irish JC. Acute Upper Airway Obstruction. Longo DL, editor. N Engl J Med. 2019;381(20):1940-49. [crossref] [PubMed]
2.
Payrard L, Iten L, Donzé J, John G. Unprovoked internal jugular vein thrombosis: a case report and literature review. Thrombosis Journal. 2021;19:2. [crossref] [PubMed]
3.
Eilbert W, Singla N. Lemierre’s syndrome. International Journal of Emergency Medicine. 2013;6(1). [crossref] [PubMed]
4.
Scerrati A, Menegatti E, Zamboni M, Malagoni AM, Tessari M, Galeotti R, et al. Internal Jugular Vein Thrombosis: Etiology, Symptomatology, Diagnosis and Current Treatment. Diagnostics. 2021;11:378. [crossref] [PubMed]
5.
Sdralis E (Ilias) K, Petousis S, Rashid F, Lorenzi B, Charalabopoulos A. Epidemiology, diagnosis, and management of esophageal perforations: systematic review. Diseases of the Esophagus. 2017;30:01-06. [crossref] [PubMed]
6.
Chew FY, Yang ST. Boerhaave syndrome. CMAJ. 2021;193:E1499. [crossref] [PubMed]
7.
Li J, Turner SR, Finlayson G, Nasir B, Yee J, McGuire AL. A Rare Case of Boerhaave Syndrome Presenting with Right Tension Pneumothorax and Review of the Literature. Int J Crit Care Emerg Med. 2017;3(1):025. [crossref]
8.
de Schipper JP, Pull Ter Gunne AF, Oostvogel HJM, van Laarhoven CJHM. Spontaneous rupture of the oesophagus: Boerhaave’s syndrome in 2008. Literature review and treatment algorithm. Dig Surg. 2009;26:01-06. [crossref] [PubMed]
9.
Senel AC, Gunduz AK. Retropharyngeal Hematoma Secondary to Minor Blunt Neck Trauma: Case Report. Rev Bras Anestesiol. 2012;62(5):731-35. [crossref]
10.
Abukhder M, Hulme J, Nathoo S, Shubhi S. Spontaneous retropharyngeal haematoma with direct oral anticoagulant medication. BMJ Case Reports CP. 2021;14(5):e240369. [crossref] [PubMed]
11.
Ida A, Nishida A, Yoshitomi S, Nojima T, Naito H, Nakao A. Retropharyngeal hematoma presenting airway obstruction: A case report. Int J Surg Case Rep. 2020;77:321-24. [crossref] [PubMed]
12.
Fox EC, Manchala V. Retropharyngeal Hematoma as an Unusual Presentation of Myelodysplastic Syndrome: A Case Report. Am J Case Rep. 2018;19:969-72. [crossref] [PubMed]
13.
Divya GM, Dahiya V, Ramachandran K, Muhammed F. Drug-induced Airway Hematoma. Int J Head Neck Surg 2015;6(4):187-89. [crossref]

DOI and Others

DOI: 10.7860/JCDR/2022/56507.16312

Date of Submission: Mar 20, 2022
Date of Peer Review: Apr 07, 2022
Date of Acceptance: Apr 19, 2022
Date of Publishing: May 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 26, 2022
• Manual Googling: Mar 30, 2022
• iThenticate Software: Apr 15, 2022 (2%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com