Management of Hematoma Above the Arytenoids on Posterior Pharyngeal Wall

Initial Assessment and Management

For a hematoma just above the arytenoids on the posterior pharyngeal wall, immediate airway assessment and management is critical, with evacuation of the hematoma if there are any signs of airway compromise 1, 2
Immediately administer supplemental oxygen if there are concerns about the hematoma 3
Position patient in head-up position to optimize airway patency 3, 4
Assess for signs of airway compromise using the DESATS approach: Difficulty swallowing/discomfort; increase in Early warning score; Swelling; Anxiety; Tachypnea/difficulty breathing; and Stridor 4
If signs of airway compromise are present, immediately call for help and proceed to hematoma evacuation 3, 5

Arrange immediate senior surgical review (ENT specialist/consultant); if not immediately available, arrange senior anesthetic review 5, 4
Perform flexible endoscopic laryngeal assessment by an experienced operator to evaluate the extent of the hematoma and airway patency 5
Consider intravenous dexamethasone to reduce upper airway edema and tranexamic acid to reduce bleeding 5, 4
Increase frequency of observations if there are ongoing concerns about potential hemorrhage 3, 4

If the patient shows signs of airway compromise due to the hematoma, a systematic approach should be taken to evacuate the hematoma 2, 6
The SCOOP approach includes: Skin exposure; Cut sutures; Open skin; Open muscles; Pack wound 2, 6
Local anesthetic infiltration is not required when opening the wound in emergency situations 2

If evacuation fails to stabilize the patient with ongoing airway compromise, emergency tracheal intubation must be considered 2, 6
Consider videolaryngoscopy at the first attempt of tracheal intubation 2, 6
In time-critical settings with imminent life-threatening airway compromise, attempt tracheal intubation after evacuation of the hematoma 2, 6
Use a smaller tracheal tube and/or adjuncts such as a bougie to facilitate intubation 6
Confirm successful intubation with capnography 6
Multiple attempts at intubation may exacerbate laryngeal edema - consider early progression to front-of-neck airway if difficulties arise 6, 7

Stridor may be a late sign of airway compromise and warrants immediate management 4
Emergency front-of-neck airway equipment, including a scalpel (number 10 blade), bougie and tracheal tube must be immediately available 7
In a cannot intubate, cannot oxygenate situation, scalpel cricothyroidotomy or emergency tracheostomy are preferred to cannula cricothyroidotomy 7

Monitor vital signs and airway patency closely, with frequent observations tailored to the patient's condition 3, 4
Ensure patients are nursed in a bed where they can easily attract attention of nursing staff 4
Monitor for subtle signs of complications including agitation, anxiety, difficulty in breathing, and discomfort 4
Consider transfer to operating theater, post-anesthesia care unit (PACU) or ICU for close observation if the patient is stable but there are ongoing concerns 5