An MRI scan of the neck will be able to show areas of soft tissue and bleeding, showing which areas may have been disrupted by the hematoma as well as the patency of the trachea and the carotid artery. 

Color flow Doppler ultrasonography can show areas of stagnant and flowing blood within the neck. In some cases, this is not enough and neck angiography must be done to show where the bleeding is coming from. 

Since the neck is so vascular with large arteries and veins, the hematomas tend to be quite large with ongoing bleeding that requires surgical intervention to stop the bleeding before there is compression of major structures in the neck. Contrast studies of the esophagus can show if it is being impeded upon by a large hematoma. 
 
In some cases laryngoscopy, pharyngoscopy, bronchoscopy or esophagoscopy can be performed to see where there are active areas of bleeding, hematoma formation or disruptions of the larynx, esophagus, trachea or major bronchi.
 
A CBC and blood typing should be performed in cases of rapidly increasing hematomas.  This is because the blood loss in major throat trauma can be extensive and there is a chance that this is a person who will need to receive at least one blood transfusion to make up for the extravasation of blood from the circulatory system to the soft tissue areas of the neck and chest.

Management of Neck Hematomas

If the patient is stable, ice to the injured area should be applied as soon as possible in order for you to slow the rate of internal bleeding as much as possible and to reduce swelling of the tissues.

Airway management is a very important part of managing neck hematomas. The airway can be compromised at any time, so if you are seeing evidence of breathing distress, endotracheal intubation should be considered.  This should be done before there is too much narrowing of the airways from pressure due to the hematoma. 

If you start breathing for the patient with an endotracheal tube and there is ongoing respiratory distress, consider that this may represent a tension pneumothorax, which needs needle decompression on the side of the tension pneumothorax along with the possibility of chest tube placement to maintain expansion of the lungs. 
 
In general, direct pressure on the area of bleeding will slow the bleeding down enough so that there is no significant compression on vital structures.  If this is not possible, such as if the source of the bleeding is deep within the neck, the patient may need a balloon tamponade to stop the bleeding internally.  If direct pressure is not possible and the airway is occluding, consider undergoing a cricothyroidotomy with a packing of the pharynx to control upper airway bleeding that is contributing to the neck hematoma.

Which Structures are at Risk in a Neck Hematoma?

The neck is a fairly compact space that contains many nerves, blood vessels, the thyroid gland, airway, and gastrointestinal structures.  The larynx and trachea are especially at risk because of a lack of supporting structures to stanch the bleeding.  Between the airway and the spinal structures is the esophagus as well as the major blood vessels of the neck.
 
There are two fascial layers that blood can pass within.  There is the deep cervical fascia that surrounds the trapezius muscles and the sternocleidomastoid muscles.   It separates out the pre-tracheal region, which includes the larynx, trachea, pericardium and the thyroid gland, the prevertebral space, which contains the brachial plexus, the phrenic nerve, the prevertebral muscles, and the axial sheath, and the carotid sheath, which houses the vagus nerve, the internal jugular vein, and the carotid artery. 

Musculoskeletal Structures 

The musculoskeletal structures that can be impinged upon by a hematoma include the cervical muscles, ligaments and tendons, the first and second ribs, the hyoid bone, the vertebral bodies, and the clavicles. Nerves that can be damaged include the phrenic nerve, the last three cranial nerves, the brachial plexus, the spinal cord, the stellate ganglion, and the recurrent laryngeal nerve.  

 

Vascular areas at risk for compression include the carotid artery, vertebral arteries, and the brachiocephalic, jugular and vertebral veins. As to visceral areas at risk, there is the esophagus, the thoracic duct, larynx, trachea, and pharynx. Glands that can be affected in a cervical hematoma include the parotid glands, parathyroid glands, submandibular glands, and the thyroid gland. 

Neck hematomas can be extremely dangerous because the bleeding can be brisk and the blood can travel through the fascial planes in order to compress vital areas of the nervous system, circulatory system, viscera, and the musculoskeletal system.  

The following video explains some treatment procedures for hematoma. Warning: the video contains graphic images.

Sacramento Traumatic Injury Lawyer

I’m Ed Smith, a Sacramento traumatic injury lawyer. If you or a loved one has suffered a neck injury in a severe car accident, call us for free, friendly advice at (916) 921-6400 or (800) 404-5400.

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Editor’s Note: This page has been updated for accuracy and relevancy [cha 3.31.21]