It should be reiterated that patients with partial airway obstruction are unpredictable in when, where, and if they will go on to complete airway obstruction. Indeed, some case reports document a decision to conservatively manage neck hematoma patients by observation, only to be confronted with sudden and catastrophic complete airway obstruction some hours later.3,4 In addition, patients going on to complete airway obstruction in this setting can do so without first developing the physical sign of stridor.2,3,8 It follows that nursing staff and airway managers must be educated to recognize the early signs of impending obstruction from a possible neck hematoma, including subtle voice changes and hoarseness, with later progression to agitation, dyspnea, and eventually stridor. Stridor, a late sign of airway compromise, is variously considered to be a sign of an extrathoracic airway narrowed by 50%34 or to a diameter of 4 mm or less.35 The patient in the presented case should be assumed to be in respiratory extremis. Once a compromising neck hematoma is suspected, plans should be undertaken for immediate definitive care: release and reexploration of the neck wound, and securing of the airway.
For temporizing a case such as this on the short term, (eg, while organizing a return to the OR, or while obtaining equipment for re-intubation), a number of maneuvers can be undertaken: