we report a case of a female patient on aspirin and warfarin who developed a retropharyngeal haematoma following minor blunt head and neck trauma . an 84 year old woman had a mechanical fall at ground level resulting in neck hyperextension . a rigid cervical collar was applied and anterior neck and chest swelling and bruising were noted beneath this . a massive retropharyngeal haematoma was observed extending between c2 and t4 vertebral body levels with displacement and compression of the trachea ( figure 1,2 ) . there was no evidence of carotid , vertebral or internal jugular vein injury and no cervical fracture . contrast enhanced axial ct image taken at the level of the hyoid bone shows a large retropharyngeal haematoma ( star ) with active intravenous contrast extravasation ( arrow ) contrast enhanced sagittal ct image shows a large retropharyngeal haematoma ( star ) extending from the c2 vertebral level to below the level of the sternal notch with tracheal compression ( arrow ) nine hours from the time of injury the patient developed stridor . although significant subglottic swelling was evident at intubation , a 6.5 mm diameter endotracheal tube was successfully and atraumatically positioned into the distal trachea . a four vessel angiogram was then obtained which revealed an actively bleeding branch of the right inferior thyroid artery . the patient was managed non - operatively with intravenous antibiotics , steroids and inr reversal . over the coming days her neck swelling decreased and serial ct showed a reduction in size of the haematoma . dysphagia necessitated nasogastric feeding for a further week and mild dysphonia persisted for two weeks . the patient otherwise made a good recovery , returning to her previous level of function by six weeks . aetiological factors implicated in retropharyngeal haematoma include blunt head and neck trauma , cervical spine injury , anticoagulation , bleeding diatheses and tumors . most cases are thought to be due to bleeding from vessels covering the anterior longitudinal ligament.(2 ) less commonly bleeding has been reported to originate from the thyrocervical trunk ( 3 ) as was likely the situation in this case . the classic clinical presentation comprises capp s triad of airway compression , displacement of the trachea anteriorly and bruising of the neck and chest.(1 ) however , the clinical presentation is highly variable and may range from mild sore throat to hoarseness , dysphagia , odynophagia , dyspnoea or stridor.(15 ) an asymptomatic interval between time of injury and onset of stridor has been described(4 ) as in this case . the first step is to secure the airway if there is any evidence of airway obstruction . the haematoma may distort the anatomy of the upper airway making visualization of the cords difficult . a surgical airway is advocated by some authors as the preferred method because endosopic intubation may be difficult and carry a higher risk of perforating the haematoma.(3 ) we elected to trial an awake endoscopic intubation method with tracheostomy equipment available if required . this intubation method allowed direct visualization of the laryngeal anatomy with minimal manipulation of the haematoma whilst maintaining cervical spine alignment . with the airway secured , most patients are successfully managed conservatively with observation , supportive treatment and monitoring with serial ct . the haematoma usually resolves but can take four weeks or more.(5 ) surgical evacuation or transoral aspiration is generally reserved for a haematoma that is rapidly expanding , impeding mechanical ventilation or failing to resolve . although surgery may lead to an earlier extubation and recovery , it does carry an increased risk of infection . ( 1 ) we have presented a case of a large retropharyngeal haematoma in an elderly anticoagulated patient following minor blunt head and neck trauma . the patient presented insidiously with capp s triad and developed delayed airway obstruction necessitating emergency fibreoptic endoscopic intubation . conservative management may be appropriate in patients with non expanding haematomas that show improvement on serial ct .