Massive sublingual hematoma secondary to anticoagulant therapy complicated by a traumatic denture: a case report

Aspirin-Induced Massive Spontaneous Sublingual Hematoma

Sublingual hematoma, a rare but potentially life-threatening condition, can arise spontaneously or secondary to various triggers, including trauma, dental procedures, or anticoagulant therapy. We present a case of massive spontaneous sublingual hematoma in a 45-year-old woman receiving aspirin therapy for rheumatic heart disease. Despite the absence of trauma or procedural triggers, the patient presented with bleeding from the floor of the mouth and significant submental swelling, prompting urgent intervention to secure the airway and manage coagulopathy. Conservative measures, including discontinuation of aspirin and intravenous vitamin K administration, led to gradual hematoma resolution and favorable patient outcomes. This case highlights the importance of prompt recognition and early management of sublingual hematoma, particularly in the context of aspirin therapy-induced coagulopathy.

Maxillofacial haemorrhagic symptoms in emergency department patients: impact of antithrombotics

PURPOSE

To investigate the effect of antithrombotics on the occurrence of maxillofacial haemorrhagic symptoms, and to determine if these haemorrhagic symptoms are predictors of maxillofacial fractures.

METHOD

A prospective cohort study was conducted of consecutive patients with maxillofacial trauma who had been admitted to the emergency department of four hospitals in the Netherlands. This study compared five haemorrhagic symptoms (peri-orbital haematoma, raccoon eyes, epistaxis, subconjunctival ecchymosis, and intra-oral haematoma) between patients not-using (NUA) and using (UA) of antithrombotics, and whether these maxillofacial haemorrhagic symptoms served as predictors for maxillofacial fractures.

RESULTS

Out of the 1005 patients, 812 (81%) belonged to the NUA group, and 193 (19%) to the UA group. UA patients exhibited higher frequencies of peri-orbital hematoma (54% vs. 39%, p < 0.001), raccoon eyes (10% vs. 5%, p = 0.01), and subconjunctival ecchymoses (16% vs. 7%, p < 0.001). In NUA, peri-orbital hematoma (OR = 2.5, p < 0.001), epistaxis (OR = 4.1, p < 0.001), subconjunctival ecchymosis (OR = 2.3, p = 0.02), and intra-oral hematoma (OR = 7.1, p < 0.001) were significant fracture predictors. Among UA, peri-orbital hematoma (OR = 2.2, p = 0.04), epistaxis (OR = 5.4, p < 0.001), subconjunctival ecchymosis (OR = 3.7, p = 0.008), and intra-oral hematoma (OR = 22.0, p < 0.001) were significant fracture predictors.

CONCLUSION

Maxillofacial haemorrhagic symptoms were observed more frequently in the UA group than in the NUA group. However, in both groups, maxillofacial haemorrhagic symptoms appear to be predictors of maxillofacial fractures. Caution is warranted in attributing these symptoms solely to antithrombotic use during emergency department assessments.

Acute airway obstruction requiring nasotracheal intubation following hypoglossal neuromonitoring: a case report

BACKGROUND

Intraoperative neurophysiological monitoring (IONM) is utilized for both the localization of critical structures and for real time detection and prevention of intraoperative neurological injury. Use of IONM to monitor the hypoglossal nerve is performed during neurosurgical, otolaryngological, and vascular procedures to improve surgical outcomes. There is a paucity of literature describing potential complications of IONM of the hypoglossal nerve, especially with respect to airway compromise. Here we present our findings regarding a case of acute airway obstruction following hypoglossal nerve monitoring.

CASE PRESENTATION

A 54-year-old male was admitted for left far-lateral craniotomy and microsurgical clipping of a left posterior inferior cerebellar artery (PICA) aneurysm. Following induction and intubation but prior to the procedure start, the patient was placed in the ¾ prone position with the left side up and his neck was flexed approximately 10 degrees. He then underwent placement of subdermal needle electrodes into the facial muscles, trapezius muscles, soft palate, and tongue for IONM. The procedure lasted 523 minutes and was completed without complication. However, approximately one hour after emergence from general anesthesia, the patient experienced progressive difficulty breathing secondary to severe lingual swelling. He required emergent placement of a nasotracheal tube guided by a fiberoptic bronchoscope. He remained intubated for 3 days and was treated with dexamethasone, after which the swelling resolved, and the patient was successfully extubated.

CONCLUSIONS

Acute lingual edema is a potentially life-threatening phenomenon that can lead to rapid airway compromise. Generally, causes of acute lingual swelling include hemorrhage, edema, infarction, and infection. In the case described above, we suspect traumatic injury to the tongue's vascular supply caused a deep tissue hematoma leading to postoperative acute lingual swelling and airway obstruction. With the widespread use of IONM, it becomes essential for providers to be aware that perioperative airway compromise is a potentially life-threatening complication, especially with respect to monitoring of the hypoglossal nerve. Awake fiberoptic nasotracheal intubation can successfully be employed to establish an emergency airway in such situations.

Isolated sublingual hematoma post internal carotid artery stenting for internal carotid artery stenosis in high-risk patients as uncommon and rare misadventure: A case report and review of literature

INTRODUCTION AND IMPORTANCE

Isolated sublingual hematoma is a rare complication seen in trauma, severe uncontrolled hypertension, dental operations, bleeding diathesis, and the use of dual antiplatelet and anticoagulant agents. In advanced and neglected cases, a sublingual hematoma may interfere with the patient's airway, causing suffocation and fatal airway obstruction. Our objective was to present a case of iatrogenic isolated sublingual hematoma in a 70-year-old business man, heavy smoker with a history of hypertension. Furthermore, to report the literature review, and to organize treatment strategies to reduce the rate of progression of the hematoma. In addition to recommend or advice a strategic plan to prevent this complication during carotid stenting.

CASE PRESENTATION

This case report has been reported in line with the SCARE Criteria. We represented a case report of an iatrogenic isolated mild/moderate sublingual hematoma in a 70-year-old business man. This hematoma developed as one of the rare complications of endovascular internal carotid artery revascularization because of injury to the sublingual branch of the lingual artery during wire manipulations or its advancement. This hematoma was treated by conservative treatment without any intervention.

CLINICAL DISCUSSION

Immediately after internal carotid artery stenting procedure, the patient developed a sudden onset of painful swelling in the floor of the mouth. The hematoma showing ecchymotic submucosal swelling underneath the tongue in the floor of the mouth. If it became enlarged, it may push the tongue against the palate and blocking the airway, causing serious airway obstruction. Fortunately, the swelling is isolated (has no extension to any side) and limited to the root and middle third of the tongue but, not extending to its tip. Its development most probably due to injured atherosclerotic sublingual branch of the lingual artery during the procedure.

CONCLUSIONS

The first step in management should be prompt airway management. Conservative treatment took place without any further intervention. To date, there is no consensus about the management regarding the hematoma itself. Mostly, clinicians start with observation for spontaneous resolution. When conservative treatment is not appropriate, surgical intervention must be performed. However, electively secure the airway is the main objective for treatment.

Spontaneous Sublingual Haematoma in a 90-year Old Patient: A Complication of Direct Oral Anticoagulants

Sublingual haematoma is a rare complication of anticoagulants and can be life-threatening. As the number of prescribed anticoagulants is increasing, the incidence of complications of these drugs will continue to increase. A report of a sublingual haematoma in an elderly patient with chronic atrial fibrillation treated with edoxban (Lixiana ©, Daiichi Sankyo Europe GmbH, München, Germany) is reported. A 90-year male presented at the emergency department with an obstructed upper airway due to a sublingual haematoma. The patient received tranexamic acid, prothrombin complex, and fresh frozen plasma. After fiberoptic nasal intubation, the patient was monitored in the intensive care unit. After four days, the patient was extubated, and after six days, the swelling resolved completely. Complications of anticoagulants are rare but can be life-threatening. Recognition of an endangered airway and reversing the effects of the anticoagulant are essential. Surgical evacuation of the haematoma could be considered but is not necessary.

Idiopathic spontaneous sublingual hematoma: a case report and literature review

PURPOSE

Sublingual hematoma is a rare complication seen in bleeding disorders, trauma, dental procedures, and the use of anticoagulants. Only a few publications have described idiopathic spontaneous sublingual hematoma, and all of them suspected severe hypertension as etiology. Our objective is to present a case of idiopathic spontaneous sublingual hematoma in a 48-year-old patient without any medical history of hypertension and to perform a literature review on this subject.

METHODS

Case report presentation based on information extracted from the electronic patient database of Ghent University Hospital including a literature review of sublingual hematoma.

RESULTS

This case report describes a 48-year-old male patient presenting with a spontaneous sublingual hematoma, which needed to be treated with an urgent tracheotomy. Drainage of the old hematoma followed 11 days later. He was not known with hypertension or any bleeding disorder. Clinical examination using fiberoptic nasolaryngoscopy, a CT scan, MRI scan, and biopsy of the sublingual salivary gland showed no focus for etiology.

CONCLUSIONS

Clinical work-up is necessary to look for a cause of a spontaneous sublingual hematoma. Idiopathic spontaneous hematoma is only a rare entity. Aggressive airway management should be the first step in treatment. To date, there is no consensus about the management regarding the hematoma itself. Mostly, clinicians start with observation for spontaneous resolution of the hematoma and when possible to treat causative factors. Surgical drainage is performed when conservative treatment is not sufficient.

Spontaneous submental hematoma, a pseudo-Ludwig's phenomenon in 101-year-old patient: case report and literature review

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Submental hematoma is a rare entity and physician should rule out other potential deferential diagnoses including angioedema, arteriovenous malformation (AVM), pseudoaneurysm, or cavernous hemangioma.

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It can occur in any age group even as old as 101 year.

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Always act proactive to secure the airway, preferably conservatively and electively early in presentation to avoid complications with acute/emergent interventions.

Objective

Submental hematoma or pseudo-Ludwig’s phenomenon, is a rare entity seen in anticoagulated patients and can precipitate upper airway obstruction. Our objective is to present a rare case of spontaneous submental hematoma due to poorly controlled hypertension in elderly patient and to perform a literature review.

Case report

101-year-old female presented to emergency room with sudden painful swelling in the floor of mouth and slurred speech. Not on anticoagulation and no history of trauma or known allergies. Physical examination and flexible laryngoscope revealed normal temperature and blood pressure of 190/100, submental/floor of mouth swelling that was tense to palpation, ecchymotic/hemorrhagic and extend to the tip of the tongue suggestive of recent submucosal bleeding and mild swelling at the base of tongue as well as small hemorrhagic vallecular cyst. CT scan ruled out AVM and pseudoaneurysm of lingual artery. She was diagnosed with spontaneous submental hematoma (SSH) probably due to the rupture of atherosclerotic vessels supplying the musculature related to the space due to uncontrolled sever hypertension. She was treated conservatively by electively securing the airway and the swelling resolved in 3 days. She got extubated and subsequently discharged home.

Methods

Systematic literature review was conducted and revealed only 5 cases since 2002 reported with this rare subgroup of spontaneous submental hematoma not related to anticoagulation. This case report has been reported in line with the SCARE criteria [1].

Results

4 cases were results of uncontrolled hypertension whereas one case was seen in cirrhotic liver patient. One patient was managed with surgical evacuation of the hematoma were in the others conservative management initiated but failed. Of those 4, 2 required an emergent airway procedure.

Conclusion

Spontaneous submental hematoma (SSH) is a clinical diagnosis and conservative management is successful in reducing the amount of swelling once the causative factors have been corrected/controlled. The main goal is to electively secure the airway and as in all emergent airway management the team must include members capable of a surgical airway.

Upper Airway Hematoma Secondary to Warfarin Therapy: A Systematic Review of Reported Cases

Upper airway hematoma (UAH) is a rare but life-threatening complication of oral anticoagulants requiring early recognition. However, no consensus exists regarding the best approach to treatment. We therefore, sought to systematically review the published literature on UAH to elaborate its demographic and clinical characteristics, treatment, complications, and outcomes. A systematic electronic search of PubMed and EMBASE for case reports, case series, and related articles of UAH related to warfarin published from inception (November 1950) to March 2015 was carried out. Categorical variables were expressed as percentage and continuous variables as mean ± standard deviation (SD). Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 20.0. All cases were reported to have UAH as a complication of anticoagulation therapy with warfarin. Demographic and clinical characteristics, treatment, complications and outcomes of UAH were studied. Thirty-eight cases of UAH were identified from 34 reports in the literature. No gender preponderance (male = 52.78%) was seen and the average age of presentation was 60.11 ± 12.50 years. Dysphagia, sore throat, and neck swelling were the most common symptoms and the mean international normalized ratio (INR)at presentation was 8.07 ± 4.04. Most cases had sublingual hematoma (66.57%) followed by retropharyngeal hematoma (27.03%). Of the cases, 48.65% were managed conservatively while the rest underwent either cricothyrotomy or intubation with the time to resolution being 7.69 ± 5.44 days. UAH is a rare butpotentially serious complication of warfarin therapy. It is more common in the elderly population with supratherapeutic INR; inciting events were present in many cases. Overall, it has a good prognosis with significant morbidity present only if concomitant respiratory compromise is present. Reversal of anticoagulation with low threshold for artificial airway placement in the event of airway compromise leads to a favorable outcome in most cases.

Pseudo-Ludwig's Phenomenon: A Rare Clinical Manifestation in Liver Cirrhosis

Pseudo-Ludwig's phenomenon, an exceedingly rare clinical entity, is characterized by non-infectious upper airway obstruction resulting from spontaneous hematoma in the sublingual space. The condition is often described in patients on anticoagulants with grossly deranged coagulation profile. We describe a case of pseudo-Ludwig's phenomenon in a cirrhotic patient with significantly deranged hemostasis profile; the first to be reported in medical literature.

Life-threatening expansive sublingual hematoma: a stab wound with lingual artery injury

Vascular injuries are a constant risk in facial trauma, although bone and soft tissues of the face have provided some protection to the larger blood vessels. However, penetrating injuries usually do not have this type of protection and can damage significant vascular arteries. This article presents a case of a stab wound, which led to airway obstruction arising to a large sublingual hematoma due to lingual artery injury. A healthy 44-year-old man was stabbed in the submandibular region and admitted with an airway obstruction. He was subjected to an emergency tracheotomy and evolved with progressive sublingual edema. Computed tomography (CT) angiography showed a left lingual artery injury with the formation of an expansive hematoma. The CT angiography findings helped to identify the cause of the hematoma and guided the surgery to drain the hematoma after ligation of the lingual artery. The treatment was safely performed as planned and evolved uneventfully. The patient recovered fast and well and presented normal functions 6 months after the treatment. This surgical technique is an effective method for treating such injuries because it can be safely performed when guided by CT angiography. The authors argue that the demand for vascular lesions should be routine in patients who have facial trauma.