Abstract
Background
Sublingual hematoma is a rare but life-threatening complication of oral anticoagulants. It is important to differentiate this from infectious processes like Ludwig’s angina. Securing the airway should be a priority and immediate reversal of anticoagulation with close monitoring is required.
Case report
We present a case of sublingual hematoma secondary to warfarin therapy without airway compromise which was managed conservatively with reversal of INR with oral vitamin K.
Conclusion
Although rare, it is crucial to differentiate sublingual hematomas from infectious processes. Reversal of anticoagulation with low threshold for artificial airway placement in the event of airway compromise is the treatment of choice.
1
Introduction
Warfarin remains the most commonly prescribed oral anticoagulant in the United States in spite of growing popularity of the newer anticoagulants, with > 25 million warfarin prescriptions in the United States in 2010 . Spontaneous sublingual hematoma is a rare complication which can lead to serious complication like acute airway compromise.
2
Case report
A 50-year-old female on chronic warfarin therapy for recent pulmonary embolism presented to the emergency department with painful red swelling under her tongue developing rapidly over few hours. About three hours prior, she felt a sore throat with associated right sided neck pain. Shortly thereafter she developed difficulty swallowing and articulating her speech due to a moderate sized painful mass on the floor of her mouth. She denied recent trauma to the area, epistaxis, melena or hematuria. She did not have any cough, chest pain, difficulty breathing, stridor or drooling.
On physical examination, she was afebrile. Her speech was fluent without stridor or respiratory distress. There was slight fullness in the submental region extending inferiorly into the midline, but no ecchymosis of the overlying skin ( Fig. 1 ). Intraoral examination revealed a tense, tender, red-purplish submucosal hematoma measuring 3 cm × 3 cm in the floor of the mouth, displacing the tongue superiorly ( Fig. 1 ). There was no extension of the swelling into the pharynx. Tongue mobility was limited. Laboratory studies revealed a supratherapeutic international normalized ratio (INR) of 5.2. She had a hemoglobin 14.5 g/dL, platelets 269 × 10 9 /L and white cell count 11.9 × 10 9 /L. Her erythrocyte sedimentation rate (ESR) and C-reactive protein were normal at 16 mm/h and 0.35 mg/dL respectively. Computed tomography of the neck showed enlargement of the right submandibular gland and possible sialolith with hemorrhage along the floor of the mouth ( Fig. 2 ).
Given the absence of airway compromise and systemic signs of infection, the patient was diagnosed with sublingual hematoma. As there were no signs of impending airway compromise, she was managed conservatively with 2.5 mg of oral vitamin K. Her warfarin was held and the INR returned to normal within 48 hours. The hematoma gradually decreased in size with improvement of her tongue mobility over the next 2 days.
2
Case report
A 50-year-old female on chronic warfarin therapy for recent pulmonary embolism presented to the emergency department with painful red swelling under her tongue developing rapidly over few hours. About three hours prior, she felt a sore throat with associated right sided neck pain. Shortly thereafter she developed difficulty swallowing and articulating her speech due to a moderate sized painful mass on the floor of her mouth. She denied recent trauma to the area, epistaxis, melena or hematuria. She did not have any cough, chest pain, difficulty breathing, stridor or drooling.
On physical examination, she was afebrile. Her speech was fluent without stridor or respiratory distress. There was slight fullness in the submental region extending inferiorly into the midline, but no ecchymosis of the overlying skin ( Fig. 1 ). Intraoral examination revealed a tense, tender, red-purplish submucosal hematoma measuring 3 cm × 3 cm in the floor of the mouth, displacing the tongue superiorly ( Fig. 1 ). There was no extension of the swelling into the pharynx. Tongue mobility was limited. Laboratory studies revealed a supratherapeutic international normalized ratio (INR) of 5.2. She had a hemoglobin 14.5 g/dL, platelets 269 × 10 9 /L and white cell count 11.9 × 10 9 /L. Her erythrocyte sedimentation rate (ESR) and C-reactive protein were normal at 16 mm/h and 0.35 mg/dL respectively. Computed tomography of the neck showed enlargement of the right submandibular gland and possible sialolith with hemorrhage along the floor of the mouth ( Fig. 2 ).
