This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
We describe a case of traumatic lingual hematoma in a patient on dual antiplatelet therapy. After securing the airway, bilateral lingual artery embolization successfully halted expanding hematoma formation. Patient subsequently required tracheostomy for continued airway edema. Although patient course was wrought with postoperative complications, we review this case to illustrate how prompt hematoma evacuation and embolization can resolve significant vasovagal bradycardia and hypotension secondary to expansile lingual hematoma.
Keywords: Lingual artery, Tongue, Antiplatelet, Lingual hematoma, EmbolizationRapid enlargement of the tongue secondary to lingual hematoma can lead to life-threatening airway emergencies, necessitating prompt recognition and management of this condition. Due to its highly vascular nature and extensive anastomotic network, the tongue is at a high risk for hemorrhage and subsequent hematoma formation following trauma [1]. There are numerous reports in the literature of lingual hematoma, ranging from traumatic to spontaneous, with or without anticoagulation use. Common causes of traumatic lingual hematomas include: MVA's, assault, child abuse, and seizures. Spontaneous lingual hematomas are usually a result of an inherited coagulopathy or treatment with anticoagulants [[2], [3], [4], [5], [6]]. Some theorize that patients with vascular disease and atherosclerosis of the lingual arterial system may be at increased risk for lingual hematoma due to vessel tortuosity, fragility, and possible shearing [7]. Regardless of etiology, management of lingual hematomas is controversial and includes observation, airway control, steroids, antibiotics, reversal of any coagulopathy, IR embolization and surgical intervention [8]. Being able to recognize the initial presentation, underlying cause and relevant anatomy of lingual hematomas is critical to the proper management and treatment of this condition.
This case involves a 75-year-old female with PMH significant for left internal carotid artery (ICA) stent in 2009 and coronary stenting in 2014 on aspirin and clopidogrel who drove herself to the ER after falling down three stair steps at home. Upon arrival to triage, the patient's chief complaint was shortness of breath and bleeding from oral cavity. She was emergently taken to trauma bay and noted to have dysarthria, dysphonia, dyspnea, ventral tongue/floor of mouth (FOM) laceration, and significant airway compromise secondary to progressive tongue swelling. With the assistance of anesthesia, the patient was successfully intubated transorally via Glidescope video laryngoscopy on the first attempt.
Immediately thereafter, ENT was called to the ER for control of actively bleeding FOM laceration. On exam, a 5 cm transverse laceration at junction of ventral tongue base and FOM was identified with active brisk bleeding, as well as obvious hematoma within the intrinsic tongue musculature extending towards the base of tongue. Also noted was a small area of left lower lip buccal mucosa avulsion, diffuse submental swelling and ecchymoses. The lower lip and tongue were diffusely enlarged, with the tongue being displaced posterosuperiorly obstructing the oral cavity and oropharynx and protruding from the mouth. There was no clear identifiable left Wharton's duct. The genioglossus and FOM were found to be separated by a hematoma cavity extending ~4–5 cm posteriorly towards the root of tongue and vallecula. The proposed source of bleeding (FOM laceration) was sutured shut with simple interrupted 3-0 vicryl tamponade sutures. The anterior oral cavity and ventral tongue were packed with fibrillar and 4 × 4 gauze. The patient was observed for several minutes and there was no evidence of any persistent bleeding that would require urgent surgical intervention. Transfusion of functioning, uninhibited platelets was initiated given the patient's coagulopathy secondary to dual anti-platelet therapy by administering a “superpack” of platelets. The patient was stabilized and taken to the radiology suite for CT imaging.
CTA neck showed a large focus of active extravasation within the central aspect of the oral tongue suggesting deep active hemorrhage ( Fig. 1 , Fig. 2 ); marked enlargement of the oral tongue and lower lip consistent with hematoma. No acute facial fractures. CT head and C-spine were negative.