warfarin and Airway-Obstruction

Sublingual hematoma is a rare but potentially fatal complication of oral warfarin sodium. Less than ten cases are reported in the English-language literature with only two of these appearing in the otolaryngologic literature. Spontaneous bleeding into the sublingual and submaxillary spaces creates a "pseudo-Ludwig's" phenomenon with elevation of the tongue and floor of mouth and subsequent airway compromise. Two new cases, along with a review of the literature are presented. Management is directed at prompt control of the airway and reversal of the coagulopathy. Sore throat is a uniform, early complaint that should be taken seriously in any patient receiving oral anticoagulation therapy.

Topics: Aged; Airway Obstruction; Emergencies; Female; Hematoma; Humans; Middle Aged; Oral Hemorrhage; Tongue Diseases; Warfarin

A man in his 70s on warfarin attended the emergency department three times over a 24-hour period, complaining of a sore throat, neck swelling and difficulty swallowing. He was initially diagnosed with pharyngitis, given antibiotics and discharged home, which was reconfirmed on the second attendance after an episode of haemoptysis. On the third, he was diagnosed with a pharyngeal haematoma causing partial airway obstruction and admitted to critical care. His international normalised ratio (INR) was reported initially as unreadable by the laboratory, then eventually came back as >20. After a thorough medication history, he said that he had recently been prescribed topical miconazole oromucosal gel by his dentist for oral candidiasis, which had interacted with the warfarin to cause this life-threatening haematoma.

Topics: Airway Obstruction; Anticoagulants; Drug Interactions; Hematoma; Humans; International Normalized Ratio; Male; Miconazole; Warfarin

Topics: Airway Obstruction; Anticoagulants; Ecchymosis; Epiglottis; Female; Hematoma; Humans; Medical Illustration; Middle Aged; Pharynx; Respiratory System; Tongue; Vocal Cords; Warfarin

A 67-year-old man was found dead, at his home. On external examination, we found a voluminous purplish black ecchymosis of the anterior neck area. On internal examination, we found a voluminous epiglottis hematoma completely obstructing the upper airway. It was associated with other sites of intra-abdominal hemorrhage. Toxicological studies revealed the presence of warfarin at a concentration of 8.4 mg/L in peripheral blood, which supposes an INR well above 4.5. To conclude, we supposed death was due to asphyxia secondary to a spontaneous epiglottic hematoma caused by a high blood concentration of warfarin. Hemorrhage in the epiglottis is very rare. To our knowledge, our patient is the only case of "sudden death" reported with spontaneous epiglottic hematoma due to high blood concentration of warfarin. In forensic practice, an anterior neck ecchymosis, without trauma, may suggest hemorrhage into soft airway tissues. Pathology findings make it possible to exclude exogenous trauma.

Topics: Aged; Airway Obstruction; Anticoagulants; Asphyxia; Death, Sudden; Ecchymosis; Hematoma; Humans; Laryngeal Diseases; Male; Warfarin

Topics: Aged; Airway Obstruction; Anticoagulants; Female; Hematoma; Humans; Mouth Diseases; Tongue Diseases; Warfarin

We describe a case of spontaneous sublingual haematoma secondary to warfarin toxicity, leading to impending airway obstruction. The case was handled with the administration of vitamin K and fresh frozen plasma, and without invasive airway handling. Furthermore, we discuss the presentation of the condition and the signs of impending airway obstruction. Preferred management includes a safe airway and reversion of coagulopathy. The prognosis is good when treatment is prompt and correct.

Topics: Administration, Oral; Aged; Airway Obstruction; Anticoagulants; Female; Hematoma; Humans; Mouth Floor; Warfarin

A 61-year-old man receiving anticoagulant therapy after the aortic valve replacement underwent emergency surgery for acute appendicitis. Although the patient was intubated with difficulty, no immediate complications were evident after extubation. On the evening of the first postoperative day he complained of a sore throat, difficulty in swallowing and dysphonia. The swelling of the tongue with right-side predominance and the swelling of the right neck were observed. The right-sided sublingual hematoma was confirmed by CT. The symptoms improved with steroid administration. The possibility of airway obstruction due to hematoma of the tongue should be considered in patients on anticoagulant therapy.

Topics: Acute Disease; Airway Obstruction; Anticoagulants; Appendicitis; Dexamethasone; Emergencies; Hematoma; Humans; Infusions, Intravenous; Laryngoscopy; Male; Middle Aged; Mouth Floor; Treatment Outcome; Warfarin

Anticoagulation with warfarin is commonly used for prevention of thromboembolic events in patients with atrial fibrillation. Bleeding is the main side effect of anticoagulation. We report the case of a 66-year-old man who developed two spontaneous synchronous upper airway haematomas while on warfarin therapy. To our knowledge, this is the first reported case of a sublingual haematoma presenting simultaneously with supraglottic laryngeal haematomas. Upper airway haematomas are rare in the absence of a history of trauma but need to be urgently assessed due to their life-threatening potential. Clinicians should be aware of the possibility of haematomas involving the upper airway in patients on anticoagulant therapy, particularly if complaining of red flag symptoms such as acute onset dysphonia, odynophagia or airway/breathing difficulties.

Topics: Aged; Airway Obstruction; Atrial Fibrillation; Hematoma; Humans; Laryngeal Diseases; Male; Mouth Floor; Warfarin

Warfarin sodium is a commonly used oral anticoagulant agent. It has been well documented that, when effective anticoagulant therapy is employed in treating thromboembolic disease, hemorrhage is a possible complication that can be spontaneous without a history of trauma. The numerous sites of bleeding are the genitourinary and gastrointestinal tracts, the central nervous system, the nose (epistaxis), the penis (priapism), the retroperitoneum, wounds (surgical or traumatic), and subcutaneous tissues during warfarin therapy, but the hemorrhage rarely causes bleeding compromising a patient's airway. We report a case of a spontaneous lingual hematoma that developed during oral anticoagulation therapy. This life-threatening complication of warfarin therapy and its successful management without surgery indicates that observation, close monitoring and reversal of anticoagulation can be a reasonable management option.

Topics: Airway Obstruction; Anticoagulants; Hematoma; Humans; Male; Middle Aged; Tongue Diseases; Warfarin

Airway obstruction secondary to bleeding from warfarin therapy is difficult to manage and uncommon but has been previously described. Previous reports have emphasized the need for reversal of therapy using vitamin K and fresh frozen plasma (FFP). Where a definitive airway has been required, cricothyroidotomy or tracheostomy seem to have been favoured. Several authors have reported failed attempts at endotracheal intubation due to the obstructive effects of a sublingual haematoma. We report here a case which illustrates how endotracheal intubation can be used successfully under the right conditions. It also highlights the superiority of prothrombin complex concentrate over FFP in achieving rapid reversal of abnormal international normalized ratio in the emergency situation.

Topics: Aged, 80 and over; Airway Obstruction; Anticoagulants; Blood Coagulation Factors; Critical Care; Hematoma; Humans; Intubation, Intratracheal; Male; Treatment Outcome; Warfarin

A 57-year-old man treated with Coumadin for an episode of paroxysmal atrial fibrillation presented to the Emergency Department with progressive dysphagia and odynophagia. Physical examination revealed a large right-sided lateral and posterior pharyngeal wall mass. Laboratory studies were significant for an international normalized ratio (INR) of 5.4 with a white blood cell count of 11,600/muL and a hematocrit of 33.2%. A lateral soft tissue radiograph and computed tomography (CT) scan of the neck demonstrated a retropharyngeal hematoma compromising the airway. Rapid reversal of the coagulopathy was achieved with fresh frozen plasma and vitamin K. Patients with space-occupying retropharyngeal masses present a significant management dilemma. The choice between observation, intubation, or a surgical airway intervention must rely upon knowledge of the natural course and high rate of airway occlusion when faced with a patient who presents with a retropharyngeal hematoma. Once symptoms of airway compromise manifest, the airway must be expeditiously secured before complete obstruction occurs. This diagnosis should be sought when an anticoagulated patient presents with upper airway symptoms.

Topics: Airway Obstruction; Anticoagulants; Atrial Fibrillation; Blood Transfusion; Deglutition Disorders; Disease Progression; Emergency Treatment; Hematocrit; Hematoma; Humans; Laryngoscopy; Leukocyte Count; Male; Middle Aged; Pharyngeal Diseases; Plasma; Risk Factors; Tomography, X-Ray Computed; Vitamin K; Warfarin

The complications of warfarin therapy have classically been described as bleeding in the genitourinary and gastrointestinal tracts, skin, central nervous system, nose, penis, or retroperitoneum. However, rarely warfarin may cause bleeding that compromises a patient's airway. A sublingual haematoma is an example of such a complication. Only 10 previous cases of sublingual haematomas have been reported.. We describe the case of a 56 year-old woman receiving oral anticoagulation who presented with a sore throat and hoarseness. Examination of her oral cavity revealed a soft, red, submucosal swelling involving the floor of mouth and ventral lingual surface bilaterally. No signs of airway compromise were observed. The patient's PT-INR was 10. Given the potential for rapid airway obstruction, the patient was admitted to a unit with closely monitored beds. Her coagulation disturbance was corrected medically and her haematoma resolved. The patient was discharged to the care of her family physician.. This case makes several important points. First, the case describes a rare, but life-threatening complication of warfarin therapy. Second, the initial signs of a sublingual haematoma are reviewed. Given the vagueness of these signs, diagnosis requires a high index of suspicion on the part of the physician. Finally, the case describes successfully management of this disorder without the use of a surgical airway. For this patient, reversal of her anticoagulation and vigilant monitoring saved her from having a surgical airway placed.

Topics: Airway Obstruction; Female; Hematoma; Humans; Middle Aged; Mouth Diseases; Mouth Floor; Warfarin

Topics: Aged; Airway Obstruction; Anticoagulants; Female; Hematoma; Humans; Laryngeal Diseases; Male; Pharyngeal Diseases; Warfarin

A case of progressive, spontaneous, nontraumatic hemorrhage into the tonsil, soft palate, hypopharynx, and larynx in a patient receiving oral anticoagulants is presented. There was no evidence of bleeding into other parts of the body. The presenting symptoms of sore-throat, dysphagia and hoarseness were mild at the time of admission. However, the bleeding later caused upper airway obstruction and aspiration, and the clinical picture during hospitalization became dramatic and life-threatening. Physicians should be aware of such possible complications in anticoagulant-treated patients, and if a hematoma is found in the pharynx or larynx the patient should be admitted for close observation and treatment. To the best of our knowledge this is the first reported case of spontaneous hemorrhage into the tonsil in a patient on oral anticoagulation.

Topics: Administration, Oral; Aged; Airway Obstruction; Female; Hemorrhage; Humans; Warfarin

Topics: Airway Obstruction; Hematoma; Humans; Male; Mediastinal Diseases; Middle Aged; Tracheal Stenosis; Tracheostomy; Warfarin

Topics: Aged; Aged, 80 and over; Airway Obstruction; Glottis; Hematoma; Humans; Laryngeal Diseases; Male; Warfarin

A patient with severe rheumatoid arthritis (RA) receiving chronic anticoagulation therapy developed acute life threatening airway obstruction. The source of obstruction was a retropharyngeal hematoma compressing the upper airway rather than acute laryngeal dysfunction from the patient's RA. Our case illustrates a new cause of acute stridor and airway obstruction in RA. Publications on upper airway obstruction in RA and airway obstruction secondary to retropharyngeal hematoma are discussed.

Topics: Airway Obstruction; Arthritis, Rheumatoid; Drug Interactions; Female; Hematoma; Humans; Middle Aged; Pharynx; Pressure; Sulindac; Warfarin

Topics: Airway Obstruction; Diagnosis, Differential; Humans; Ludwig's Angina; Male; Middle Aged; Warfarin

We treated a patient for warfarin-induced sublingual hematoma causing upper-airway obstruction. This complication of oral anticoagulation therapy is rare; only three other cases have been reported in the English literature. All reported patients developed acute respiratory embarrassment necessitating emergency airway establishment. Sublingual hematomas usually resolve spontaneously, and surgical drainage is rarely necessary.

Topics: Airway Obstruction; Cricoid Cartilage; Hematoma; Humans; Male; Middle Aged; Mouth Floor; Oral Hemorrhage; Thyroid Cartilage; Warfarin

Described are the cases of two patients who presented with vocal cord hematomas consequent to poor control of anticoagulation. Both patients presented with hoarseness and cough. One required intubation due to respiratory obstruction. Vocal cord hematomas should be considered in patients who present with upper airway symptoms while anticoagulated.

Topics: Aged; Airway Obstruction; Female; Glycolates; Hematoma; Hoarseness; Humans; Laryngeal Diseases; Male; Middle Aged; Ticrynafen; Vocal Cords; Warfarin

In a patient taking oral anticoagulants, the complaint of pharyngeal pain, a change in the voice, dysphagia, respiratory difficulty, or a neck mass should prompt a thorough investigation to rule out hemorrhage into the upper airway. This case report describes an anticoagulated patient who experienced precipitous hemorrhagic upper airway obstruction. She was successfully treated with tracheostomy, plasma infusion, and parenteral vitamin K1.

Topics: Airway Obstruction; Emergencies; Female; Hematoma; Hemorrhage; Humans; Middle Aged; Respiratory Tract Diseases; Thrombophlebitis; Tracheotomy; Vitamin K 1; Warfarin

Topics: Adult; Airway Obstruction; Drug Synergism; Hematoma; Humans; Male; Mouth Floor; Phenylbutazone; Warfarin

Topics: Adult; Airway Obstruction; Epiglottis; Female; Humans; Oral Hemorrhage; Tongue Diseases; Warfarin

I report a patient in whom warfarin sodium induced upper airway obstruction secondary to a spontaneous nontraumatic hemorrhage into the sublingual space. Treatment of this obstructive sublingual space hematoma with conservative medical management is reviewed. I discuss the role of warfarin sodium in coagulation and in the production of this pseudo-Ludwig phenomenon.

Topics: Airway Obstruction; Hematoma; Humans; Male; Middle Aged; Mouth Diseases; Mouth Floor; Warfarin

The retropharyngeal space is a rare site of spontaneous hemorrhage and the formation of a hematoma in this location is a rarer complication of therapy with anticoagulants. Nineteen cases of retropharyngeal hematoma have been reported in the literature, only two of which have been associated with anticoagulation therapy. In the case reported here, a retropharyngeal hematoma developed in a 61-year-old man who had been receiving anticoagulants. The complication was associated with a violent tussive episode. Airway obstruction necessitated a tracheostomy, and the persistent hematoma required external drainage.

Topics: Airway Obstruction; Drainage; Hematoma; Humans; Male; Middle Aged; Pharyngeal Diseases; Vitamin K 1; Warfarin