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Spontaneous sublingual hematoma as a complication of severe hypertension: first report of a case. (Original Article).



Abstract

We describe what we believe is the first reported case of a sublingual sublingual /sub·lin·gual/ (-ling´gwal) hypoglossal; beneath the tongue.

sub·lin·gual
adj. Abbr. SL
Below or beneath the tongue; hypoglossal.
 hematoma secondary to severe hypertension. The patient, a 77-year-old woman, experienced a spontaneous hematoma of the floor of the mouth, tongue, and sublingual space that eventually caused an airway obstruction. We performed an emergency tracheostomy under local anesthesia and then evacuated the hematoma through an incision along the floor of the mouth. The patient recovered uneventfully.

Introduction

Sublingual hematoma is an uncommon complication of coagulopathy and trauma. (1-5) Although hypertension is a recognized risk factor for intracranial bleeding and epistaxis, it is not for sublingual hematoma. In fact, to the best of our knowledge, spontaneous sublingual hematoma secondary to hypertension has not been previously reported. In this article, we describe such a case.

Case report

A 77-year-old woman came to us complaining of a progressive enlargement of her tongue. The swelling was of sudden onset, and within a few hours she was not able to close her mouth. Her tongue was protruding past her lips, and she was beginning to experience difficulty breathing. She denied any history of trauma. She had had a myocardial infarction a few years earlier and a stroke 1 year earlier, but she had not taken her medication for several months. She could not provide any other information regarding her medication or her stroke.

On examination, the patient's tongue was grossly enlarged, red, congested con·gest·ed
adj.
Affected with or characterized by congestion.


congested ENT adjective Referring to a boggy blood-filled tissue. See Nasal congestion.
, and appeared to be continuous with the floor of her mouth (figure 1). Her submandibular submandibular /sub·man·dib·u·lar/ (sub?man-dib´u-ler) below the mandible.
submandibular (sub´mandib´y
 areas on both sides were swollen. Her blood pressure was 240/120 mm Hg, and her pulse rate was 100 beats per minute beats per minute Cardiac pacing The unit of measure for the frequency of heart depolarizations or contractions each minute–or pulse rate . She had very minimal stridor Stridor Definition

Stridor is a term used to describe noisy breathing in general, and to refer specifically to a high-pitched crowing sound associated with croup, respiratory infection, and airway obstruction.
, an oxygen saturation of 96%, and no cyanosis cyanosis (sī'ənō`sĭs), bluish coloration of the skin, mucous membranes, and nailbeds, resulting from a lack of oxygenated hemoglobin in the blood. . Her coagulation coagulation (kōăg'ylā`shən), the collecting into a mass of minute particles of a solid dispersed throughout a liquid (a sol), usually followed by the precipitation or  profile and electrocardiographic electrocardiographic

emanating from or pertaining to electrocardiography.


electrocardiographic monitoring
maintenance of a more or less continuous surveillance of a patient's cardiac status by means of electrocardiography.
 results were normal. Because her airway was stable, she was scheduled for a tracheostomy and an evacuation of the hematoma once her blood pressure had stabilized. She was started on hydralazine hydralazine /hy·dral·a·zine/ (hi-dral´ah-zen) a peripheral vasodilator used in the form of the hydrochloride salt as an antihypertensive.

hy·dral·a·zine
n.
 infusion, but she developed severe stridor after a few hours because the hematoma continued to enlarge.

An emergency tracheostomy was performed under local anesthesia, and the hematoma was evacuated through an incision along the floor of the mouth. Diffuse hematoma was noted in the substance of the tongue, and large clots were evacuated from the sublingual and submandibular areas. Numerous bleeding vessels were observed in the tongue musculature and submandibular area, and they were ligated. The patient, who was fully edentulous edentulous /eden·tu·lous/ (-tu-lus) without teeth.

e·den·tu·lous
adj.
Having no teeth; toothless.
, exhibited no sign of trauma to the tongue or floor of the mouth.

Postoperatively, the patient's blood pressure was controlled and the swelling subsided after several days. Computed tomography (CT) revealed the presence of a diffuse hematoma in the tongue musculature (figure 2). She was subsequently discharged in good condition.

Discussion

Hemorrhage and hematoma of the oral cavity can be fatal. Spontaneous bleeding into the sublingual and submaxillary submaxillary /sub·max·il·lary/ (-mak´si-lar?e) below the maxilla.

sub·max·il·lar·y
adj.
1. Of or relating to the lower jaw; mandibular.

2. Situated beneath the maxilla.
 spaces can create a "pseudo-Ludwig's phenomenon," in which the tongue and floor of the mouth become elevated and cause airway compromise. (1) Sublingual hematoma has been caused by warfarin-induced coagulopathy, (1) tongue trauma, (2) a simple puncture of the tongue substance, (3) maxillofacial trauma, (4) and tongue biting during a hypocalcemic event in an end-stage renal failure patient. (5)

To the best of our knowledge, spontaneous hemorrhage in the sublingual and lingual areas secondary to uncontrolled hypertension has not been previously reported. Our case is indeed unusual in that hypertensive bleeds typically occur intracranially or as epistaxis. The etiology of the hematoma in our patient was probably similar to that of hypertensive epistaxis in that vessel wall arteriosclerosis arteriosclerosis (ärtĭr'ēōsklərō`sis), general term for a condition characterized by thickening, hardening, and loss of elasticity of the walls of the blood vessels.  was probably a contributing factor.

The initial management step of securing the airway is of vital importance, of course. A large hematoma that obstructs the airway renders laryngoscopic intubation intubation /in·tu·ba·tion/ (in?too-ba´shun) the insertion of a tube into a body canal or hollow organ, as into the trachea.

endotracheal intubation
 impossible. In such a case, an emergency tracheostomy under local anesthesia is necessary. Once the precipitating cause has been treated, evacuating the hematoma and achieving hemostasis usually resolves the acute condition.

References

(1.) Cohen cohen
 or kohen

(Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male.
 AF, Warman SP. Upper airway obstruction secondary to warfarin-induced sublingual hematoma. Arch Otolaryngol Head Neck Surg 1989;115:718-20.

(2.) Hing NR, Bowler MD, Byth PL, Daly CG. Lingual haematoma leading to upper airway obstruction. Br J Oral Maxillofac Surg 1985;23:322-5.

(3.) Kattan B, Snyder HS. Lingual artery hematoma resulting in upper airway obstruction. J Emerg Med 1991;9:421-4.

(4.) Chase CR, Hebert JC, Faruham JE. Post-traumatic upper airway obstruction secondary to a lingual artery hematoma. J Trauma 1987;27:9534.

(5.) Ng KP. Lingual haematoma: Yet another unusual cause of upper airway obstruction. Med J Malaysia 1998;53:112-4.

From the Department of Otolaryngology (Dr. Prepageran and Dr. Raman) and the Department of Oral Maxillofacial Surgery (Dr. Ismail and Dr. Rahman), University of Malaya Medical Center, Kuala Lumpur, Malaysia.

Reprint requests: Narayanan Prepageran, Department of Otolaryngology, University of Malaya Medical Center, Kuala Lumpur, 50603 Malaysia. Phone: +60-3-7950-2062; fax: +60-3-7955-6963; e-mail: prepageran@yahoo.com
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Author:Rahman, Zainal Ariff Abdul
Publication:Ear, Nose and Throat Journal
Date:Aug 1, 2002
Words:806
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