Spontaneous Upper Airway Hematoma

Laryngoscopic Clinic

A 50-year-old woman presented to our emergency department with a 1-week history of progressive sore throat, odynophagia, and dysphagia. She had a history of valvular heart disease status postmitral valve replacement and had been receiving anticoagulation with warfarin (5 mg daily) for 26 years. She denied recent illness. On physical examination, she had stable vital signs without fever or acute respiratory distress. Laryngoscopic examination revealed edematous and ecchymotic mucosa over the epiglottis, pharyngoepiglottic folds, tongue base, posterior pharyngeal wall, arytenoids, and vocal folds (Figure 1). Laboratory studies revealed a normal white blood cell count. Hematological investigations revealed prothrombin time of >100 seconds, an international normalized ratio (INR) of 15.7 and partial thromboplastin time of 68.9 seconds. She was informed that awake tracheotomy would need to be performed if she had the onset of respiratory stridor even at risk of severe operative bleeding. She was immediately admitted to the 1intensive care unit for observation and normalization of her coagulopathy. On day 2, the INR was corrected after administration of vitamin K and fresh frozen plasma. Follow-up laryngoscopy showed extensive ecchymosis over the tongue base and the mucosa of larynx and hypopharynx but rapid resorption of the edema on day 4 (Figure 2). The patient’s hospital stay was uncomplicated.

Figure 1.

Laryngoscopic examination revealed edematous and ecchymotic mucosa over the epiglottis, pharyngoepiglottic folds, tongue base and posterior pharyngeal wall, and arytenoids.

Figure 2.

Follow-up laryngoscopy showed extensive ecchymosis over the tongue base and the mucosa of larynx and hypopharynx after resolution of the edema on day 4.

Spontaneous upper airway hematoma is uncommon but is a life-threatening complication of warfarin therapy. ^{1 –3} Thirty-eight cases of upper airway hematoma secondary to warfarin therapy were reported in a systematic literature review. ¹ Most cases presented with dysphagia, sore throat, neck swelling, and respiratory compromise. The most common site of hematoma was sublingual, followed by retropharyngeal and laryngeal regions. Half of the cases were managed conservatively while the rest underwent cricothyrotomy, tracheotomy, or intubation. ¹ Although it had an overall good outcome with the time to resolution of hematoma being within 1 week, significant morbidity and even sudden death were reported if concomitant respiratory compromise was present. ^{1 –3} When a patient with warfarin treatment presents with symptoms related to the upper airway, physicians must consider the possibility of this complication. If the airway compromised, emergent airway management and rapid correction of the coagulopathy are required.