A 68-year-old man with aortic stenosis status post mechanical valve replacement and paroxysmal atrial fibrillation on warfarin aggressively brushed his teeth and tongue the night prior to admission and presented to the emergency department with enlargement of the posterior aspect of the tongue. Laboratory analyses were significant for a supratherapeutic International Normalized Ratio (INR) > 9 and a prothrombin time > 100 seconds. Computed tomography of the neck with contrast showed a soft tissue density suggestive of hematoma at the base of the tongue, inferior to the hard palate, and in the musculature of the floor of the mouth. There was also edema in the vallecula region causing near total airway closure (Figure 1). He was intubated for airway protection and received a transfusion of fresh frozen plasma and prothrombin complex. His warfarin was held. Flexible laryngoscopy performed by otorhinolaryngology demonstrated a resolving hematoma 5 days later. Heparin infusion was started once his INR became subtherapeutic, and he was extubated. He received speech therapy and showed significant improvement of his dysphagia prior to discharge.
Figure 1.
(A) Axial and (B) sagittal views of a soft tissue computed tomography of the neck showing subtotal airway occlusion of the oropharynx (red arrows) due to the sublingual hematoma at the base of the tongue.