Case study
Haematoma of the Floor of the Mouth Associated to Acute Myocardial Infarction
Hematoma de suelo oral asociado al síndrome coronario agudo
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array:4 [ "nombre" => "Alejandro" "apellidos" => "Pelaz" "email" => array:1 [ 0 => "alejandropelazgarcia@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Jeremías" "apellidos" => "Bayón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Lorena" "apellidos" => "Gallego" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Luis" "apellidos" => "Junquera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía Maxilofacial, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía Maxilofacial, Hospital de Cabueñes, Gijón, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hematoma de suelo oral asociado al síndrome coronario agudo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1300 "Ancho" => 975 "Tamanyo" => 196551 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Left view. Subsequent growth of the haematoma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The oral floor and tongue are both generously irrigated by branches arising from the external carotid artery, among which are the lingual, facial and submental arteries.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Haemorrhage and haematoma at this level are usually associated with soft tissue or bone trauma of this territory or with certain surgeries on it. Haematomas in the oral floor have also been described in haemophilic patients<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and in relation to the use of acenocoumarol,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> streptokinase<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> or heparin.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Bleeding complications associated with the use of tissue plasminogen activator have been well documented. However, we have registered only 3 cases of oral floor haematomas related to using alteplase.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Case</span><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of an 80-year-old male patient admitted to our hospital due to an acute coronary syndrome with posterior inferior ST elevation myocardial infarction (STEMI). Four hours after the onset of chest pain and having established the diagnosis of STEMI, we began conventional therapy (aspirin, clopidogrel, heparin sodium and thrombolysis with 9000<span class="elsevierStyleHsp" style=""></span>units of alteplase). After 90<span class="elsevierStyleHsp" style=""></span>min, not fulfilling reperfusion criteria, we proceeded to perform a rescue percutaneous coronary intervention (PCI) of the right coronary artery.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Immediately after completing the thrombolysis, a haematoma appeared in the oral floor, with progressive growth (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). After 4<span class="elsevierStyleHsp" style=""></span>h, the patient began to show obvious signs of airway involvement. Being unable to carry out conventional intubation, we proceeded to perform an emergency tracheostomy under local anaesthesia. Once the surgery was completed, we explored the oral area thoroughly, finding no traumatic lesions that explained the haematoma. Nevertheless, we did confirm the synchronous presence of other smaller haematomas located in the abdomen, right forearm and left hand. We also observed epistaxis and haematuria.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Any unrecognised oropharyngeal trauma can lead to haematomas in the oral floor or upper airways, especially severe in patients with coagulation disorders. The genesis of these haematomas is often related to lesions secondary to bites in the context of an episode of syncope or convulsive crisis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In this context, it is crucial to conduct a thorough exploration of the oral mucosa to rule out an aetiopathogenic cause of the haematoma. In our patient, we could not identify any suspicious area, so we must accept that it originated spontaneously.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The indexed literature contains 3 similar cases.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a> Two of them occurred in the context of acute coronary syndrome<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> and another during a transient ischemic attack.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> On two occasions, no traumatic injury was identified to justify their apppearance.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">At any rate, it is important to consider that, in critically ill patients with coagulation disorders, any manoeuvre aimed at maintaining airway patency, including both the placement of a Guedel airway and naso- or endotracheal intubation, may become an involuntary aetiopathogenic agent of the haematoma.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Another point to consider is the type of measures to be applied after the onset of this complication and their adequate timing. Surgical drainage is not usually indicated in the initial moments of the haematoma, due to the diffuse and widespread nature of the bleeding.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> At this stage, a close control of size and growth rate together with an evaluation of the position and size of the tongue are considered as appropriate measures. For some authors, the administration of corticosteroids, antibiotics and oxygen therapy is recommendable.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> If the haematoma is self-limited, its reabsorption usually occurs around the tenth day.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Uncontrolled progression of the episode generally leads to a clinical situation similar to Ludwig angina,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> characterised by oral floor elevation, increased tongue volume with superior and posterior displacement and loss of mobility. The presence of dysarthria, dysphagia, drooling and dyspnoea require the adoption of an urgent therapeutic attitude to preserve airway patency. Treatment can range from intubation (orotracheal or nasotracheal) to cricothyroidotomy or tracheostomy.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">According to the latest protocols, an active major haemorrhage would require performing a primary percutaneous coronary intervention at the expense of thrombolysis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Consequently, it seems advisable to carry out an oropharyngeal examination before performing thrombolysis, especially in patients who have suffered a loss of consciousness, trauma or manipulation of the airway in the context of cardiopulmonary resuscitation.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interests</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres94853" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec82004" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres94852" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec82005" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-06-14" "fechaAceptado" => "2010-07-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec82004" "palabras" => array:3 [ 0 => "Haematoma of the floor of the mouth" 1 => "Alteplase" 2 => "Acute myocardial infarction" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec82005" "palabras" => array:3 [ 0 => "Hematoma de suelo oral" 1 => "Alteplasa" 2 => "Síndrome coronario agudo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We report the case of an 80-year-old man who developed a haematoma in the floor of the mouth after receiving alteplase in the treatment of an acute myocardial infarction. Both the treatment received and appropriate preventive measures to avoid such haematomas are described.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de un paciente varón de 80 años de edad, ingresado en nuestro hospital por un síndrome coronario agudo tratado con alteplasa, tras lo cual desarrolló un hematoma de suelo oral espontáneo. Describimos tanto el tratamiento recibido como las medidas preventivas para evitar su aparición.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Pelaz A, et al. Hematoma de suelo oral asociado al síndrome coronario agudo. Acta Otorrinolaringol Esp. 2011;62:462–4.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 731 "Ancho" => 975 "Tamanyo" => 147617 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Anterolateral view of the haematoma affecting the oral floor that compromises the volume in the oral cavity.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1300 "Ancho" => 975 "Tamanyo" => 196551 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Left view. Subsequent growth of the haematoma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lingual hematoma threatening airway obstruction in a patient on oral anticoagulation with warfarin" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B. Özpolat" 1 => "M. Ali Yilmaz" 2 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2021 March | 0 | 32 | 32 |
| 2021 February | 0 | 13 | 13 |
| 2021 January | 0 | 8 | 8 |
| 2020 December | 0 | 7 | 7 |
| 2020 November | 0 | 3 | 3 |
| 2020 October | 0 | 3 | 3 |
| 2020 September | 0 | 5 | 5 |
| 2020 June | 0 | 3 | 3 |
| 2020 May | 0 | 2 | 2 |
| 2020 April | 0 | 4 | 4 |
| 2020 March | 82 | 3 | 85 |
| 2020 February | 59 | 12 | 71 |
| 2020 January | 72 | 5 | 77 |
| 2019 December | 93 | 12 | 105 |
| 2019 November | 63 | 13 | 76 |
| 2019 October | 83 | 5 | 88 |
| 2019 September | 39 | 7 | 46 |
| 2019 August | 42 | 4 | 46 |
| 2019 July | 44 | 17 | 61 |
| 2019 June | 36 | 23 | 59 |
| 2019 May | 148 | 60 | 208 |
| 2019 April | 77 | 34 | 111 |
| 2019 March | 35 | 20 | 55 |
| 2019 February | 34 | 6 | 40 |
| 2019 January | 22 | 5 | 27 |
| 2018 December | 15 | 8 | 23 |
| 2018 November | 25 | 10 | 35 |
| 2018 October | 23 | 2 | 25 |
| 2018 April | 17 | 5 | 22 |
| 2018 March | 23 | 0 | 23 |
| 2018 February | 9 | 1 | 10 |
| 2018 January | 10 | 0 | 10 |
| 2017 December | 10 | 5 | 15 |
| 2017 November | 17 | 6 | 23 |
| 2017 October | 13 | 4 | 17 |
| 2017 September | 15 | 9 | 24 |
| 2017 August | 10 | 5 | 15 |
| 2017 July | 13 | 6 | 19 |
| 2017 June | 16 | 25 | 41 |
| 2017 May | 19 | 12 | 31 |
| 2017 April | 19 | 5 | 24 |
| 2017 March | 30 | 21 | 51 |
| 2017 February | 29 | 6 | 35 |
| 2017 January | 23 | 6 | 29 |
| 2016 December | 24 | 6 | 30 |
| 2016 November | 31 | 8 | 39 |
| 2016 October | 32 | 5 | 37 |
| 2016 September | 47 | 18 | 65 |
| 2016 August | 21 | 11 | 32 |
| 2016 July | 21 | 1 | 22 |
| 2016 June | 29 | 10 | 39 |
| 2016 May | 31 | 7 | 38 |
| 2016 April | 40 | 28 | 68 |
| 2016 March | 35 | 14 | 49 |
| 2016 February | 41 | 19 | 60 |
| 2016 January | 34 | 13 | 47 |
| 2015 December | 31 | 14 | 45 |
| 2015 November | 18 | 20 | 38 |
| 2015 October | 33 | 14 | 47 |
| 2015 September | 33 | 14 | 47 |
| 2015 August | 30 | 5 | 35 |
| 2015 July | 45 | 5 | 50 |
| 2015 June | 12 | 5 | 17 |
| 2015 May | 20 | 8 | 28 |
| 2015 April | 22 | 8 | 30 |
| 2015 March | 35 | 7 | 42 |
| 2015 February | 16 | 4 | 20 |
| 2015 January | 35 | 6 | 41 |
| 2014 December | 38 | 5 | 43 |
| 2014 November | 13 | 4 | 17 |
| 2014 October | 26 | 6 | 32 |
| 2014 September | 28 | 5 | 33 |
| 2014 August | 32 | 5 | 37 |
| 2014 July | 20 | 2 | 22 |
| 2014 June | 21 | 1 | 22 |
| 2014 May | 29 | 3 | 32 |
| 2014 April | 24 | 2 | 26 |
| 2014 March | 22 | 4 | 26 |
| 2014 February | 23 | 2 | 25 |
| 2014 January | 18 | 2 | 20 |
| 2013 December | 25 | 4 | 29 |
| 2013 November | 27 | 2 | 29 |
| 2013 October | 17 | 6 | 23 |
| 2013 September | 18 | 3 | 21 |
| 2013 August | 10 | 2 | 12 |
| 2013 July | 1 | 0 | 1 |
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