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Acute Airway Obstruction in a Patient Being Treated With Anticoagulation Therapy

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 71-year-old man presented to the emergency department with dyspnea, dysphonia, dysphagia, and neck swelling. He denied chills, fever, neck stiffness, new medications, otalgia, sick contacts, trismus, and use of an angiotensin-converting enzyme inhibitor. His complex medical history included factor V Leiden deficiency requiring therapeutic anticoagulation, heart failure with atrial fibrillation, and chronic obstructive pulmonary disease associated with 110-pack-year smoking history. Laboratory studies demonstrated an international normalized ratio of 16.4, a prothrombin time of 118.1 seconds, and a partial thromboplastin time of 81.4 seconds. On examination, the patient had substantial dysphonia, fullness in the left submandibular region, and ecchymosis of the lateral left neck extending toward the midline. Contrast-enhanced computed tomography performed in the emergency department revealed a large, intermediate-density, modestly enhancing, left-sided submucosal lesion extending from the nasopharynx inferiorly to the glottis with encroachment on the airway (Figure). Flexible fiberoptic laryngoscopy demonstrated a large submucosal mass extending from the left posteroinferior nasopharyngeal wall to the left lateral and posterior pharyngeal walls, obstructing the view of the left supraglottis, glottis, and piriform sinus. The right side of the epiglottis was ecchymotic and edematous. The mass extended farther along the aryepiglottic fold to involve the arytenoid and interarytenoid space, as well as the false vocal fold on the left. The vocal cords were only partially visualized. Given the important laryngoscopy findings, the decision was made to proceed with awake fiberoptic nasotracheal intubation in the operating room to secure the patient’s airway.

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D. Spontaneous airway hemorrhage with obstructive hematoma

Warfarin sodium was first approved for inhibiting coagulation in the 1950s. Warfarin inhibits the vitamin K-dependent clotting factors in the coagulation cascade, factors II, VII, IX, and X, as well as proteins C and S, leading to systemic anticoagulation.1 Indications for its use include prophylaxis and treatment of venous thrombosis and pulmonary embolism, prevention of thromboembolic events associated with atrial fibrillation or cardiac valve replacement, and reduction of the risk of death or recurrent cardiovascular events after myocardial infarction.1 The most frequent adverse reaction to warfarin is hemorrhage.1 The most common sites of bleeding are the gastrointestinal, genitourinary, cutaneous, and intracranial locations.2,3

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Article Information

Corresponding Author: Amal Isaiah, MD, PhD, Department of Otorhinolaryngology–Head and Neck Surgery, University of Maryland School of Medicine, 16 S Eutaw St, Ste 500, Baltimore, MD 21201 (aisaiah@som.umaryland.edu).

Published Online: January 21, 2021. doi:10.1001/jamaoto.2020.5172

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient’s spouse for granting permission to publish this information.

References
1.
Coumadin (warfarin sodium). Full prescribing information. Bristol Myers Squibb. Accessed August 29, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/009218s118lbl.pdf
2.
Uppal  HS , Ayshford  CA , Syed  MA .  Spontaneous supraglottic haemorrhage in a patient receiving warfarin sodium treatment.   Emerg Med J. 2001;18(5):406-407. doi:10.1136/emj.18.5.406PubMedGoogle ScholarCrossref
3.
Forfar  JC .  A 7-year analysis of haemorrhage in patients on long-term anticoagulant treatment.   Br Heart J. 1979;42(2):128-132. doi:10.1136/hrt.42.2.128PubMedGoogle ScholarCrossref
4.
Karmacharya  P , Pathak  R , Ghimire  S ,  et al.  Upper airway hematoma secondary to warfarin therapy: a systematic review of reported cases.   N Am J Med Sci. 2015;7(11):494-502. doi:10.4103/1947-2714.170606PubMedGoogle ScholarCrossref
5.
Jandreau  SW , Mayer  D .  Spontaneous bilateral arytenoid hematoma in a patient on warfarin.   Am J Emerg Med. 1998;16(7):674-676. doi:10.1016/S0735-6757(98)90174-7PubMedGoogle ScholarCrossref
6.
Cohen  AF , Warman  SP .  Upper airway obstruction secondary to warfarin-induced sublingual hematoma.   Arch Otolaryngol Head Neck Surg. 1989;115(6):718-720. doi:10.1001/archotol.1989.01860300072020PubMedGoogle ScholarCrossref
7.
Gooder  P , Henry  R .  Impending asphyxia induced by anticoagulant therapy.   J Laryngol Otol. 1980;94(3):347-352. doi:10.1017/S0022215100088885PubMedGoogle ScholarCrossref
8.
Koch  CA , Olsen  SM , Saleh  AM , Orvidas  LJ .  Spontaneous epiglottic hematoma secondary to supratherapeutic anticoagulation.   Int J Otolaryngol. 2010;2010:201806. doi:10.1155/2010/201806PubMedGoogle Scholar
9.
Rosenbaum  L , Thurman  P , Krantz  SB .  Upper airway obstruction as a complication of oral anticoagulation therapy: report of three cases.   Arch Intern Med. 1979;139(10):1151-1153. doi:10.1001/archinte.1979.03630470061019PubMedGoogle ScholarCrossref
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