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Correspondence |
Royal Victoria Hospital, Montreal, Canada, E-mail: roupenhatz{at}hotmail.com
To the Editor:
Compromise of the upper airway associated with tracheal intubation often involves trauma to the teeth or gums.1 Less frequently, other anatomical structures are involved. We report a case of an epiglottic hematoma following an uneventful general anesthetic. Consent for the use of personal health information was obtained in accordance with our local institutional guidelines.
A 75-yr-old female patient presented for elective left inguinal hernia repair. Her medical history included paroxysmal atrial fibrillation (AF) and sick sinus syndrome. A pacemaker was inserted one week prior to her surgery. She had previous surgeries under general anesthesia without complication. Her medications included warfarin 3.5 mg po qd for AF and celecoxib 200 po mg qd for arthritic pain. The former was discontinued ten days and the latter two days prior to her operation. Other medications included sotalol 40 mg po bid and transdermal fentanyl 25 ·g every three days. Her preoperative platelet count, prothrombin time (PT), and activated partial thromboplastin time (APTT) were in the normal range. The procedure was done under general anesthesia. Following induction of anesthesia, a 7.5-mm endotracheal tube was inserted into the trachea without difficulty (Cormack Lehane grade I view). Surgery was uneventful. At the end of the procedure the oropharynx was suctioned prior to tracheal extubation, and the patient was transferred to the recovery room. Several hours later the patient complained of sore throat and hoarseness. This was attributed to the tracheal intubation, and she was discharged home with reassurance that the symptoms would resolve. However, five days later she presented to the emergency room with worsening sore throat, hoarseness and dysphagia. There were no clinical signs of upper airway obstruction. Notably, she had not yet resumed warfarin or celecoxib. The x-ray and computed tomography scan showed an enlarged epiglottis with normal subglottic anatomy (Figures 1
, 2). Fibreoptic examination of the upper airway revealed a large epiglottic hematoma. The patient was subsequently admitted to the intensive care unit and treated for three days with dexamethasone 8 mg iv q8h (no supplemental oxygen was administrated, the patient remained on R/A). Fibreoptic examination three days later showed a decrease in epiglottic size, and the patient was discharged the following day. She has remained symptom free since.
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This report highlights that sore throat, hoarseness and dysphagia following endotracheal intubation could be presenting symptoms of the rare, but potentially serious complication of an epiglottic hematoma. This entity should be considered in the differential diagnosis of upper airway lesions when confronted with this triad of symptoms following anesthesia where endotracheal intubation was performed, especially in patients receiving concurrent anticoagulation therapy.
Footnotes
Accepted for publication December 21, 2005.
References
1 Owen H, Waddell-Smith. Dental trauma associated with anaesthesia. Anaesth Intensive Care 2000; 28: 133–45.[Medline]
2 Cheng KS, Li HY. Epiglottic hematoma secondary to endotracheal intubation. Acta Anaesthesiol Sin 1999; 37: 49–52.[Medline]
3 Brown I, Kleinman B. Epiglottic hematoma leading to airway obstruction after general anesthesia. J Clin Anesth 2002; 14: 34–5.[Medline]
4 Lee M, Berger HW, Granada MG. Acute upper airway obstruction. Sodium warfarin-induced hemorrhage into the base of the tongue and epiglottis. Chest 1980; 77: 454–5.
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