These images demonstrate sublingual hematoma progression in a patient presenting for repeat laparoscopy after cholecystectomy complicated by incomplete hemostasis (fig.1, A to C, arrows). On postoperative day one, the patient reported frenulum tenderness, purpura, and an expanding mass beneath her tongue (fig.1A). Otolaryngology evaluation was obtained, and no immediate intervention was deemed necessary for the sublingual hematoma. Spontaneous resolution occurred over subsequent weeks (fig.1C).

Fig. 1.
Hematoma (arrows) in the immediate postoperative period (A), progression to mucosal flap at 8 days (B), and regression at 12 days (C) before resolving to baseline appearance.

Hematoma (arrows) in the immediate postoperative period (A), progression to mucosal flap at 8 days (B), and regression at 12 days (C) before resolving to baseline appearance.

Sublingual hematomas most frequently arise as the result of trauma, post-surgical bleeding, or idiopathically in patients prescribed oral anticoagulants.  They may also arise as a rare and life-threatening complication of airway manipulation during general anesthesia.

Though infrequent, injuries to the tongue and surrounding structures represent the greatest number of soft-tissue injuries following direct laryngoscopy.  Patients with Mallampati grade three and four airways may face increased incidence of injury.  Blind insertion of laryngoscopes, endotracheal tubes, and orogastric tubes are all common features of a general anesthetic which may serve as sources of trauma. Risk may be mitigated by inserting these implements under direct visualization when possible.

Utilizing video laryngoscopy, there remains potential for frenulum injury during airway instrumentation. Direct laryngoscopy necessitates visualization of the blade during insertion; however, video laryngoscopes may be inserted blindly as the operator views the screen. Injuries are also possible at extubation when blind placement of bite blocks or the use of a Yankauer suction tip may pose a risk to soft tissue structures.

While the precise insult which caused the pictured hematoma is undetermined, it is believed to be the result of oropharyngeal instrumentation (video laryngoscopy) given emergence in the immediate postoperative period. Notably, hematologic testing failed to reveal inborn or acquired coagulopathy.

Management of upper airway hematomas is guided by the degree of respiratory impairment and involves frequent reexamination, correction of coagulation deficits, and intubation if impending total obstruction.  Absent airway compromise, expectant management may be employed without the need for invasive measures. Early consultation with Otolaryngology may be warranted and appropriate pain management is necessary to aid diet progression and phonation. Following resorption of the hematoma, functional status is expected to return to near baseline prior to the injury.