Unusual case of soft palate and uvula haematoma in a patient on anticoagulant drugs

Background

Oral haematomas are rare complications that can occur spontaneously or following trauma to the buccal cavity by intubation, extubation, dental prosthetics such as tooth crowns.1–4 Case reports found in literature also described haematoma formation secondary to medication namely thrombolytic agents, anticoagulants and dual antiplatelet therapy.5 Warfarin is one anticoagulant drug that can be a causative or exacerbating factor for oral haematomas.6 Despite its long years of extensive use in the medical field, warfarin remains responsible for many bleeding complications in patients, particularly due to multiple interactions with different drugs.7 Oral haematomas are an unusual complication of warfarin which can be easily missed, especially if asymptomatic. If undetected, this haematoma could grow in size or bleed leading to obstructive complications and other potentially life-threatening problems. Hence, prompt diagnosis and management are vital.

Case presentation

A 91-year-old Caucasian man presented to our medical team in view of haemoptysis which started immediately after eating a very hot traditional snack (known in Maltese as pastizz sn. or pastizzi pl., these are a traditional Maltese savoury snack made up of fat based flaky pastry and cottage cheese filling, served piping hot). As a result, the patient burned the superior aspect of his oral cavity, just over the soft palate and uvula. The patient reported production of one cup of fresh blood with clots which resolved spontaneously after a few minutes. He did not have any obstructive symptoms such as swallowing or breathing problems. He was previously well controlled on warfarin 3.5 mg for atrial fibrillation (AF), with no history of bleeding complications. The patient ensured compliance to treatment and no recent changes in treatment.

The patient’s haemoptysis had not recurred by the time he had arrived to the hospital’s emergency department about 1 hour after onset. Clinical examination was unremarkable except for a single 2 cm by 2 cm dark red round bullous lesion in the buccal cavity, which was observed on the patient’s soft palate, just anterior to the uvula, along the midline (figure 1A,B). This lesion was large enough to obscure the uvula on oropharyngeal examination using a torch and tongue depressor. There was no active bleeding from this lesion or elsewhere. The patient had no dentures or loose teeth, but poor dental hygiene was evident. There were no other obvious abnormalities of the oropharynx. The lesion was not causing any pain or discomfort, so much so that the patient was unaware of its presence until we informed him after having examined him.

The patient did not have further episodes of haemoptysis throughout the admission, he remained haemodynamically stable throughout and had no complications. The haematoma did not change in size for the duration of the admission.

Investigations

Blood tests were taken, these included a complete blood count and renal profile. The haemoglobin was 142 g/L and the platelet level was 157×10⁹/L. An international normalised ratio (INR) was also tested and results showed a slightly elevated level of 3.53. Prothrombin time was 40.2 s. The urea level and liver function tests were unremarkable. A chest X-ray was taken and was negative for any abnormal radiological signs of lung consolidations or haemorrhages.

Differential diagnosis

The patient in question developed a traumatic haematoma caused by ingestion of a hot object while on anticoagulant treatment. Our initial working diagnosis was that of upper airway haematoma (UAH), which is a known, although rare, complication that could occur secondary to warfarin treatment. Factors such as trauma or excessive coughing may make it even more susceptible for UAH to form. This was our final diagnosis in this patient in view of history of presenting complaint and drug history.

Another differential diagnosis was that of angina bullosa haemorrhagica (ABH) of the soft palate, which is a benign blood-filled blister or bulla within the subepithelial mucosa. However, this condition excludes haematomas caused by haematostatic disorders, therefore since our patient was on warfarin with an elevated INR, the diagnosis did not fully fit. Moreover, ABH is usually painful however in our case, the patient was not in any pain.

Dermatological diagnoses were also considered as part of our work up. Bullous conditions such as bullous lichen planus, bullous pemphigus, epidermolysis bullosa acquisita and cicatricial pemphigoid could also present as lesions of the oral mucosa. The typical features on presentation of these autoimmune conditions have include multiple painful fluid filled blister formation and plaque formation. These possible diagnoses could be confirmed by immunofluorescence done on a biopsy of the lesion, which would be evident for IgM, IgG or C3 antibodies. Since the patient presented with a painless, solitary nodule with no plaques, these diagnoses were unlikely and no biopsy was done to prevent running the unnecessary risk of bleeding complications during biopsy.

Treatment

We admitted the patient for strict anticoagulation control and monitoring for any increase in size of the haematoma and other complications including any further haemoptysis.

Cardiology advice was sought for so as to help weigh the benefit of omitting warfarin to minimise risk of bleeding against the risk of a cerebrovascular event occurring in view of history of AF. This was also discussed with the patient, who expressed concern regarding the risk of omitting warfarin with respect to cerebrovascular events. However, he also fully understood the risk of bleeding if he were to continue taking warfarin at the same dose. A compromise was reached between our team, the cardiology team and the patient himself to omit the warfarin for a total of 7 days, to minimise the risk of further bleeding and restart warfarin afterwards if the lesion resolved with no bleeding complications. The cardiology team also advised that should the warfarin be restarted again, the target INR range could be lowered to 1.8–2.0, rather than the standard 2.0–3.0.

Ear, nose and throat specialist advice was also sought, who advised prescribing oral prednisolone 40 mg daily for 5 days and oral omeprazole 20 mg daily for 5 days as gastroprotection.

The patient was admitted for 3 days, during which he administered a single stat dose of 5 mg of vitamin K orally on the same day of presentation, with the aim to lower his INR. Daily INR tests were taken to monitor response. Eventually the INR went down to 1.69 on day three and no further doses of oral vitamin K were administered.

The patient was well and managing oral intake. No airway obstruction developed and the lesion did not change in size. He was discharged on day three with a follow-up in 7 days at outpatients’ department. The patient was advised to avoid consumption of very hot foods and to prevent trauma to oral mucosa (by gentle toothbrushing and avoiding using toothpicks in mouth) and to seek urgent medical advice should he develop any symptoms such as dysphagia, stridor or dyspnoea.

Outcome and follow-up

The patient was reviewed at 7 days (figure 2A,B) and 21 days (figure 2C,D) postpresentation at the outpatients’ department. He remained stable and the previously described haematoma had completely resolved and all that was left after 7 days was a small 1 cm diameter erythematous patch in the midline, in the same area of the previously present haematoma. The patient was advised to restart warfarin at a reduced dose of 3 mg 7 days postpresentation. Target INR range was lowered from 2.0−3.0 to 1.8−2.0 to minimise bleeding risks. On day 21, he had complete resolution of any and all observable features of his previous pathology. INR on day 21 was 1.87. The patient was followed up by his general practitioner thereafter.