血液透析患者咬舌后经导管动脉栓塞治疗的气道威胁性舌血肿

文献信息

中文摘要

背景： 舌血肿是一种罕见但可能危及生命的疾病，因为其存在快速气道梗阻的风险。接受抗血栓治疗或进行血液透析的患者可能尤其处于进展性出血的高风险之中。我们报告一例由咬舌引起、经纤维支气管镜引导气管插管和经导管动脉栓塞（TAE）成功处理的气道威胁性舌血肿。
病例介绍： 一名有卒中相关偏瘫和失语症病史的血液透析患者，正在接受阿司匹林治疗以进行脑血管疾病的二级预防。她有在睡眠和进食期间反复不自主咬舌的病史。在住院期间疑似睡眠中咬舌后，出现了进行性舌肿胀并伴有即将发生的气道梗阻。增强计算机断层扫描显示右侧舌内有活动性对比剂外渗。由于舌血肿迅速增大使气道受损迫在眉睫，在视频喉镜尝试失败后，成功实施了清醒纤维支气管镜引导气管插管。随后的血管造影显示右侧舌动脉远端局灶性血管不规则，与疑似出血部位相符，选择性TAE成功止血。因延迟血液透析以及近期输血并静脉输液导致明显的全身容量超负荷，也可能促成了舌肿胀的快速进展。由于预计气道受损将持续较长时间，遂早期行气管造口术，舌血肿逐渐消退，未出现缺血性并发症。
讨论： 尽管咬舌通常被认为是轻微损伤，但在具有出血危险因素（如血液透析和抗血小板治疗）的患者中，它可能导致危及生命的舌血肿。早期识别、及时保护气道、通过增强计算机断层扫描识别活动性出血以及选择性TAE，可能提供一种有效的多学科治疗策略，同时避免手术探查。
结论： 临床医生应认识到，在高风险患者中，看似轻微的舌创伤可迅速进展为严重的气道梗阻。当发现活动性出血时，应考虑早期气道控制联合选择性TAE。

英文摘要

BACKGROUND: Lingual hematoma is a rare but potentially life-threatening condition because of the risk of rapid airway obstruction. Patients receiving antithrombotic therapy or undergoing hemodialysis may be at particularly high risk of progressive hemorrhage. We report a case of airway-threatening lingual hematoma caused by tongue biting that was successfully managed with fiberoptic intubation and transcatheter arterial embolization (TAE).
CASE PRESENTATION: A hemodialysis patient with a history of stroke-related hemiplegia and aphasia was receiving aspirin for secondary prevention of cerebrovascular disease. She had a history of recurrent involuntary tongue biting during both sleep and meals. Following presumed tongue biting during sleep while hospitalized, progressive tongue swelling developed with impending airway obstruction. Contrast-enhanced computed tomography demonstrated active contrast extravasation within the right side of the tongue. Because rapid enlargement of the lingual hematoma made airway compromise imminent, awake fiberoptic intubation was successfully performed after failed attempts using video laryngoscopy. Subsequent angiography demonstrated focal vascular irregularity of the distal right lingual artery corresponding to the suspected bleeding site, and selective TAE achieved successful hemostasis. Marked systemic fluid overload, caused by delayed hemodialysis and recent blood transfusion with intravenous fluid administration, may also have contributed to the rapid progression of tongue swelling. Early tracheostomy was performed because prolonged airway compromise was anticipated, and the lingual hematoma gradually resolved without ischemic complications.
DISCUSSION: Although tongue biting is generally considered a minor injury, it may result in life-threatening lingual hematoma in patients with bleeding risk factors such as hemodialysis and antiplatelet therapy. Early recognition, prompt airway protection, contrast-enhanced computed tomography to identify active bleeding, and selective TAE may provide an effective multidisciplinary treatment strategy while avoiding surgical exploration.
CONCLUSION: Clinicians should recognize that seemingly minor tongue trauma can rapidly progress to critical airway obstruction in high-risk patients. Early airway control combined with selective TAE should be considered when active hemorrhage is identified.