Airway-threatening lingual hematoma after tongue biting in a hemodialysis patient treated with transcatheter arterial embolization.

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.