Lingual Hematoma: What Signs Should I Look For?

Click on my name to be redirected to a nice lingual hematoma, caused by a gbr procedure that I performed in the mandible a couple of years ago. Everything ended up well at last.

It is the first case.

Thanks for sharing your case with us of surgical complication

Almost every surgical journal publishes a case of acute hematoma, after placement of implants at the anterior mandible. Look for elevation at the floor of the mouth, protrusion of the tongue, respiratory embarassment, submental swelling, trouble swallowing and or changes of mucosal color. If you are not versed in intubation or emergent surgical airway intervention, then you best get your patient help fast. When in doubt, treat or seek care fast, because these people can go south fast. Intubation is extremely challenging in this situation, so everyone should have an LMA ( laryngeal mask ), that should fit the patient that is being operated. A good pre-op ct should lessen the likelihood of this . Bv. Vinci oral and facial surgery, Baton Rouge, la.

Nice documentation Dr Rosetti, but these are just 'normal' hematomas due to bigger flap surgeries and they are intrinsic part of the job. The floor of mouth hematomas indeed typically occur after perforating the lingual cortex (chin osteotomy, implant placement, bicortical chin graft). I've had this once and heard of it many times especially in edentulous patients where two implants for overdenture were to be placed. If you've perforated on the lingual in the canine region, which you will notice by probing the osteotomy, or by soft tissue sticking to the drill (or brisk bleeding), probability of a hematoma is great and you should strip the periosteum all the way down an coagulate any perforation you can see in it. Literature reports it can even happen without perforating the cortex, by retraction of severed perforating arteries. I think the safest way is to have the patient wait postop and to check after 30 ms in any case. Slow bleeding will cause the floor of mouth turn blackish first, so you can re-open; but acute bleeding will obstruct the airway in a few minutes. This is why I do this surgery only in the hospital. I agree CT will lessen the likelihood and with a big fossa it is safer to strip off the lingual periosteum and retract it while drilling so you can check and get ahead of this agonizing complication.

Dear Gary, I am aware that the case I posted just refers to an episode of chronic bleeding caused by the management of soft tissue, and was not a life-threatening haemorrage. I just intended to give an idea of what an haemorrage of the floor of the mouth looks like (anyway it caused a collection of blood of approximately 20cc in the neck). I have never had a massive bleeding of the floor of the mouth and I have always wondered what would be the best approach to cope with such an occurence before reaching an emergency department. stripping the periosteum to find and close the severed blood vessel? When and how? And what if the bleeding comes from below the mylohyoid line (in case of violation of the cortex below the lingual shelf)? I have read that intubation may be the best approach in some cases, but it is unlikely that a dentist can perform it correctly. Is tracheotomy a viable option? Have some guidelines been published? Thankyou

Abcd are the universal guidelines!!!! You can't go wrong, if you maintain this order and keep the case in your" wheelhouse ". Just as SB said, he only does them in a hospital setting, because he thinks this is in the patient's best inteterest. Are you doing this procedure, with these unanswered questions? If so, do you just cross your fingers, before proceeding? Bv

Oh Baker, Baker, the fact that someone asks a question, doesn’t necessarily mean that he/she does not have the answer, or at least one of the possible answers. I had the opportunity to discuss the topic, that can reveal to be very articulated, many times with colleagues and maxillo-facial surgeons, receiving different (and sometimes contrasting) answers… Many times I performed cricothyrotomies and even tracheostomies on cadavers, but none survived… Despite my experience and the education achieved, I still have many questions about it (like in every other aspect of my practice) and I think that a confrontation with people like Gary, who reported such an experience, is an opportunity (thanks Osseonews). If you wish to answer my questions, you are welcome. This may start an interesting discussion. Differently, if you like to discuss about my experience in dental surgery, we are off-topic here. Regards. Paolo Crossing my fingers before the surgery?!? I had never thought about it…It may work. Thanks.

Poalo, Poalo , I finally looked at your cases. I am sorry, but I'm afraid you have mistaken lingual hematoma for echimosis and bruising. Certainly there is some swelling, but your first patient needs submental liposuction, followed by a platysma plication and neck lift. He has more of a lipoma than a hematoma. Might I suggest autogenous bone for these cases. You are putting a figurative " heavy load " on your graft success. You do in fact need passive primary closure for these kind of cases. I rather like the " tenting" technique that you are using, but I would not use anything less than 50% autogenous bone. These look as if they are treatment planned with some real consideration for the end product. Good work, in my opinion. Bv

Sometimes reading these posted answers is like reading online posts for dating services, one does not know if what is posted is true, Poalo you stated to look at your website for a nice lingual hematoma which turned out alright. This is misleading information. An honest person would have admitted the mistake and said thank you for the correction. A lingual hematoma is best handled by avoidance with a ct scan in an atrophic mandible and a surgical guide with careful technique. I've never had this happen to me personally (Thank God) but I would apply pressure to the lingual plate while I was waiting for the paramedics to arrive. I would also insert an oral (if the patient would tolerate it) or nasal airway, oral to help tamponade the bleeding and a nasal for airway behind the tongue. I hope I would not soil myself! I always hate to see doctors getting into an ego altercations vs just being honest. I do get some pearls from reading this blog and I hope I can contribute useful information also.