To be or knot to be: sudden sublingual hematoma caused by tying a traditional headscarf

Sublingual hematoma is a rare and potentially life-threatening condition usually associated with oral anticoagulant therapy or orofacial trauma. A 77-year old female was seen at our department for sudden and progressive hematoma involving the sublingual and submental spaces, without a history of coagulopathy, oral anticoagulant therapy, or major trauma. However, there was a history of repeated mechanical pressure under the chin caused by a headscarf, worn as a part of the traditional folk wear. Coagulation screening revealed a decrease in vitamin K–dependent coagulation factors and an increase in the international normalized ratio, which was considered to be a result of previous prolonged antibiotic treatment for urinary infection, followed by a diarrheic syndrome. The patient was treated with fresh frozen plasma and vitamin K, without the need for active airway management. We have suggested that specifically located and repeated mechanical pressure of low intensity leads to hematoma formation in a patient with coagulation disorder. Airway maintenance and coagulopathy reversal were the mainstay of treatment.