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Hard to Swallow: A Mediastinal Hematoma Causing Esophageal Compression After Endobronchial Ultrasound-guided Transbronchial Needle Aspiration.

To the Editor: Dysphagia is a common symptom in many elderly patients. Among individuals over 50 years of age, there is an estimated prevalence of 16% to 22%.1 There are 2 basic mechanisms responsible for dysphagia; disordered motor function or mechanical lesions leading to obstruction. These lesions are typically intrinsic, such as strictures, rings, webs, and tumors.1 Rarely extrinsic esophageal compression, from mediastinal masses, vascular compression, or surgical changes cause obstruction.1 Esophageal compression secondary to mediastinal hematomas is rare. Herein we report a case of a subcarinal mediastinal hematoma causing esophageal compression following endobronchial ultrasoundguided transbronchial needle aspiration (EBUS-TBNA). A 66-year-old female with mechanical aortic and mitral valve replacements on chronic anticoagulation was referred to pulmonary clinic for ongoing fevers, weight loss, and dyspnea on exertion. A computed tomographic (CT) angiogram of the chest revealed mild left hilar and mediastinal lymphadenopathy (Fig. 1). Given her clinical symptoms, a bronchoscopy with endobronchial ultrasound-guided biopsies was planned. Warfarin was held in preparation for the bronchoscopy and she started enoxaparin in the interim. On the day of her procedure, the international normalized ratio (INR) was 1.6 and enoxaparin had been held for 12 hours. She underwent bronchoscopy with EBUSTBNA using a standard 22-G needle of station 7 and 10 L. Of note, no significant vascularity of either of the lymph nodes was noted on endobronchial ultrasound. There was no significant intraprocedural bleeding noted and the procedure was completed without complication, and she restarted her anticoagulation (weight-based therapeutic enoxaparin bridge to warfarin) the following day. She was started on her usual dose of warfarin; however, on recheck of INR 2 days after reinitiation of anticoagulation, her INR was subtherapeutic, and therefore her dose was increased by 25% with recheck planned for 4 days later. Six days later she presented to the Emergency Department due to dysphagia, nausea, and vomiting. Her laboratory results were notable for a supratherapeutic INR of 5.6. CT was completed showing a subcarinal mass causing a shift of the esophagus with significant external compression (Figs. 2, 3). The subcarinal mass was most consistent with a hematoma (+67 Hounsfield units), in the setting of supratherapeutic INR and recent bronchoscopy with EBUS-TBNA. She was seen by thoracic surgery who recommended holding anticoagulation for 24 hours. Repeat imaging the following day showed a stable subcarinal hematoma after which anticoagulation was resumed. Follow-up CTs at 1 and 6 months showed progressive improvement and complete resolution, respectively (Fig. 4). The patient was ultimately diagnosed with anaplastic lymphoma and began treatment with cisplatinbased chemotherapy. EBUS-TBNA is a safe procedure, with complications occurring only 1.2% of the time and hemorrhage 0.68% of the time.2 Mediastinal hematomas typically are caused by traumatic