A 73-year-old Caucasian woman was rushed to our Accident and Emergency department after discovering a large swelling in her mouth on awakening. She had intermittent bleeding from the site with mild pain. Her history consisted of a recently constructed set of complete acrylic dentures made one week previously by her general dental practitioner. It was reported these had been slightly uncomfortable ever since she had received them. Later questioning further revealed that our patient had worn her dentures continuously, even at night, but had not yet returned to her dentist for a follow-up. Her medical history was significant for rheumatic fever as a child, resulting in valvular heart disease for which our patient had mitral and aortic mechanical valve replacements in 1991 and 2002, respectively. Warfarin 5 mg had been initiated to obtain a target INR between 2.5 and 3.5. Our patient also had hypothyroidism, which was being treated with thyroxine replacement therapy. On arrival to the hospital, her full blood count was found to be within the normal range, however her INR was recorded as 5.5. A clinical examination revealed a large, soft, dark red swelling involving the anterior region of the floor of her mouth, indicative of sublingual hematoma. The Wharton's duct of the submandibular gland was distinctly visible on opening. As a result of the hematoma, the tongue was displaced superiorly and there was mild limitation of tongue movement. Our patient was acyanotic at the time of admission and on general examination there was no signs of stridor or major airway restriction. Further flexible endoscopic examination did not reveal any edema or obstruction within the pharynx or larynx. On palpitation there were firm, bilateral swellings noted in the submandibular and submental regions. Her mouth opening was approximately 7 mm on first presentation. Some hoarseness of her voice was appreciated, but our patient's vital signs were stable. Oxygen (5 L/minute) was delivered through a nasal cannula and our patient was advised to sit in an upright position at this time. Our patient was transferred to our Acute Assessment Unit where close monitoring of her airway was undertaken. Warfarin was stopped and 2000 IU of Beriplex® prothrombin complex concentrate supplemented with 2 mg intravenous vitamin K was administered to reverse the anticoagulation. In addition, 100 mg of intravenous hydrocortisone was provided to assist in decreasing any associated edema. At approximately two hours post-transfusion the INR was corrected to 1.0. Although the airway was patent on arrival, the hematoma was seen to be increasing in size during this time and our patient was at risk of airway occlusion. Immediate decompression of the sublingual space was performed under general anesthetic. A conscious intubation was carried out using a fiber-optic flexible nasal endoscope. Had this not have been successful a surgical cricothyroidotomy or tracheostomy would have been required to facilitate the surgery. After successful intubation, an initial horseshoe-shaped incision was made followed by blunt dissection above the mylohyoid muscle. The lingual nerve and Wharton's duct of the submandibular gland were identified and preserved. Bipolar diathermy was carried out, as well as packing of the area with absorbable oxidized cellulose agent (Surgicel®) to prevent any further bleeding. As the nasopharynx and hypopharynx were found to be clear with no obvious obstructions, a clinical decision was made to extubate our patient after surgery. Our patient was transferred to our Intensive Care Unit where she remained for four days. She was given 1 mg/kg (70 mg) of subcutaneous low-molecular-weight heparin (LMWH), which continued daily for 10 days. On day three, our patient's warfarin treatment was restarted at a dose of 2 mg initially in combination with LMWH. Daily checks of her INR were carried out and as a result, her warfarin dosage was gradually increased accordingly. During this time our patient experienced a few occasional bouts of mild bleeding from the surgical site that were easily stopped with 5% tranexamic acid mouthwash. Ecchymosis later appeared over the anterior surface of the neck. Adequate healing was soon noted in the area of the surgical site, with no evidence of further bleeding. Our patient was discharged on the 12th hospital day with a therapeutic range INR of 2.8, achieved with 4 mg of warfarin. She was advised to discontinue wearing her dentures until any necessary adjustments had been made by her general dental practitioner. At review two months later she is doing well with no signs of recurrence.