previous reports describe patients chewing on patches , applying more than the number of prescribed patches to the skin , and applying a patch to an area with a skin abrasion  all of which can lead to fentanyl toxicity .
continued vigilance among healthcare providers to detect misuse of this transdermal medication is of paramount importance to prevent untoward adverse events including death .
herein , we describe a fentanyl patch complication , which meets our institutional review board standards for minimal risk reporting in a de - identified manner , as provided below , and which , to our knowledge , has not been previously reported .
a 60-year - old man presented to our clinic for a follow - up visit , at which time he appeared despondent .
two years prior , he had been struck by a motor vehicle and fractured his first lumbar vertebra .
this fracture was treated with an l1 corpectomy and an instrumented fusion from t12 to l2 .
this complication coupled with the diagnosis of cancer , as outlined below , resulted in the patient being treated almost ever since with transdermal fentanyl for a chronic pain syndrome . a few months earlier , a hematologic evaluation for leukocytosis had led to the diagnosis of systemic mastocytosis with an associated clonal hematologic non - mast cell lineage disease , chronic myelomonocytic leukemia type 1 ( cmml-1 ) .
the steroids were tapered slowly over months , and the patient started azacytidine in place of hydroxycarbamide to treat his cmml-1 . however , during this evaluation process and treatment for mastocytosis and cmml-1 , the patient remained on a fentanyl patch ( 100-g / h patch every 72 h ) .
he had no history of a psychiatric disorder , but he had experimented with psychotropic substances in his youth and had a flat affect at baseline .
when the patient presented for his second cycle of azacytidine , he appeared despondent and described shortness of breath .
an accompanying friend reported that the patient had been less communicative over the preceding 4 days and had complained of shortness of breath .
the patient 's heart rate was 96 beats / min , blood pressure 116/77 mm hg , spo2 94% , temperature 37.0c , and respiratory rate 16 breaths / min .
the circumference of the left leg was 5 cm greater than that of his right leg , and his lungs were clear to auscultation .
the results of this presentation raised concerns about a pulmonary embolus , and the patient was thought to be at high risk ( well 's score of 7 due to clinical signs of deep venous thrombosis , likely diagnosis of pulmonary embolism , and active malignancy ) .
he was not treated immediately with anticoagulation due to his thrombocytopenia ( 36  10/l ) and renal insufficiency ( creatinine 2.3 mg / dl ) .
a lower - extremity doppler ultrasound did not reveal occlusive thrombus and chest radiography was unremarkable .
computerized tomography ( ct ) of the chest with contrast was not pursued due to renal insufficiency . however , because of declining sensorium concurrent with a dropping blood pressure of 89/45 mm hg , a ct of his head was obtained .
this imaging revealed an 8-mm left frontal and parietal subacute on chronic subdural hematoma without mass effect ; this finding remained stable on subsequent scans .
the patient 's worsening mental status and other symptomatology in the setting of an unclear diagnosis prompted hospitalization . shortly thereafter , the patient experienced a brief tonic seizure that resolved spontaneously followed by a second more prolonged tonic seizure that involved right gaze deviation and tonic posturing of both arms .
direct laryngoscopy revealed a transparent , folded , plastic - appearing item superior to the glottis .
full bronchoscopy was performed to ensure that no other foreign objects had been aspirated , and none were found .
the patient had no explanation for the discovery of a fentanyl patch in his larynx , but he denied any intention to harm himself . to date , it remains unclear exactly how the patch came to be positioned in this patient 's larynx .
the patient was discharged from the hospital with follow - up plans for the treatment of his hematologic conditions .
this case represents an unusual and unexpected complication related to the ongoing use of a fentanyl patch .
this patient apparently attempted to ingest a fentanyl patch , which became lodged within his larynx .
heat can increase the absorption of fentanyl , and , perhaps , the higher laryngeal body temperature resulted in increased transmucosal absorption of the medication , hence the manifestations of overdose , despite the patient 's long - standing use of this medication .
this case provides further confirmation of the need for sustained , heightened vigilance for drug adherence with transdermal fentanyl . in a systematic review of the complications of opioid medications , fentanyl was the opioid most commonly implicated in such untoward events .
the most frequent cases of misuse included drug - drug interactions which potentiated narcotic effects or resulted in serotonin syndrome .
other problems with fentanyl relate to the acceleration of its transdermal absorption or experimentation with alternate routes of administration .
although external heat sources have been used to maximize the euphoric effects of fentanyl , other patients have suffered unintentional overdoses from hyperthermia , sun tanning , and warming blankets .
patients have been reported to lick and chew or rectally insert transdermal fentanyl patches , and inject or inhale volatilized extracts from the patches .
inappropriate use of transdermal fentanyl patches may be more common than currently recognized and should be considered in fentanyl - treated patients who present with signs of narcotic toxicity .
the patient in this report had a near fatal event after asphyxiation with a fentanyl patch .
this case represents the first report , to our knowledge , of asphyxiation with transdermal fentanyl and highlights the need for an awareness for complications with the use of narcotics , particularly of transdermal fentanyl and particularly under circumstances in which the prescribed patch is absent from the skin .
 narcotics are frequently prescribed to alleviate pain in patients with serious medical illnesses such as cancer . because of their nonoral route of administration , 
 fentanyl patches are now being frequently prescribed . 
 however , the widespread use of fentanyl patches has been associated with medication errors and misuse [ butts and jatoi : j opioid manag 2011;7:3545 ] . 
 the transdermal delivery of fentanyl may lead to unusual , unanticipated complications . 
 herein , we describe a fentanyl patch complication , which , to our knowledge , has not been previously reported . 
Introduction
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Discussion