Spontaneous tonsillar hemorrhage from infectious causes is extremely rare and post-tonsillectomy hemorrhage, although also relatively rare, is an unavoidable complication of the procedure. Hemorrhage in association with tonsillitis or tonsillectomy is potentially dangerous and can be life threatening. We report here the presentation and management of a 42-yr-old man with severe spontaneous hemorrhage from infected tonsils and post-tonsillectomy hemorrhage. We suggest that if attempts to control the bleeding are not successful or if severe spontaneous tonsillar hemorrhage occurs repeatedly or a malignancy is suspected, tonsillectomy and close postoperative follow up is recommended.
Spontaneous tonsillar hemorrhage is a rare complication of acute or chronic tonsillitis, most likely due to the early use of antibiotics (
A 42-yr-old man was referred to us by his local physician after a 1.5 hr episode of oral bleeding. His history was positive for a sore throat for 3 months that had been treated intermittently with antibiotics. There was no prior history of oral bleeding. An examination revealed bilateral tonsillar hypertrophy with hyperemia, and a blood clot in the lower pole of the right tonsil. However, no active bleeding was seen. The white blood cell count, hemoglobin, prothrombin/partial thromboplastin levels and bleeding time were normal. The blood clot was removed and the lower pole of the right tonsil was cauterized with silver nitrate. Oral antibiotics were prescribed and the patient was scheduled for a tonsillectomy.
Seven days later the patient presented to the emergency room because of spitting fresh blood from the mouth for 1 hr. His tonsils were congested and fresh blood was seen oozing from the lower pole of the right tonsil (
On postoperative day 4, the patient presented to the emergency room with a history of bright red bleeding from the mouth for a few hours. His hemoglobin level was 6.9 g/dL and he received 2 units of packed red blood cells. In the operating room, diffuse oozing from the tonsillar beds was cauterized with bipolar diathermy hemostasis under general anesthesia. The hemoglobin level was 9.5 g/dL (post-transfusion). On postoperative day 9, the patient complained of fresh bleeding from the mouth. The bleeding was controlled by bipolar diathermy hemostasis under local anesthesia. The hemoglobin level was 6.7 g/dL and the patient received 2 units of packed red blood cells.
During hospitalization, further evaluations for a bleeding disorder were carried out. However, there was no clinical or laboratory evidence of a hematological or clotting disorder. On postoperative day 14, the patient was discharged from the hospital.
Spontaneous tonsillar hemorrhage is diagnosed due to the bleeding of intact tonsils after iatrogenic or prior surgical causes have been ruled out. Griffies et al. (
A spontaneous tonsillar hemorrhage presents as bleeding or blood clots identified in the mouth. Therefore, hemoptysis, hematemesis, posterior epistaxis, carcinoma related to the naso- or hypopharynx and hematological and clotting disorders should be considered in the differential diagnosis of spontaneous tonsillar hemorrhage (
It is possible that inflammation of the tonsils results in increased blood flow to the tonsils and then necrosis or trauma of the congested tonsillar vessels leads to spontaneous tonsillar hemorrhage (
The treatment of spontaneous tonsillar hemorrhage generally consists of local control with silver nitrate cauterization, epinephrine injection, suture ligation and unilateral or bilateral tonsillectomy (
No potential conflict of interest relevant to this article was reported.
Intraoral photograph showing bleeding from the lower pole of the right tonsil (arrow).
Section of tonsil showing prominent subepithelial blood vessels beneath the covering stratified squamous epithelium and the underlying lymphoid germinal center with reactive hyperplasia. There was no other primary pathologic vascular abnormality visible (H&E, ×100).