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Spontaneous tonsillar hemorrhage
CASE REPORTS JEFFREY M. BUMPOUS, MD Case Report Editor
Spontaneous tonsillar hemorrhage VANDANA KUMRA, MD, A. PAUL VASTOLA, MD, STEFAN KEISERMAN, MD, and FRANK E. LUCENTE, MD, Brooklyn, New York
S
pontaneous tonsillar hemorrhage is a rare complication of tonsillitis. Common in the preantibiotic era, tonsillar bleeding was often catastrophic, due to erosion of great vessels. More recently, oropharyngeal bleeding has been reported with infectious mononucleosis and bacterial infection. Still, this symptom is rarely included in textbooks as a possible consequence or complication of tonsillitis.1-4 We present 3 cases of spontaneous tonsillar hemorrhage in pediatric patients; the pathogenesis and treatment options of the condition are discussed. CASE 1
A 13-year-old boy with a history of recurrent tonsillitis (3 times a year for 3 years) presented to his pediatrician with a history of sore throat for 1 week with hemoptysis—3 episodes that day. There was no prior bleeding history. Vital signs were stable. Examination revealed enlarged, inflamed palatine tonsils that met in the midline. There were prominent vessels over both tonsils without active bleeding. The white blood cell (WBC) count, hemoglobin, and prothrombin/partial thromboplastin (PT/PTT) levels were normal. The patient was started on oral antibiotics and scheduled for tonsillectomy in 6 weeks. Later that night the patient had a self-limited episode of hemoptysis. Tonsillectomy was performed the next day; hemoptysis resolved. CASE 2
An 11-year-old girl presented with a sore throat for 2 weeks with 10 episodes of hemoptysis over 3 days. Vital signs were stable. An examination of the oropharynx
From the State University of New York at Brooklyn (Drs Kumra and Lucente) and Maimonides Medical Center (Drs Vastola and Keiserman). Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, San Francisco, California, September 7-10, 1997. Reprint requests: Vandana Kumra, MD, 262 Central Park West, New York, NY 10024. Otolaryngol Head Neck Surg 2001;124:51-2. Copyright © 2001 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2001/$35.00 + 0 23/4/112434 doi:10.1067/mhn.2001.112434
revealed enlarged, inflamed, and friable palatine tonsils. Prominent vessels were noted over both tonsils, with active bleeding on the right tonsil. Bleeding resolved with local pressure and silver nitrate cautery. Laboratory values were notable for a leukocytosis; hemoglobin and PT/PTT levels were normal. The patient completed a 1week course of antibiotics. Tonsillectomy was performed, and the child had no further sequelae. CASE 3
A 5-year-old girl with a history of chronic tonsillitis— treated with antibiotics intermittently for 8 weeks—was brought to the emergency room after the patient had an episode of hematemesis. In the emergency room, the patient was noted to be pale, BP was 90/60 mm Hg, pulse was 143 beats/min, and temperature was 100.8°F. An examination revealed enlarged tonsils with minimal erythema and no exudate. No active bleeding was noted in the oral cavity. Nasopharyngoscopy revealed prominent adenoid tissue without blood in the larynx/nasopharynx. Lab-oratory values showed a leukocytosis, and normal hemoglobin and PT/PTT levels. The family denied any bleeding history. The patient was transferred to the intensive care unit where she had 500 cc of hematemesis. Before emergent exploration, the patient was intubated and transfused with packed red blood cells (PRBC) and fresh frozen plasma (FFP). Tonsils and adenoids were noted to be friable. Results of an esophagogastroduodenoscopy were normal, and the patient underwent an adenotonsillectomy. On postoperative day 6, the patient presented to the emergency room after an episode of hematemesis. Patient was tachycardic and hypotensive. She received 2 units of PRBCs and FFP. In the operating department, diffuse oozing from tonsillar beds was cauterized. On postoperative day 12, the patient had an episode of epistaxis, and nasopharyngeal bleeding was cauterized. The patient’s hematologic work-up revealed von Willebrand’s disease, type 2. DISCUSSION
Hemorrhage from intact tonsils is a rarely reported complication of acute or chronic tonsillitis. Previous reports of tonsillar bleeding as a complication of infec51
52
Otolaryngology– Head and Neck Surgery January 2001
KUMRA et al
tious mononucleosis have been noted.2 “Bleeding quinsy” has been reported, presumably after spontaneous drainage of peritonsillar abscess.3 More recently, bacterial tonsillitis has been identified as the most common cause of this complication.4 The pathophysiology in spontaneous tonsillar bleeding stems from the acute inflammation of the tonsils resulting in increased blood flow to the tonsils with secondary edema and vascular congestion. Increased blood flow to inflamed tonsils has been shown using a xenon-131 clearance technique.5 Diffuse parenchymal bleeding occurs when engorgement of the tonsillar vasculature leads to extravasation of red blood cells. Bleeding can also occur from specific surface vessels that can be damaged by the necrosis of the inflamed tissue surrounding them. Spontaneous tonsillar hemorrhage is usually readily recognizable by the presence of fresh blood in the oropharynx or by the identifications of specific bleeding points in the tonsils. Hemoptysis and hematemesis should be included as a presentation symptom for this disorder, as evidenced by the patients presented here. The delay in recognizing oropharyngeal blood may be due to a collection of blood in the hypopharynx, from the lower pole of the tonsils, which did not spill into the oropharynx because of blockade by the enlarged tonsils. The blood is repeatedly swallowed by the patients to avoid aspiration. The enlarged tonsils prevent visualization of the hypopharynx and pooled blood. The epigastric pain is a result of the
retching and vomiting caused by the stomach’s reaction to swallowed blood, yet initially the epigastric pain was felt to be an indication of a primary gastrointestinal disorder, and a gastrointestinal work-up was initiated. In conclusion, we present 3 patients with hemorrhage from intact tonsils as a complication of tonsillitis. The different time intervals to tonsillectomy are the result of the success of local conservative measures, and the seriousness of the bleeding. Tonsillectomy in the presence of acutely inflamed tonsils is a surgical challenge due to the increased vascularity and poorly defined surgical plane and should be avoided unless absolutely necessary. For patients who have had a significant amount of bleeding or who have recurrent bleeding, we believe that interval tonsillectomy should be performed. Increased recognition and awareness is needed to assure quick and knowledgeable treatment of this potentially dangerous complication of tonsillitis. REFERENCES 1. Negus VE. Acute tonsillitis: diagnosis and treatment and complications. Practitioner 1943;60:895-6. 2. Caster P, Smith E. Pathology of infectious mononucleosis. Blood 1948;3:831-57. 3. Salinger S, Pearlman S. Haemorrhage from pharyngeal and peritonsillar abscess. Arch Otolaryngol 1933;18:464-509. 4. Levy S, Brodsky L, Stanievich J. Hemorrhagic tonsillitis. Laryngoscope 1989;99:15-8. 5. Ozdemeir I, Ercun MT, Kaya S. Measurement of tonsillar blood flow in normal pathological conditions by the use of the 133/XE clearance technique. Arch Otorhinolaryngol 1985;242:53-6.
Spontaneous tonsillar hemorrhage VANDANA KUMRA, MD, A. PAUL VASTOLA, MD, STEFAN KEISERMAN, MD, and FRANK E. LUCENTE, MD, Brooklyn, New York
S
pontaneous tonsillar hemorrhage is a rare complication of tonsillitis. Common in the preantibiotic era, tonsillar bleeding was often catastrophic, due to erosion of great vessels. More recently, oropharyngeal bleeding has been reported with infectious mononucleosis and bacterial infection. Still, this symptom is rarely included in textbooks as a possible consequence or complication of tonsillitis.1-4 We present 3 cases of spontaneous tonsillar hemorrhage in pediatric patients; the pathogenesis and treatment options of the condition are discussed. CASE 1
A 13-year-old boy with a history of recurrent tonsillitis (3 times a year for 3 years) presented to his pediatrician with a history of sore throat for 1 week with hemoptysis—3 episodes that day. There was no prior bleeding history. Vital signs were stable. Examination revealed enlarged, inflamed palatine tonsils that met in the midline. There were prominent vessels over both tonsils without active bleeding. The white blood cell (WBC) count, hemoglobin, and prothrombin/partial thromboplastin (PT/PTT) levels were normal. The patient was started on oral antibiotics and scheduled for tonsillectomy in 6 weeks. Later that night the patient had a self-limited episode of hemoptysis. Tonsillectomy was performed the next day; hemoptysis resolved. CASE 2
An 11-year-old girl presented with a sore throat for 2 weeks with 10 episodes of hemoptysis over 3 days. Vital signs were stable. An examination of the oropharynx
From the State University of New York at Brooklyn (Drs Kumra and Lucente) and Maimonides Medical Center (Drs Vastola and Keiserman). Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, San Francisco, California, September 7-10, 1997. Reprint requests: Vandana Kumra, MD, 262 Central Park West, New York, NY 10024. Otolaryngol Head Neck Surg 2001;124:51-2. Copyright © 2001 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2001/$35.00 + 0 23/4/112434 doi:10.1067/mhn.2001.112434
revealed enlarged, inflamed, and friable palatine tonsils. Prominent vessels were noted over both tonsils, with active bleeding on the right tonsil. Bleeding resolved with local pressure and silver nitrate cautery. Laboratory values were notable for a leukocytosis; hemoglobin and PT/PTT levels were normal. The patient completed a 1week course of antibiotics. Tonsillectomy was performed, and the child had no further sequelae. CASE 3
A 5-year-old girl with a history of chronic tonsillitis— treated with antibiotics intermittently for 8 weeks—was brought to the emergency room after the patient had an episode of hematemesis. In the emergency room, the patient was noted to be pale, BP was 90/60 mm Hg, pulse was 143 beats/min, and temperature was 100.8°F. An examination revealed enlarged tonsils with minimal erythema and no exudate. No active bleeding was noted in the oral cavity. Nasopharyngoscopy revealed prominent adenoid tissue without blood in the larynx/nasopharynx. Lab-oratory values showed a leukocytosis, and normal hemoglobin and PT/PTT levels. The family denied any bleeding history. The patient was transferred to the intensive care unit where she had 500 cc of hematemesis. Before emergent exploration, the patient was intubated and transfused with packed red blood cells (PRBC) and fresh frozen plasma (FFP). Tonsils and adenoids were noted to be friable. Results of an esophagogastroduodenoscopy were normal, and the patient underwent an adenotonsillectomy. On postoperative day 6, the patient presented to the emergency room after an episode of hematemesis. Patient was tachycardic and hypotensive. She received 2 units of PRBCs and FFP. In the operating department, diffuse oozing from tonsillar beds was cauterized. On postoperative day 12, the patient had an episode of epistaxis, and nasopharyngeal bleeding was cauterized. The patient’s hematologic work-up revealed von Willebrand’s disease, type 2. DISCUSSION
Hemorrhage from intact tonsils is a rarely reported complication of acute or chronic tonsillitis. Previous reports of tonsillar bleeding as a complication of infec51
52
Otolaryngology– Head and Neck Surgery January 2001
KUMRA et al
tious mononucleosis have been noted.2 “Bleeding quinsy” has been reported, presumably after spontaneous drainage of peritonsillar abscess.3 More recently, bacterial tonsillitis has been identified as the most common cause of this complication.4 The pathophysiology in spontaneous tonsillar bleeding stems from the acute inflammation of the tonsils resulting in increased blood flow to the tonsils with secondary edema and vascular congestion. Increased blood flow to inflamed tonsils has been shown using a xenon-131 clearance technique.5 Diffuse parenchymal bleeding occurs when engorgement of the tonsillar vasculature leads to extravasation of red blood cells. Bleeding can also occur from specific surface vessels that can be damaged by the necrosis of the inflamed tissue surrounding them. Spontaneous tonsillar hemorrhage is usually readily recognizable by the presence of fresh blood in the oropharynx or by the identifications of specific bleeding points in the tonsils. Hemoptysis and hematemesis should be included as a presentation symptom for this disorder, as evidenced by the patients presented here. The delay in recognizing oropharyngeal blood may be due to a collection of blood in the hypopharynx, from the lower pole of the tonsils, which did not spill into the oropharynx because of blockade by the enlarged tonsils. The blood is repeatedly swallowed by the patients to avoid aspiration. The enlarged tonsils prevent visualization of the hypopharynx and pooled blood. The epigastric pain is a result of the
retching and vomiting caused by the stomach’s reaction to swallowed blood, yet initially the epigastric pain was felt to be an indication of a primary gastrointestinal disorder, and a gastrointestinal work-up was initiated. In conclusion, we present 3 patients with hemorrhage from intact tonsils as a complication of tonsillitis. The different time intervals to tonsillectomy are the result of the success of local conservative measures, and the seriousness of the bleeding. Tonsillectomy in the presence of acutely inflamed tonsils is a surgical challenge due to the increased vascularity and poorly defined surgical plane and should be avoided unless absolutely necessary. For patients who have had a significant amount of bleeding or who have recurrent bleeding, we believe that interval tonsillectomy should be performed. Increased recognition and awareness is needed to assure quick and knowledgeable treatment of this potentially dangerous complication of tonsillitis. REFERENCES 1. Negus VE. Acute tonsillitis: diagnosis and treatment and complications. Practitioner 1943;60:895-6. 2. Caster P, Smith E. Pathology of infectious mononucleosis. Blood 1948;3:831-57. 3. Salinger S, Pearlman S. Haemorrhage from pharyngeal and peritonsillar abscess. Arch Otolaryngol 1933;18:464-509. 4. Levy S, Brodsky L, Stanievich J. Hemorrhagic tonsillitis. Laryngoscope 1989;99:15-8. 5. Ozdemeir I, Ercun MT, Kaya S. Measurement of tonsillar blood flow in normal pathological conditions by the use of the 133/XE clearance technique. Arch Otorhinolaryngol 1985;242:53-6.