Spontaneous Tonsillar Hemorrhage in a 21-Year-Old
Spontaneous Tonsillar Hemorrhage in a 21-Year-Old
A 21-year-old Caucasian British man with tonsillar hemorrhage was urgently referred to our hospital for specialist treatment from a nearby hospital with no out-of-hours ear, nose and throat (ENT) coverage. Despite the ENT senior house officer (SHO) at our hospital having reservations about the apparent presentation, the referring surgical SHO was adamant that the bleeding, albeit not having followed any throat surgery, was profuse.
Our patient's medical history was largely unremarkable, apart from the recreational use of cocaine five days prior to presentation. Our patient had been experiencing swallowing discomfort for five days, exclusively on the right side of his throat, and mainly at night. He had noticed pus in the right tonsil on the previous morning, and had been prescribed penicillin V by his general practitioner.
Our patient's hemoglobin during the initial assessment was 13.5g/dL. Our patient arrived by ambulance two hours after his initial referral, around midnight. On examination, the ENT SHO noticed blood spurting from the body of the right tonsil and immediately contacted the on-call ENT surgeon. The on-call surgeon suggested pressure with adrenaline-soaked pledgets, and notification of the on-call anesthetist and the emergency theatre team pending his arrival.
Upon his arrival 20 minutes later the ENT surgeon noticed trickling of blood from the right tonsil, and asked that our patient be taken to an operating theatre despite the reluctance expressed by the emergency theatre team. Our patient's hemoglobin immediately before being anaesthetized was 10.5g/dL, and his coagulation profile only showed an increased fibrinogen value, as expected from his continuing bleeding (Figure 1) but was otherwise normal. Intra-operatively, the blood trickling was not controlled after two attempts at superficial cautery by bipolar diathermy, and a right tonsillectomy with meticulous hemostasis was performed. Our patient was discharged the next day. The histology of the excised tonsil was suggestive of a benign non-specific ulcer on a background of chronic non-specific tonsillitis, with enlargement of the germinal centers. There was no evidence of vascular malformation, vasculitis, or fibrin thrombi formation.
(Enlarge Image)
Figure 1.
Abnormal initial fibrinogen value as a result of the continuous bleeding of our patient.
Case Presentation
A 21-year-old Caucasian British man with tonsillar hemorrhage was urgently referred to our hospital for specialist treatment from a nearby hospital with no out-of-hours ear, nose and throat (ENT) coverage. Despite the ENT senior house officer (SHO) at our hospital having reservations about the apparent presentation, the referring surgical SHO was adamant that the bleeding, albeit not having followed any throat surgery, was profuse.
Our patient's medical history was largely unremarkable, apart from the recreational use of cocaine five days prior to presentation. Our patient had been experiencing swallowing discomfort for five days, exclusively on the right side of his throat, and mainly at night. He had noticed pus in the right tonsil on the previous morning, and had been prescribed penicillin V by his general practitioner.
Our patient's hemoglobin during the initial assessment was 13.5g/dL. Our patient arrived by ambulance two hours after his initial referral, around midnight. On examination, the ENT SHO noticed blood spurting from the body of the right tonsil and immediately contacted the on-call ENT surgeon. The on-call surgeon suggested pressure with adrenaline-soaked pledgets, and notification of the on-call anesthetist and the emergency theatre team pending his arrival.
Upon his arrival 20 minutes later the ENT surgeon noticed trickling of blood from the right tonsil, and asked that our patient be taken to an operating theatre despite the reluctance expressed by the emergency theatre team. Our patient's hemoglobin immediately before being anaesthetized was 10.5g/dL, and his coagulation profile only showed an increased fibrinogen value, as expected from his continuing bleeding (Figure 1) but was otherwise normal. Intra-operatively, the blood trickling was not controlled after two attempts at superficial cautery by bipolar diathermy, and a right tonsillectomy with meticulous hemostasis was performed. Our patient was discharged the next day. The histology of the excised tonsil was suggestive of a benign non-specific ulcer on a background of chronic non-specific tonsillitis, with enlargement of the germinal centers. There was no evidence of vascular malformation, vasculitis, or fibrin thrombi formation.
(Enlarge Image)
Figure 1.
Abnormal initial fibrinogen value as a result of the continuous bleeding of our patient.
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