Spontaneous tonsillar hemorrhage managed with emergency tonsillectomy in a 21-year-old man: a case report

INTRODUCTION: Spontaneous tonsillar hemorrhage is defined as continuous bleeding for more than one hour, or more than 250mL of blood loss regardless of the duration of bleeding. It is an often under-diagnosed and under-reported complication of acute or chronic tonsillitis, with controversial management. We suggest that an emergency tonsillectomy should be performed as first-line treatment for this potentially life-threatening condition on the basis of the relevant anatomy. CASE PRESENTATION: A 21-year-old Caucasian British man was referred to the ear, nose and throat emergency service at our facility because of profuse tonsillar hemorrhage, with no history of tonsillectomy. Our patient had been experiencing right-sided swallowing discomfort for five days. On examination, blood spurting from the body of the right tonsil was seen, which was not manageable conservatively. Our patient was taken to an operating theatre, with his pre-operative hemoglobin having dropped by three units within three hours. The bleeding was not controlled by superficial cautery using 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. CONCLUSIONS: The tonsillar blood supply comes from branches essentially approaching the tonsil from underneath its body. Ear, nose and throat surgeons and accident and emergency doctors need to be aware that an episode of spontaneous tonsillar hemorrhage is not likely to be controlled conservatively, because the source of bleeding requires removal of the tonsil to be accessed. Hence, performing a tonsillectomy seems a reasonable first-line treatment in such cases.