Lingual artery embolization for severe and uncontrollable postoperative tonsillar bleeding.

Abstract

We performed emergent angiography of the external carotid artery to evaluate a patient who experienced uncontrollable oropharyngeal bleeding 3 days following an adenotonsillectomy. Angiography demonstrated a left lingual artery disruption and hemorrhage. We then performed a coil embolization of the left lingual artery, which immediately halted the hemorrhage. We conclude that coil embolization is a rapid and effective strategy for the management of massive, uncontrollable postoperative tonsillar bleeding.

Introduction

An estimated 4,300 cases of postoperative hemorrhage following tonsillectomy occur in the United States each year.[1] The reported incidence of postadenotonsillectomy hemorrhage that requires surgical control ranges between 5 and 20%.[2-4] The scope of this notable morbidity has remained largely uninfluenced by and independent of modern surgical techniques and medication.[5] Comparisons of various surgical techniques--including bipolar and monopolar dissection,[6-9] laser tonsillectomy,[10] and obliteration of the tonsillar fossa by suturing the faucial pillars[11]--have shown that these procedures produce different degrees of intraoperative blood loss and postoperative pain, but they have not demonstrated any significant differences in postoperative hemorrhage rates. Agents such as fibrin glue have also been used to reduce the incidence of postoperative hemorrhage, but results thus far have been inconclusive.[5]

In this article, we describe a case of massive postoperative bleeding in a 10-year-old girl. We treated the patient with emergent coil embolization of the left lingual artery, which resulted in immediate hemostasis.

Case report

A healthy 10-year-old girl came to our institution with a history of chronic mouth breathing, stridorous snoring, and recurrent sore throat. She had had two previous episodes of tonsillitis, which were treated with appropriate antibiotics, and she had recently developed intermittent obstructive sleep apnea. The physical examination was significant only for a deviated septum seen on anterior rhinoscopy and large tonsils (4+) bilaterally. We performed a routine adenotonsillectomy for adenotonsillar hyperplasia, which resulted in an estimated blood loss of 50 ml. The patient was discharged home the same day.

Three days later, the patient returned to the emergency room following two episodes of bright red bleeding from her mouth; each episode had resolved spontaneously. She was observed overnight and explored in the operating room the following morning. A large clot was removed from the left resection bed, and hemostasis was achieved. However, in the recovery room, the girl spontaneously hemorrhaged approximately 1,500 ml from her oropharynx. An emergent tracheotomy was performed. Once the patient was stabilized, she was taken immediately to the angiography suite. Angiography with oropharyngeal contrast extravasation revealed that the left lingual artery was disrupted (figure 1).

To control the bleeding via an endovascular route, we placed a 6F sheath in the right femoral artery. A 6F Envoy guiding catheter (Cordis Corp.; Miami Lakes, Fla.) was advanced into the left internal carotid artery. A 0.018-inch RapidTransit microcatheter (Cordis) was then advanced over a 0.016-inch microwire, and the left lingual artery was selectively catheterized. The vessel was then embolized and sacrificed with the aid of Guglielmi detachable coils (Boston Scientific/Target Therapeutics; Fremont, Calif.) until the anterograde flow was arrested. We used these coils because they allow for complete control of the coils until they are detached. This reduces the risk of an inadvertent coil migration into the internal carotid artery. Migration occurs when a catheter becomes dislodged from its tenuous position in the lingual artery and recoils into the internal carotid artery.

Once the vessel was occluded (figure 2), we removed the packing from the oropharynx and inspected the left tonsillar bed. A coil could be seen protruding out of the mucosa, and it was removed. Hemostasis was confirmed. Repeat imaging demonstrated a gap in the coil mass that was left by the missing coil (figure 3). This observation confirmed the fact that the patient had a side-wall type vascular injury (figure 4).

The patient was observed in the intensive care unit and discharged from the hospital 12 days later in excellent condition.

Discussion

Postsurgical hemorrhage is responsible for the majority of post-tonsillectomy fatalities. [2-4] Significant risk factors include older age, chronic tonsillitis, excessive intraoperative bleeding, and an elevated postoperative mean arterial pressure. [2] Szeremeta et al found that postoperative bleeding occurred in 2.8% of patients who underwent electrocautery tonsillectomy and 7.6% of patients who underwent mechanical tonsillectomies. [4] Others have not found that postoperative hemorrhage rates correlate with operative technique. [3,4]

There is a general consensus regarding the management of postsurgical tonsillar bleeding. In 1995, Cressman and Myer surveyed 17 pediatric otolaryngology fellowship programs (100% response) and found that (1) most favor admission for observation; (2) there is little difference in the method of managing immediate and delayed hemorrhage; (3) removal and inspection of clots is recommended when they occur in the tonsillar fossa; (4) approximately two-thirds of respondents attempt to control active bleeding in the emergency room, whereas the rest proceed directly to the operating room; (5) after multiple episodes, a full hematologic evaluation is warranted; and (6) the age and the cooperativeness of a child is an important determinant in the decision-making process. [12]

The importance of the case described here is the finding that surgical control of delayed postoperative tonsillar r bleeding was not successful because of the etiology of the hemorrhage (a side-wall tear in the lingual artery). Four other reports in the literature (two in the English language) have described the use of coil embolization for uncontrollable tonsillar bleeding. [13-16] of these reports described the treatment of iatrogenic pseudoaneurysms--one in the internal carotid artery [13] and one in the lingual artery. [14] These reports, in addition to ours, suggest that endovascular therapy can be a useful intervention when post-tonsillectomy bleeding persists despite routine interventions. Coil embolization of bleeding vessels can also minimize morbidity following this common and well-described operative complication.

References

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