Endovascular Embolization for Control of Post-Tonsillectomy Hemorrhage

Abstract

Post-operative hemorrhage is a potentially life-threatening complication of tonsillectomy. While standard surgical maneuvers including the use of electrocautery, application of topical hemostatic agents, direct pressure, and suturing of the tonsillar pillars have traditionally been used for the treatment of severe bleeding, endovascular approaches are an important adjunct when other techniques are unsuccessful. Here, we describe the case of a 10-year-old female who presented with severe bleeding four days after tonsillectomy and adenoidectomy for chronic tonsillitis. She was taken emergently to the operating room where pulsatile bleeding was noted from the right inferior tonsillar pole. Hemostasis could not be achieved using electrocautery despite multiple attempts. The patient was taken for emergent angiography, which demonstrated an irregularity of the right tonsillar artery consistent with arterial vasospasm, and which corresponded to the intraoral site of bleeding localized by the surgeon. Coil embolization of the tonsillar artery was successfully performed, and the patient experienced no further bleeding. We conclude that endovascular embolization of branches of the external carotid artery is an effective treatment for severe post-tonsillectomy hemorrhage in children and should be considered when attempts at surgical control are ineffective. This procedure requires exceptional collaboration between the surgical, radiology, and anesthesia teams.

Keywords: endovascular procedures; interventional radiology; post-tonsillectomy hemorrhage; tonsillectomy.

Figure 1. Pre-embolization angiogram of the right external carotid in the antero-posterior (A) and lateral (B) projections.

MA, maxillary artery; FA, facial artery; LA, lingual artery; ECA, external carotid artery; OA, occipital artery

Figure 2. Selective angiography of the right FA in the lateral projection. (A) Irregularity and abnormal truncation of the TA artery is seen, as indicated by the arrow. No active extravasation is noted. (B) This site corresponded to the location of a radiopaque probe used by the surgeon to indicate the site of bleeding transorally during angiogram.

FA, facial artery; TA, tonsillar artery

Figure 3. Post-embolization angiography of the right FA in the antero-posterior (A) and lateral (B) projections, demonstrating the coils in satisfactory position.

FA, facial artery