Introduction
Spontaneous tonsillar bleeding is now a rare event. However, prior to the introduction of antibiotics, vessel erosion and bleeding were recognised complications of acute tonsillitis and peritonsillar abscess.Reference Salinger and Pearlman1 Pathogenesis theories describe the erosion of superficial capsular vessels on the tonsil itself,Reference Lee, Lee, Hong, Yu, Lee and Chun2 or of neighbouring vessels such as the facial and internal carotid arteries. The presence of aberrant vessels and the increased blood flow to inflamed tissuesReference Ozdemeir, Ercun and Kaya3 as a consequence of inflammatory mediators would support these hypotheses.
The current literature suggests that the majority of spontaneous tonsillar bleeding cases occur in children or young adults, and one mortality has been reported.Reference Byard4 For this reason, a clear management protocol needs to be established.
Methods
We conducted a search of the Medline database from 1974 to the present, with no language barriers, together with a search of relevant publications' bibliographies. The following keywords were used: ‘bleeding’, ‘blood’, ‘palatine’, ‘tonsil’ and ‘spontaneous’. Seventeen publications were identified and reviewed.Reference Byard4–Reference Vaughan and Parker20
Discussion
The majority of the literature on spontaneous tonsillar haemorrhage is in the form of case reports. We identified a total of 30 case descriptions. Acute and chronic tonsillitis were implicated in 24 patients.Reference Rocha, Dell'Aringa, Nardi, Kobari and de Melo5–Reference Dawlatly, Satti and Bohliga8 Other causes included: coagulopathies such as Von Willebrand disease,Reference Kumra, Vastola, Keiserman and Lucente7 factor IX deficiencyReference Levy, Brodsky and Stanievich9 and idiopathic thrombocytopenic purpura;Reference Seuno, Yamada, Yamaguchi, Yamaguchi and Nomura10 hypertension;Reference Murty, Samani, Moloney and Bleeding11 and tonsillar cancer.Reference Jurkiewicz-Lobodzinska, Gerwel and Siewruk-Kalicka12, Reference Suh, Djalilian, Lake and Devine18 This list highlights an important differential diagnosis not to be overlooked in older patients with spontaneous tonsillar haemorrhage. Infectious mononucleosis has been acknowledged as a predisposing factor.Reference Griffies, Wotowic and Wildes13, Reference Koay and Norval17, Reference Kelly and Sanders19 An association with measles was reported in one case.Reference John, Thomas and Semeraro14 Syphilis infection can present with painless ulceration of the tonsil, with a risk of tonsillar bleeding.Reference Fiumara and Walker21, Reference Viers22 Tonsillitis in children with spontaneous tonsillar haemorrhage is largely due to streptococcal or haemophilus infection.Reference Shatz15
Reported presentations of spontaneous tonsillar haemorrhage range from tonsillar bleeding to haematemesis, haemoptysis, melaena and epistaxis,Reference Kumra, Vastola, Keiserman and Lucente7, Reference Jawad and Blayney16 which can make diagnosis challenging. The pathogenesis involves vessel erosion secondary to infection. There are two recognised patterns of bleeding: diffuse parenchymal bleeding and localised bleeding from dilated surface vesselsReference Levy, Brodsky and Stanievich9 (these can be major vessels or smaller peripheral vessels). The majority of cases involve venous bleeding.
Proposed management strategies include arteriography for severe bleeding and local intervention for peripheral bleeding.Reference Griffies, Wotowic and Wildes13 Cases of tonsillitis should be treated with intravenous antibiotics, and several papers advocate early tonsillectomy as definitive management.Reference McCormick and Hassett6–Reference Dawlatly, Satti and Bohliga8 Local pressure, silver nitrate cauteryReference Kumra, Vastola, Keiserman and Lucente7 and nebulised adrenalineReference Rowlands, Hicklin and Hinton23 have been used in previously reported cases.
One study reviewed a series of 860 patients deemed susceptible to spontaneous tonsillar haemorrhage due to predisposing factors including chronic tonsillitis, infectious mononucleosis and neoplasm. Ten cases of spontaneous tonsillar haemorrhage were identified, eight of which were due to tonsillitis, giving a 1.1 per cent incidence of spontaneous tonsillar haemorrhage with tonsillitis.Reference Griffies, Wotowic and Wildes13
Another study assessed 11 patients with spontaneous tonsillar haemorrhage, and found a slight male predominance (male:female ratio of 6:5), a mean age of 29.6 years and an age range of four to 63 years.Reference Seuno, Yamada, Yamaguchi, Yamaguchi and Nomura10
Conclusion
Spontaneous tonsillar haemorrhage is a rare but recognised entity. The literature indicates that most cases occur in young people and are secondary to acute or chronic tonsillitis; however, other causes must be considered. Management involves the use of antibiotics, and early tonsillectomy is recommended (see Table I).
Reported cases of spontaneous tonsillar haemorrhage
*11 patients. Year = year of publication; pt = patient; y = years; IV = intravenous; mths = months; GA = general anaesthetic
This review has demonstrated that there are currently few reported cases of spontaneous tonsillar haemorrhage. We have devised a treatment protocol based on the available evidence, in order to improve the diagnosis and management of this condition (see Figure 1).
Management plan for spontaneous tonsillar bleeding.
