Spontaneous Tonsillar Hemorrhage in a SARS-CoV-2 Positive Male.

Introduction: Spontaneous Tonsillar Hemorrhage, also described as Hemorrhagic Tonsillitis, is a rare complication of acute or chronic tonsillitis with a reported incidence of less than 1.1% of all infectious tonsillitis cases worldwide. Case Report: A 19-year-old male with a history of chronic tonsillitis presented to the emergency department for a three-day history of progressively worsening odynophagia and blood-tinged saliva for greater than 48 hours, and found to have "kissing tonsils" on exam with bilateral exudates and venous oozing.
Conclusion: Emergent airway assessment is critical in patients presenting with potential airway obstruction. In patients presenting with spontaneous tonsillar hemorrhage, hemostasis should also be achieved, whether topically, or through emergent tonsillectomy should the patient's clinical status warrant it.

Case report

A 19-year-old male with a history of chronic tonsillitis presented to the emergency department for a 3-day history of progressively worsening odynophagia and blood-tinged saliva for greater than 48 hr.

Physical examination revealed a well-appearing, though anxious, non-tachycardic, normotensive, and afebrile male without respiratory distress actively spitting out blood from the oropharynx. He had bilateral tonsillar hypertrophy graded at 4+, bilateral tonsillar exudates, and left-sided dark-red parenchymal venous oozing (Figure 1, Figure 2 ). The uvula and dentation were intact, and the trachea was midline. Anterior cervical lymphadenopathy was present on the left. A complete blood count, coagulation panel, hepatic function panel, and renal function panel were all within normal limits. A rapid strep test as well as heterophile antibody testing was negative; however, laboratory testing was positive for severe acute respiratory syndrome coronavirus 2. Benzocaine spray was applied as a topical anesthetic, followed by silver nitrate for hemostatic control, and the patient referred to the otolaryngology service for tonsillectomy the next morning. The patient’s perioperative and postoperative courses were without complications.

Figure 1

Hemorrhagic tonsillitis with bilateral tonsillar hypertrophy (Grade 4+). (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Figure 2

Close-up view detailing tonsillar hypertrophy, exudates, and venous oozing. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Discussion

Spontaneous tonsillar hemorrhage, also described as hemorrhagic tonsillitis, is a rare complication of acute or chronic tonsillitis and defined as either continuous tonsillar bleeding for greater than 1 hr, or the loss of 250 mL of blood regardless of duration (Griffies et al., 1988). Before the widespread use of antibiotics for bacterial tonsillitis, its incidence and mortality were greater. Due to its rarity, literature in the last few decades is comprised mainly of case reports, with a reported incidence of only 1.1% of all infectious tonsillitis cases worldwide (Griffies et al., 1988).

The pathophysiology of hemorrhagic tonsillitis is primarily thought to be secondary to inflammation resulting in parenchymal edema and vascular congestion to the point of extravasation (Kumra et al., 2001). Infection-related erosion and necrosis of the tonsillar blood vessels are also contributing factors (Kumra et al., 2001). Common pathogens of spontaneous tonsillar hemorrhage include beta-hemolytic streptococcus, Haemophilus influenza, and Epstein-Barr virus. Spontaneous tonsillar hemorrhage has also been reported in cases of coagulopathies such as von Willebrand disease, factor IX deficiency, and idiopathic thrombocytopenic purpura (Salem et al., 2010).

Assessment for airway management should be included in the patient’s initial evaluation. Indications for airway intervention include the failure to oxygenate, the failure to ventilate, or the failure to maintain a patent airway. One can perform a rapid and effective bedside assessment through the use of pulse oximetry, the patient’s respiratory rate, the presence or absence of accessory muscle use, and the visualization of the airway for obstructive tonsillar masses and/or blood. Airway management is extremely important before any further evaluation or treatment.

Following an airway assessment, and management if indicated, hemostasis should be achieved. This is typically accomplished with chemical cauterization using silver nitrate, as well as the use of local epinephrine if needed. Definitive treatment includes antibiotics to reduce inflammation if thought to be bacterial in origin, and the consideration of emergent tonsillectomy if the patient’s clinical status warrants it—such as the presence of arterial or uncontrollable venous bleeding, or the inability of the patient to maintain a patent airway (Salem et al., 2010; Sandman & Mitchell, 2019).

CRediT authorship contribution statement

Kelly Tang: Writing - original draft, Writing - review & editing. Hannah Virginia Wade: Writing - original draft, Writing - review & editing. Christian Isaac Wade: Conceptualization, Writing - original draft, Writing - review & editing, Supervision.