Recurrent post-tonsillectomy bleeding due to an iatrogenic facial artery pseudoaneurysm

Abstract

This is a report of an illustrative case of recurrent post-tonsillectomy bleeding that was caused by an iatrogenic facial artery pseudoaneurysm and controlled by endovascular embolization. A 37 year-old female who underwent bilateral tonsillectomy for chronic tonsillitis had recurrent secondary hemorrhage despite multiple operative interventions to control the bleeding. Because of the recurrent nature of the bleeding, an angiography of the external carotid artery was performed demonstrating a pseudoaneurysm of the left facial artery with active extravasation. This was successfully embolized with ethylene vinyl alcohol copolymer and the bleeding did not recur. Most post-operative bleeds can be managed with bedside or intraoperative interventions. However, pseudoaneurysms should be considered in the differential diagnosis of recurrent bleeds refractory to surgical control.

Bilateral thalamic stroke after tonsillectomy in patient with collateral extracranial anastomosis – case report

“…Bleeding associated with post-tonsillectomy pseudoaneurysm occurs almost exclusively after 24 hours, usually 8-30 days after surgery [1,5,6]. Recurrent post-tonsillectomy bleeding episodes with spontaneous cessation indicate the possibility of pseudoaneurysm formation and should be considered a warning sign of serious hemorrhage [2,6].…”

“…Recurrent post-tonsillectomy bleeding episodes with spontaneous cessation indicate the possibility of pseudoaneurysm formation and should be considered a warning sign of serious hemorrhage [2,6]. Facial and lingual arteries are most frequently involved due to their proximity to the inferior tonsillar pole, making this area especially vulnerable to injury if the sutures are placed deeply and hemostasis is achieved by electrocautery, which promotes necrosis [3,5].…”

“…Primary hemorrhage occurs within 24 hours postoperatively and is related to surgical technique and/or coagulopathy [2,3]. Secondary hemorrhage occurs after 24 hours and is related to separation of slough from granulating fossa [4,5]. Multiple factors increase the risk of secondary hemorrhage, including older age, chronic tonsillitis and elevated postoperative mean arterial pressure [1,3].…”

“…Multiple factors increase the risk of secondary hemorrhage, including older age, chronic tonsillitis and elevated postoperative mean arterial pressure [1,3]. Recurrent delayed bleeding episodes may indicate pseudoaneurysm of the injured artery in the tonsillar bed [2,5,6]. According to many authors [1,2,4,5] embolization of the damaged vessel seems to be a better treatment than ligation of the external carotid artery (ECA) because it combines diagnostic evaluation with direct selective therapy.…”

“…Recurrent delayed bleeding episodes may indicate pseudoaneurysm of the injured artery in the tonsillar bed [2,5,6]. According to many authors [1,2,4,5] embolization of the damaged vessel seems to be a better treatment than ligation of the external carotid artery (ECA) because it combines diagnostic evaluation with direct selective therapy. However, life-threatening bleeding requires immediate ligature with exclusion of possible vascular anastomoses.…”