Pseudoaneurysm of the lingual artery secondary to tonsillectomy treated with selective embolization

Recurrent severe secondary haemorrhage due to facial artery pseudoaneurysm following styloidectomy via tonsillectomy approach: A case report

A 41-year-old female who underwent right-sided styloidectomy via tonsillectomy approach experienced refractory short-lasting severe secondary haemorrhage on the third, seventh and thirteen postoperative days. On examination under general anaesthesia, no major vessel injury was noticed. Contrast-enhanced computerized tomography scan of the neck was done because no obvious bleeder was seen and refractory nature of bleeding. Contrast-enhanced computerized tomography scan neck showed pseudoaneurysm of facial artery which was managed with endovascular embolization successfully.

Early presentation of traumatic pseudoaneurysm of deep lingual artery as a massive oral bleed

Tongue trauma with active bleed is most commonly due to the ruptured lingual artery and its branches, whereas delayed haemorrhage is usually secondary to pseudoaneurysm formation. This case is a unique presentation of traumatic tongue bleeds with early formation of pseudoaneurysm of a lingual artery branch. We present our experience in its management. A contrast-enhanced CT (CECT) with angiography detected right deep lingual artery pseudoaneurysm, which was managed by endovascular gelfoam embolisation followed by tongue laceration repair. Tongue bleed stopped immediately post embolisation; tongue viability and functions restored on postoperative day 1 of repair. No complications like secondary haemorrhage or tongue necrosis were noted at 1-month follow-up. High index of suspicion for lingual artery and/or its branch pseudoaneurysm is crucial in acute and uncontrollable traumatic tongue bleed. A CECT is a minimum norm in early diagnosis. Choice of management is the cornerstone of a successful outcome.

Treatment of hemorrhagic head and neck lesions by direct puncture and n-BCA embolization

Life-threatening bleeding in the head and neck region requires urgent management. These hemorrhagic lesions, for example, a ruptured pseudoaneurysm, are often treated by transarterial embolization (TAE), but prior intervention or surgery, inflammation, anatomic variants, and vessel tortuosity may render an endovascular approach challenging, time-consuming, and sometimes impossible. We report two cases of severe head and neck hemorrhages successfully embolized with n-butyl cyanoacrylate via direct puncture, and propose this approach as a fast, safe, and effective alternative to TAE.

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

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.

Treatment of hemorrhagic head and neck lesions by direct puncture and nBCA embolization

Life-threatening bleeding in the head and neck region requires urgent management. These hemorrhagic lesions, for example, a ruptured pseudoaneurysm, are often treated by transarterial embolization (TAE), but prior intervention or surgery, inflammation, anatomic variants, and vessel tortuosity may render an endovascular approach challenging, time-consuming, and sometimes impossible. We report two cases of severe head and neck hemorrhages successfully embolized with n-butyl cyanoacrylate via direct puncture, and propose this approach as a fast, safe, and effective alternative to TAE.

Tratamento endovascular de sangramento tardio pós tonsilectomia

Resumo A tonsilectomia é um dos procedimentos mais realizados por otorrinolaringologistas e possui como principal complicação a hemorragia. Alguns casos podem se manifestar tardiamente e se relacionam com a formação de pseudoaneurismas. Apesar de rara, essa é uma complicação grave e pode levar ao óbito se não tratada devidamente. Em casos de sangramento significativo, as reintervenções cirúrgicas são necessárias, sendo as 3 formas mais comuns: sutura, cauterização ou por tratamento endovascular. O nosso estudo tem por objetivo apresentar o histórico de uma paciente de 28 anos, sexo feminino, com sangramento maciço pós tonsilectomia no 31º dia de pós-operatório. Foi realizada abordagem endovascular e diagnosticada lesão em artéria facial esquerda. O tratamento definitivo foi por embolização seletiva de artéria facial com micromola e partículas de polivinil álcool (P.V.A.) 500 μm, nessa ordem de utilização, a fim de evitar-se embolização distal. O método endovascular mostrou-se seguro, definitivo e seletivo.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

BACKGROUND

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS

A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION

Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

Delayed endovascular coil extrusion after embolisation for post-tonsillectomy haemorrhage: case report and literature review

Objective:

To report a rare case of delayed endovascular coil extrusion following embolisation of a lingual artery pseudoaneurysm.

Case report:

A 23-year-old woman presented with dysphagia and odynophagia 11 months after having experienced massive post-tonsillectomy haemorrhage. At that time, the bleeding had been stopped by embolisation of a lingual artery pseudoaneurysm and the external carotid artery. Clinical examination at admission showed extrusion of the embolisation coils in the lateral lower pharyngeal wall. The coils were removed under general anaesthesia in the presence of an interventional radiologist. The procedure and post-operative period were without complication and no bleeding was observed. The dysphagia and pain disappeared and the subsequent seven-month follow-up period was uneventful.

Conclusion:

Although selective embolisation is a safe and effective treatment for severe post-tonsillectomy haemorrhage, the possibility of delayed coil extrusion should be kept in mind.

Posterior plica synechia: rare complication of adenotonsillectomy

Tonsillectomy is one of the most common operations performed by otolaryngologists. Fever, otalgia, dehydration, sore throat, and hemorrhage are common complications. In this clinical report, a 7-year-old boy was presented with a synechia between the posterior plicae together with recurrence of adenoid hypertrophy after adenotonsillectomy 1 year previously. The synechia and adenoid were resected, and the patient was discharged from the hospital after 2 days. The complication in this case was most likely caused by traumatic injury of the posterior plicae during the previous tonsillectomy. This complication is, however, very rare.

Transarterial endovascular treatment in the management of life-threatening intra- and postoperative haemorrhages after otorhinolaryngological surgery

Management of life-threatening postsurgical bleeding is complex. If conservative or surgical therapy is demanding, an endovascular treatment can be considered. The goal of this study was to evaluate the outcome of endovascular approaches in the diagnosis and therapy of otherwise intractable postoperative haemorrhages with a study design of outcomes research. Charts of all patients with postsurgical bleedings receiving endovascular treatment were reviewed for clinical outcome, complications, and demographic data. 15 patients were identified. They had rhinosurgery (12/15), tonsillectomy (2/15) or transoral tumour debulking (1/15) prior to the endovascular procedure. In more than 70%, the source of bleeding was directly located angiographically and subsequently superselectively embolized. The remaining patients suffered from post-rhinosurgical epistaxis and underwent a bilateral embolization of the sphenopalatine artery. All bleedings were successfully controlled and no procedure-related complication was noted. In conclusion, endovascular treatment of life-threatening postsurgical haemorrhages should be considered if the source of bleeding is unknown or if surgery is difficult and may result in devastating postoperative complications.

Idiopathic lingual artery aneurysm: CT findings and endovascular therapy. A case report

SUMMARY

We describe a 65-year-old woman with an asymptomatic idiopathic lingual artery aneurysm which is suspected to be congenital. We review the literature on external carotid artery branch aneurysms, diagnostic evaluation and discuss treatment options for the various types and the specific chosen in the case presented.

Post-tonsillectomy pseudoaneurysm: an underestimated entity?

Objective:

To identify patients undergoing arteriography to verify vascular complications of tonsillectomy, with an emphasis on pseudoaneurysm.

Patients and methods:

We undertook a retrospective analysis of the case records of 8837 patients who had undergone tonsillectomy between 1988 and 2004 at our institution, together with a review of expert reports written for professional boards and civil courts as well as personal experiences or communication. We also conducted a literature review using the PubMed database.

Results:

We identified seven cases with vascular abnormalities. In addition, we identified three cases of pseudoaneurysm formation, involving two children and one adult patient, with bleeding 21, 36 and 58 days after tonsillectomy. Successful management included embolisation (two patients) and revision surgery (one patient).

Conclusion:

Post-tonsillectomy pseudoaneurysm formation is extremely rare and unrestricted by age. Correct diagnosis depends largely on a high index of clinical suspicion. Delayed and repeated episodes of gushing haemorrhage with spontaneous cessation appear to be a significant clinical marker. Immediate arteriography, with simultaneous embolisation, is highly recommended. The lingual artery is the most commonly involved vessel.

Lethal outcome of post-tonsillectomy hemorrhage

Despite the large number of tonsillectomies performed little knowledge exists about post-tonsillectomy hemorrhage (PTH) with lethal outcome. This study was performed to evaluate clinical features in a larger patient population with emphasis on the onset of this complication. A nationwide collection of cases was performed based on personal communication, expert reports to lawsuits and professional boards, and case reports received after a plea published in a professional national journal. Clinical data of 29 patients were collected of whom the 18 were children (64%). With one exception all patients experienced secondary PTH (>24 h) occurring 1-28 days after tonsillectomy. Aspiration contributed to lethal outcome in 13 cases. Fatalities were unavoidable although 21 patients were in the hospital. Massive vomiting of blood was observed in 11 patients. There were 11 patients without (group A) and 18 with (group B) episodes of repeated bleeding. This study suggests that particularly children are endangered by lethal PTH. Inpatient treatment was unable to prevent lethal outcome in this selected patient population. However, it appears wise to re-admit patients with delayed PTH, since excessive PTH may occur. These unexpected and unpredictable situations require an immediate and adequate medical treatment by a skilled staff. The paucity of data currently does not allow calculation of a cut-off point at which the risk of life-threatening PTH significantly decreases. Secondary PTH remains a substantial complication.

External carotid artery blood supply to the orbit

The utility of angiography and embolisation of selected branches of the external carotid artery is occasionally helpful in the management of recurrent epistaxis, pre-operative devascularisation of tumours such as angiofibromas, and other head and neck conditions. The use of embolisation for recalcitrant post-tonsillectomy bleeding due to the formation of an aneurysm or pseudoaneurysm of branches of the external carotid artery has been described [P. Simoni, J. Bello, B. Kent, Pseudoaneurysm of the lingual artery secondary to tonsillectomy treated with selective embolization, Int. J. Pediatr. Otorhinolaryngol. 59 (2) (2001) 125-128]. There are also reports of pseudoaneurysm formation on the internal carotid following tonsillectomy [F. Tovi, A. Leiberman, Y. Hertzanu, L. Golcman, Pseudoaneurysm of the internal carotid artery secondary to tonsillectomy, Int. J. Pediatr. Otolaryngol. 13 (1987) 69-75]. The repeated presentation of a 5-year-old girl with post-operative tonsillectomy bleeding on three separate occasions, each approximately 1 week apart, prompted the consideration of the diagnosis of aneurysm formation, and hence, angiography was performed. The anomalous finding from this study precluded embolisation due to the risk of blindness. This experience has prompted this review which highlights the important issues of angiographic assessment prior to embolisation. The relevance of this to external carotid artery ligation is also reflected upon.

Severe delayed posttonsillectomy haemorrhage due to a pseudoaneurysm of the lingual artery

A 3.5-year-old child is presented with severe, recurrent haemorrhages after a tonsillectomy. The haemorrhages were caused by a pseudoaneurysm of the lingual artery, which was visualised more than 2 weeks postoperatively by angiography. The pseudoaneurysm was successfully embolised by coils. Coiling is an adequate therapeutic option for severe posttonsillectomy haemorrhage due to arterial damage.

Transcatheter arterial embolisation of a ruptured pseudoaneurysm of the lingual artery with n-butyl cyanoacrylate

Pseudoaneurysms can arise due to localized arterial wall disruption, owing to various factors such as inflammation, trauma, neoplasm, or surgical procedures. Once ruptured, bleeding can be life-threatening. Thus, a treatment for pseudoaneurysm is necessary. We describe a case of post-surgical ruptured pseudoaneurysm of the lingual artery that was successfully treated by transcatheter embolisation with n-butyl cyanoacrylate (NCBA).

Post-tonsillectomy hematoma of the mouth floor

Tonsillectomy is one of the most common operations performed by otolaryngologists. Sore throat, otalgia, fever, dehydration, uvular edema, and tonsillar hemorrhage are common complications. Hematoma of the mouth floor, an unusual complication, was reported. A 21-year-old man presented with a soft, dark-red swelling of the mouth floor three days after undergoing tonsillectomy. The hematoma of the mouth floor subsided spontaneously 2 weeks later. The complication in this case was most likely caused by the blood vessel insult, which resulted from suspension of the mouth with tongue retraction during surgery. This procedure should be done carefully to prevent this complication. Hematoma of the mouth floor can cause airway obstruction, and if present, health providers should be alert to the possibility of airway compromise.

Pseudoaneurysm of the Lingual Artery After Temperature-Controlled Radiofrequency Tongue Base Reduction: A Severe Complication

Temperature-controlled radiofrequency reduction (TCRF) of the tongue base has been developed as an alternative option for the treatment of patients with obstructive sleep apnea syndrome. The technique is propagated as an easy and safe surgical method. The case of a 34-year-old male patient with obstructive sleep apnea syndrome who underwent TCRF is reported. Fourteen days after surgery was performed, heavy bleeding at the base of the tongue occurred. Computed tomography and digital subtraction angiography imaging revealed a pseudoaneurysm of the lingual artery, which was treated endovascularly by detachable and free platinum coils during the same session. The article reports the first case of pseudoaneurysm under TCRF of the tongue base and discusses the diagnostic and therapeutic procedure to handle and avoid life-threatening complications under this method of treatment.

An unusual complication of tonsillectomy

We report the case of a 30-year-old man who experienced a potentially fatal haemorrhage on the tenth post-operative day after the development of a pseudoaneurysm of the muscular branch of the lingual artery. Due to the nature of the development of these pseudoaneurysms they are difficult to detect until such time that they present with a massive haemorrhage or a rapidly expanding parapharyngeal swelling. There are only several reported cases in the literature to date.

Endovascular treatment of a pseudoaneurysm of the descending palatine artery after orthognathic surgery: technical note

We report the clinical presentation (relapsing epistaxis after Le Fort I osteotomy), craniofacial digital subtraction angiography findings, and endovascular embolization through a microcatheter, in a 26-year-old patient with a pseudoaneurysm of the descending palatine artery.

Lethal post-tonsillectomy hemorrhage

BACKGROUND

Post-tonsillectomy hemorrhage (PTH) seems to be a rare but unavoidable complication. Due to the frequency of performed tonsillectomies, it can be estimated that a certain amount may result in a lethal outcome. This study was undertaken to evaluate the clinical features of these rare cases.

MATERIAL AND METHODS

Retrospective case series of five patients with lethal post-tonsillectomy hemorrhage are reported after they had undergone tonsillectomy by four different surgeons. The relevant literature was reviewed.

RESULTS

The youngest patient was 42 months and the oldest almost 13 years old. All patients were male. Three patients had left the hospital against surgeon's recommendation 5 days following tonsillectomy. Preceding episodes of bleeding prior to the lethal bleeding occurred in two patients. Lethal PTH occurred in four patients within 5-9 days, the latest bleeding 39 days after surgery. In the literature, lethal PTH was described for eight patients since 1958. The youngest patient was 4 years, the oldest 18 years old (mean: 8.6 years; median: 6.5 years). In three patients, lethal PTH occurred on the day of surgery and the latest bleeding 54 days after surgery.

CONCLUSION

Due to the paucity of reports, little reliable information can be obtained from the literature. It remains unclear, whether or not this reflects the true incidence of this complication. The experience with the five reported cases suggests, that immediate surgical treatment may have avoided lethal outcome in most cases. Therefore, a close postoperative follow-up is advisable to detect any episode of bleeding as soon as possible which should be referred to a specialist. Certainly, the collected data do not suffice to establish general guidelines, indicating that further collection of cases is required to assess characteristics of lethal PTH.