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Post‐tonsillectomy Lingual Artery PseudoaneurysmFred M. Baik B.A.1, Angela A. Chang M.D.1, Douglas A. Green M.D., Ph.D2,
Ramin S. Pakbaz M.D.3, and Chris M. Bergeron M.D.11 Division of Otolaryngology‐Head and Neck Surgery, Department of Surgery, University of California, San Diego, CA, USA
2 Department of Radiology, University of California, San Diego, CA, USA3 Department of Neurosurgery, University of California, San Diego, CA, USA
Common linguo‐facial trunksVariations in the branching patterns of the external carotid artery are not uncommon (Fig 2). Anatomical studies report that a unilateral common linguo‐facial trunk is seen in roughly 20% of the population,6‐8 while bilateral
INTRODUCTION
CASE PRESENTATION
REFERENCES
DISCUSSION, cont’d
A 27 year‐old female presented to an outside Emergency Department with a two day history of oral bleeding following tonsillectomy performed ten days earlier. An otolaryngologist was not available at this location so the patient was intubated and airlifted to our institution, where she was taken directly to the operating room. Intraoperative examination noted brisk bleeding emanating from exposed constrictor muscle, deep within the inferior pole of the left tonsillar fossa. Hemostasis was achieved using electrocautery, Surgiflo™, and suture. The patient was admitted to the surgical ICU for observation. The patient bled again overnight and was taken back to the operating room emergently. Hemorrhage was again controlled with cautery and suture. Due to brisk bleeding, we elected to take the patient to the angiography suite. Angiogram revealed a pseudoaneurysm of the left lingual artery, which originated from a medialized common linguo‐facial trunk (Fig 1A, B); a right common linguo‐facial trunk was also noted. The pseudoaneurysm was successfully coiled and embolized (Fig 1C). The patient did not experience further bleeding and was discharged two days later. She was seen for follow up one month later and reported no episodes of hemorrhage or other sequelae.
Figure 1. Angiographic Images. A. lateral view of left lingual artery pseudoaneurysm, arising from a common linguo‐facial trunk. B. frontal view of left lingual artery pseudoaneurysm. C. coiled lingual pseudoaneurysm and embolized proximal lingual artery
ABSTRACTObjectives: To review a case of post tonsillectomy lingual artery pseudoaneurysm and resultant hemorrhage in a patient with a common linguo‐facial trunk
Study Design: Case report and review of the literature.
Methods: A patient with a post‐tonsillectomy lingual artery pseudoaneurysm was studied. Clinical history, laboratory data, and imaging studies were reviewed.
Results: A 27 year‐old female presented to an outside Emergency Department with a two day history of oral bleeding following tonsillectomy ten days earlier. An otolaryngologist was not available at this location so the patient was intubated and airlifted to our institution, where she was taken directly to the operating room. Intraoperative examination noted brisk bleeding emanating from the deep muscle at the inferior pole of the left tonsillar fossa. Hemostasis was achieved and she was admitted to the surgical ICU for observation. The patient bled again overnight and was subsequently taken back to the operating room. Hemorrhage was controlled and angiography was performed to better evaluate the source. Angiogram revealed a pseudoaneurysm of a lingual artery, originating from a medialized common linguo‐facial trunk. The pseudoaneurysm was successfully coiled and embolized. The patient did not experience further bleeding and was discharged home two days post embolization.
Conclusion: We hypothesize that common linguo‐facial trunks arise from the external carotid artery at a highly medialized angle, placing the lingual and/or facial artery in closer proximity to the tonsillar fossa. In the setting of intra‐oral surgery such as tonsillectomy, this orientation may increase the risk of iatrogenic vessel injury. Angiography should be considered in cases of delayed recurrent hemorrhage following tonsillectomy.
[1] Russo CA et al. Ambulatory Surgery in U.S. Hospitals, 2003—HCUP Fact Book No. 9. AHRQ Publication No. 07‐0007, January 2007. Agency for Healthcare Research and Quality, Rockville, MD. [2] van Cruijsen N et al. Severe delayed posttonsillectomy haemorrhage due to a pseudoaneurysm of the lingual artery. Eur Arch Otorhinolaryngol. 2008 Jan;265(1):115‐7. [3] Griffies WS et al. Spontaneous tonsillar hemorrhage. Laryngoscope. 1988 Apr;98(4):365‐8. [4] Windfuhr JP et al. Post‐tonsillectomy pseudoaneurysm: an underestimated entity? J Laryngol Otol. 2010 Jan;124(1):59‐66.Review. [5] Menauer F et al. Pseudoaneurysm of the lingual artery after tonsillectomy. A rare complication. Laryngorhinootologie. 1999 Jul;78(7):405‐7. [6] Hayashi N et al. Surgical anatomy of the cervical carotid artery for carotid endarterectomy. Neurol Med Chir (Tokyo). 2005 Jan;45(1):25‐9. [7] Lucev N et al. Variations of the great arteries in the carotid triangle. Otolaryngol Head Neck Surg 122:590–591. [8] Lippert H et al. Arterial variations in man. Classification and frequency. J.F. Bergmann Verlag, Müchen, 1985, p 83. [9] Fazan VP et al. An anatomical study on the lingual‐facial trunk. Surg Radiol Anat. 2009 Apr;31(4):267‐70. [10] Lemaire V et al. Thyrolingual trunk arising from the common carotid artery: a case report. Surg Radiol Anat 23:135–137, 2001. [11] Nizankowski C. Common truncus thyrolinguofacialis. Anat Anz. 1972;132(5):530‐4.
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Tonsillectomy is the third most common surgical procedure performed in the United States.1 With an incidence of around 3%, post‐tonsillectomy hemorrhage can be a serious complication.2 Causes of post‐tonsillectomy hemorrhage may be stratified into non‐iatrogenic and iatrogenic categories. Non‐iatrogenic causes may include bacterial tonsillitis, infectious mononucleosis, or neoplasm, and result in spontaneous tonsillar hemmorhage.3 Iatrogenic causes of hemorrhage include trauma during surgical dissection, sharp injury from injection of local anesthetic or during suturing. While uncommon, iatrogenic injuries may also cause the formation of a pseudoaneurysm, another source of post‐operative bleeding. In this case report, we describe post‐tonsillectomy hemorrhage in a patient with iatrogenic pseudoaneurysm in the lingual artery of a common linguo‐facial trunk.
Figure 3. Hypothesized Medialization from a Common Linguo‐Facial Trunk, axial views.
DISCUSSION
PseudoaneurysmsPseudoaneurysms, also known as false aneurysms, typically arise from blunt or penetrating injury of the arterial wall. Bleeding from the injured site results in a periarterial hematoma that is bound by surrounding connective tissue or adventitia of the vessel wall. An endothelial layer eventually lines the hematoma and expands the potential space. This endothelial layer is fragile and ruptures with increased volume and pressure, resulting in a larger hematoma. This cycle may repeat, causing multiple episodes of severe bleeding and subsequent quiescent periods,4 as was observed in our patient. Bleeding from pseudoaneurysms may also present as a painful cervical mass or unilateral palatal swelling.5 The lingual artery is the most common site of pseudoaneurysm formation during tonsillectomy.4
ConclusionTreatment of hemorrhage resulting from a pseudoaneurysm requiresrapid diagnosis based on a high index of suspicion and the availability of immediate consultation for arteriography and embolization. In our patient, the pharyngeal constrictors appeared to have been partially resected during the original surgery, increasing our index of suspicion and necessitating angiographic evaluation.
With a reported incidence of 20%, anomalous common linguo‐facial trunk may increase the risk of iatrogenic lingual artery injury during tonsillectomy. Presence of a lingual artery pseudoaneurysm should be considered in the differential diagnosis of recurrent post tonsillectomy hemorrhage.
linguo‐facial trunks have a prevalence of 4.8%.9 Other rare variations include common thyrolingual trunks9 and common thyrolinguofacial trunks.11 There is no significant difference between lingual artery diameters arising from common linguo‐facial trunks and those arising from the external carotid artery.9 This may suggest the physiologic blood flow in the lingual branch of a common trunk is not compromised.
We postulate that the anomalous branching pattern of a common linguo‐facial trunk may have implications in the surgical field. We hypothesize that common trunks appear may (1) tend to have a more medial course, and/or (2) have a more medial origin (Fig 3). This places the lingual and/or facial artery in closer proximity to the tonsillar fossa, thereby increasing the risk of iatrogenic injury.
Figure 2. Common Linguo‐Facial Trunk