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Tonsillar Bleeding and Clot Removal - Is It True?

Why Clots Must Be Removed

• Sits over an open vessel or granulating, sloughy tissue, masking active or intermittent bleeding underneath.
• Gives a false sense of security - the bleeding appears to have stopped, but the vessel has not been properly secured.
• Can suddenly dislodge, causing a sudden, profuse hemorrhage (as secondary bleeding is classically associated with slough/infection loosening the clot around day 5-10).

"Any residual clot in the tonsil fossa should be removed and regular gargling with a dilute solution of hydrogen peroxide may be beneficial."

• Bailey and Love's Short Practice of Surgery, 28th Ed., p. 808

What Happens After Clot Removal?

• Bipolar diathermy to cauterize bleeding points
• Suturing/undersewing of the granulating tonsillar fossa
• Haemostatic gauze application with direct pressure
• Tranexamic acid (TXA) - nebulized or IV - is now commonly used as a first-line measure in emergency settings before operative intervention

Primary vs. Secondary Hemorrhage

Important Clinical Note

• Under controlled conditions (preferably in theatre under general anaesthesia)
• With airway management ready (patients with tonsillar hemorrhage are treated as having a full stomach due to swallowed blood - Bailey & Love, p. 808)
• With ENT/otolaryngology involvement

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Muscles of the Tongue

1. Extrinsic muscles - arise from bony/aponeurotic structures outside the tongue and insert into it. They move the tongue as a whole.
2. Intrinsic muscles - entirely within the tongue, with no bony attachments. They change the shape of the tongue.

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Extrinsic Muscles (4 muscles)

1. Genioglossus

The largest and most important extrinsic muscle. The fan-shaped genioglossus forms most of the tongue's substance. Bilateral contraction protrudes the tongue; unilateral contraction deviates it to the opposite side.

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2. Hyoglossus

A thin, quadrilateral sheet. The lingual artery runs deep to it; the hypoglossal nerve and lingual nerve run superficial to it - an important surgical relationship.

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3. Styloglossus

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4. Palatoglossus

Palatoglossus forms the anterior pillar of the fauces (palatoglossal arch). It is the only tongue muscle NOT supplied by CN XII.

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Intrinsic Muscles (4 pairs)

Intrinsic muscles do not have separate origins and insertions in the classical sense - they run within the connective tissue framework (lingual septum + lingual aponeurosis) of the tongue.

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Quick Memory Aid

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Pathological Conditions of the Tongue

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1. Congenital / Developmental Conditions

Ankyloglossia (Tongue-Tie)

• Short or anteriorly attached frenulum restricts tongue movement
• Causes feeding difficulties in neonates and speech problems
• Inability to protrude the tongue is a hallmark sign
• Treatment: frenotomy / frenuloplasty

Macroglossia (Enlarged Tongue)

Microglossia

Lingual Thyroid

• Failure of thyroid to descend from foramen caecum
• Appears as a nodular mass at the base of tongue midline
• Must be distinguished from median rhomboid glossitis and carcinoma

Bifid Tongue

• Cleft or split at the tip - very rare

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2. Surface / Papillary Changes (Glossitis)

Geographic Tongue (Benign Migratory Glossitis)

• Appearance: Map-like red patches with whitish-yellow borders; absent filiform papillae in affected areas
• Behaviour: Patches shift day to day ("migratory")
• Associations: Atopy, psoriasis, Reiter syndrome, AIDS, lithium therapy
• Symptoms: Usually asymptomatic; occasional glossodynia
• Key fact: Coexists with fissured tongue in 50% of cases
• Treatment: Reassurance; no cure needed

Fissured Tongue (Scrotal Tongue / Lingua Plicata)

• Appearance: Deep longitudinal and transverse grooves on dorsum, often with a central furrow resembling scrotal rugae
• Associations: Melkersson-Rosenthal syndrome, Down syndrome, psoriasis
• Complication: Food debris collects in grooves → secondary infection/halitosis
• Treatment: Mouthwashes to keep furrows clean; no treatment usually needed

Median Rhomboid Glossitis

• Lozenge-shaped area of smooth, red, papilla-free mucosa in the midline anterior to the foramen caecum
• Feels nodular
• Now considered a form of chronic atrophic oral candidiasis (not a developmental anomaly as once thought)
• Must be distinguished from lingual thyroid and carcinoma

Hairy Tongue (Lingua Villosa)

• Black hairy tongue: Elongation of filiform papillae + chromogenic bacterial/fungal overgrowth (often Candida + tobacco)
• Causes: Antibiotics, smoking, poor oral hygiene, dry mouth
• Appearance: Brown-black, fur-like dorsal tongue
• Treatment: Tongue brushing, stop causative agents

Glossitis - Atrophic (Bald Tongue)

• Complete loss of papillae → smooth, shiny, "bald" tongue
• Causes:
  • Iron-deficiency anaemia
  • Vitamin B12 / folate deficiency (megaloblastic anaemia)
  • Plummer-Vinson syndrome (iron deficiency + dysphagia + koilonychia)
  • Pellagra (B3 deficiency)
  • Riboflavin (B2) deficiency
• Often accompanied by glossodynia (burning tongue)

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3. Inflammatory / Infectious Conditions

Acute Glossitis

• Diffuse painful swelling and redness of tongue
• Causes: bacterial infection (streptococcal, dental abscess spread), viral, thermal/chemical burns
• Can cause airway compromise in severe cases

Oral Candidiasis (Thrush)

• White, curd-like plaques that scrape off, leaving red/bleeding base
• Most common on tongue, buccal mucosa
• Predisposing factors: antibiotics, steroids, immunosuppression, diabetes, dentures
• Types: pseudomembranous (classic thrush), erythematous (atrophic), chronic hyperplastic

Oral Hairy Leukoplakia

• White, corrugated (hairy) plaques on the LATERAL borders of the tongue
• Caused by Epstein-Barr virus (EBV) in immunocompromised patients (classically HIV/AIDS)
• Cannot be wiped off (unlike candida)
• Does NOT transform to malignancy

Herpetic (Herpes Simplex) Glossitis

• Vesicles → painful ulcers on tongue/oral mucosa
• Primary: widespread, with fever and cervical lymphadenopathy
• Recurrent: smaller, clustered ulcers

Syphilitic Tongue

• Primary: Painless chancre on tongue (rare)
• Secondary: Mucous patches (snail-track ulcers) on lateral tongue
• Tertiary (gumma): Deep ulcer with punched-out edges; heals with scarring - "scrotal tongue" pattern
• Syphilitic leukoplakia is a significant premalignant risk

Tuberculous Ulcer

• Rare; usually secondary to pulmonary TB
• Painful, irregular, undermined-edge ulcer, usually on dorsum
• Biopsy needed to confirm

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4. Premalignant Lesions

Leukoplakia

• Definition: White patch on oral mucosa that cannot be scraped off and cannot be diagnosed as any other condition
• On tongue: whitish opaque thickened epithelium on dorsum or lateral borders
• Histology ranges from hyperkeratosis (low risk) → dysplasia → carcinoma in situ
• Malignant transformation rate: ~5-17% (highest risk: non-homogeneous/speckled type)
• Risk factors: tobacco, alcohol, candida, syphilis, betel nut

Erythroplakia

• Red velvety patch that cannot be attributed to any other diagnosis
• Far more sinister than leukoplakia - up to 90% show severe dysplasia or carcinoma
• Often asymptomatic and overlooked
• Early SCC most commonly presents as erythroplakia - KJ Lee's

Submucous Fibrosis

• Progressive fibrosis of oral submucosa → trismus + tongue stiffness
• Strongly linked to betel nut chewing (Asian subcontinent)
• High malignant transformation risk

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5. Malignant Conditions

Squamous Cell Carcinoma (SCC) of the Tongue

• Most common malignancy of the tongue (>90% of all tongue cancers)
• Most common site: lateral border and undersurface of the tongue
• Oral tongue = 2nd most common site of oral cancer (30%)

• Tobacco (smoking + smokeless/betel nut)
• Alcohol
• HPV (especially base of tongue - HPV-16)
• Chronic irritation, poor oral hygiene
• Premalignant lesions (leukoplakia, erythroplakia)
• Increasing incidence in young patients with no known risk factors (genetic susceptibility)

• Early: painless ulcer/indurated lesion with rolled edges on lateral border
• Late: pain, tongue fixation, difficulty swallowing/speaking, cervical lymphadenopathy, referred otalgia

• Presents later (posterior location - asymptomatic until large)
• Higher rate of occult nodal metastases
• HPV-related tumors are a distinct, better-prognosis subgroup

Lymphoma

• Can present as tonsillar/lingual mass
• Non-Hodgkin lymphoma is the most common

Kaposi Sarcoma

• Purple/red vascular lesion in HIV-positive patients
• Can affect tongue and oral mucosa

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6. Systemic Disease Manifestations

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7. Vascular Lesions

Hemangioma

• Soft, compressible, bluish swelling; blanches on pressure
• Cavernous hemangioma can cause macroglossia

Lymphangioma

• Most common cause of macroglossia in children
• Soft, translucent vesicular surface ("frogspawn" appearance)
• Does not blanch on pressure

Ranula

• Mucous retention cyst on the floor of the mouth arising from sublingual/submandibular gland
• Presents as a bluish, translucent fluctuant swelling beneath tongue

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8. Traumatic / Miscellaneous

• Ulcers from sharp teeth / dentures: Most common on lateral tongue border - must not be confused with early SCC
• Burns: Thermal, chemical (aspirin burns)
• Biting injuries: Especially during seizures
• Tongue lacerations: Heal well due to rich blood supply

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Quick Summary Table

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