We report a case of hypopharyngeal swelling secondary to a spontaneous thyroid cyst haemorrhage. Haemorrhage is a known complication of thyroid cysts, and usually presents as external swelling and localised pain.

A 93-year-old woman developed hypopharyngeal swelling, dysphagia and odynophagia. A computed tomography scan was consistent with thyroid cyst haemorrhage. The patient was treated with needle aspiration and intravenous steroid injections, with full recovery at thyroid clinic review.

To our best knowledge, there has been no previous report of a hypopharyngeal swelling occurring secondary to spontaneous thyroid cyst haemorrhage. Our case is unusual because of the risk of airway compromise at the level of the hypopharynx, secondary to thyroid cyst haemorrhage.

Antiplatelet agents such as aspirin and clopidogrel are increasingly encountered in clinical practice. Otorhinolaryngological surgeons are involved in the peri-operative decision of whether to continue treatment and risk haemorrhage or to discontinue treatment and risk thrombosis.

Literature relating to the risk of spontaneous or operative haemorrhage was reviewed. The morbidity and mortality associated with cessation of agents was evaluated. Published guidelines were also evaluated. A protocol for the management of antiplatelet agents in the peri-operative period, with particular reference to ENT operations, is presented.

Significant morbidity and mortality is associated with the premature cessation of antiplatelet agents. Data from cardiac surgery suggest that operative blood loss only marginally increases in patients on aspirin and clopidogrel. However, the management of antiplatelet agents in the peri-operative period should be made after multidisciplinary consultation.

To identify those patients most at risk of developing a compressive post-operative haematoma following thyroid surgery.

Retrospective analysis of patients undergoing thyroid surgery. Factors associated with the group of patients who developed a post-operative haematoma were examined using a matched pairs, case–control design.

Following 355 thyroid operations, seven patients developed a post-operative haematoma requiring return to the operating theatre for bleeding control. A post-operative systolic blood pressure of greater than 150 mmHg, in the post-anaesthetic care unit, was the major significant factor identified by regression analysis (p = 0.002). Current smoking status was also a significant factor (p = 0.04).

In our facility, a post-anaesthetic systolic blood pressure in excess of 150 mmHg was associated with an increased risk of haemorrhage following thyroid surgery.

Juvenile nasopharyngeal angiofibroma may be successfully resected using endoscopic techniques. However, the use of coblation technology for such resection has not been described. This study aimed to document cases of Fisch class I juvenile nasopharyngeal angiofibroma with limited nasopharyngeal and nasal cavity extension, which were completely resected using an endoscopic coblation technique.

We retrospectively studied 23 patients with juvenile nasopharyngeal angiofibroma who underwent resection with either traditional endoscopic instruments (n = 12) or coblation (n = 11). Intra-operative blood loss and overall operative time were recorded.

The mean tumour resection time for coblation and traditional endoscopic instruments was 87 and 136 minutes, respectively (t = 9.962, p < 0.001). Mean intra-operative blood loss was 121 and 420 ml, respectively (t = 28.944, p < 0.001), a significant difference. Both techniques achieved complete tumour resection with minimal damage to adjacent tissues, and no recurrence in any patient.

Coblation successfully achieves transnasal endoscopic resection of juvenile nasopharyngeal angiofibroma (Fisch class I), with good surgical margins and minimal blood loss.

To evaluate the significance of advanced post-operative haemostasis investigation in cases of recurrent, severe post-tonsillectomy bleeding.

Of the 120 patients treated at our tertiary centre between 2006 and 2010 due to post-tonsillectomy haemorrhage, 22 with recurrent, severe episodes of bleeding underwent further, advanced haemostasis investigation.

Underlying haemorrhagic disease was not diagnosed in any case. Isolated abnormal clotting factor levels were identified in two patients. Decreased fibrinogen concentration due to dilutional coagulopathy was found in nine cases (40.9 per cent).

Recurrent, severe post-tonsillectomy haemorrhage is rarely related to undiagnosed haemostatic disorders. Thus, advanced haemostasis studies have little therapeutic relevance. However, repetitive post-tonsillectomy bleeding may be related to decreased fibrinogen levels due to dilutional coagulopathy. Therefore, fibrinogen concentration should be tested, and dilutional coagulopathy treated promptly.

To formulate a management plan for spontaneous tonsillar bleeding.

A Medline search was performed and all literature reviewed.

Seventeen publications were identified worldwide, describing 55 cases of spontaneous tonsillar bleeding.

Although spontaneous tonsillar bleeding is a rare presentation, it is documented in the literature. Reported cases indicate an increased incidence in young patients, associated with a higher mortality rate. We propose a management plan for this potentially fatal condition.

Blood oxygen concentration decrease may be associated with haemostatic impairments. We aimed to study the effect of oxygen decrease in a rabbit model of thrombosis and bleeding.

A total of 44 rabbits were anaesthetized, ventilated and monitored for blood pressure, blood arterial gas, temperature and carotid blood flow. The Folts model was used: a stenosis (75%) and an injury were carried out on the carotid artery, inducing thrombosis. Blood flow decreased as thrombus size increased until the pressure gradient was such that the thrombus was released and local arterial blood flow was suddenly restored. This is known as a cyclic flow reduction. After counting baseline cyclic flow reductions during a 20-min period (P1), rabbits were randomized blindly to one of three groups: hyperoxic, FiO2=100%; normoxic, FiO2 was decreased to obtain a PaO2 between 80 and 120 mmHg; hypoxic, PaO2 < 80 mmHg. Then CFRs were recorded over a second 20-min period (P2). At the end of the experiment, a hepatosplenic section was done and the amount of blood loss was recorded. After each period, the following parameters were measured: blood gas, ear-immersion bleeding time, haemoglobin, platelet count, prothrombin time, activated partial thromboplastin time and fibrinogen.

Oxygen decrease during hypoxic and normoxic periods was associated with a decrease in cyclic flow reductions. Bleeding time increased in the hypoxic group unless hepatosplenic bleeding remained stable. A slight increase in activated partial thromboplastin time was observed in the normoxic and hypoxic groups.

An abrupt decrease in oxygen administration was responsible for an antithrombotic effect. Increase in bleeding time occurred during hypoxia. No clinically relevant variation of any haemostasis parameters was observed.

To evaluate the relationship between the incidence of primary post-tonsillectomy haemorrhage and the daily weather condition, over a five-year period.

This was a retrospective study carried out in the ENT department of the Split University Hospital between January 2000 and December 2004.

Out of 3377 patients undergoing tonsillectomy, primary post-operative haemorrhage occurred in 83 (2.5 per cent). The season, daily atmospheric pressure and daily change in atmospheric pressure did not have any significant influence on post-tonsillectomy haemorrhage incidence. However, there was a statistically significant increase in the incidence of primary post-operative haemorrhage when cyclonic conditions prevailed (p = 0.035).

The incidence of primary post-tonsillectomy haemorrhage in our study population was 2.5 per cent. Avoiding tonsillectomy during cyclonic weather conditions may reduce the incidence of primary post-tonsillectomy haemorrhage.

The myocardial performance index is a non-geometric, heart rate-independent echocardiography-derived index of left ventricular performance combining systolic and diastolic function. There is an ongoing debate whether the myocardial performance index is affected by preload or not. Moreover, a systematic evaluation of the effect of changing tidal volume ventilation on the myocardial performance index is still lacking. The aim of our study was to assess whether acute changes in preload and/or different depth of tidal volume ventilation affect the myocardial performance index.

In all, 14 anesthetized pigs (35 ± 2 kg) were studied during changing tidal volumes (VT 5, 10 and 15 mL kg−1) at baseline, after removal of 500 cm3 of blood (haemorrhage) and after retransfusion of shed blood plus additional 500 cm3 6% hydroxyethyl starch (fluid loading). Echocardiographic measurements at each experimental stage included myocardial performance index, left ventricular end-diastolic area and fractional area change. Central venous pressure, pulmonary capillary wedge pressure, cardiac output and stroke volume index were obtained by a pulmonary artery catheter. Global end-diastolic volume was obtained by transpulmonary thermodilution.

Comparing different loading conditions, we found significant changes in cardiac output, stroke volume index, central venous pressure, pulmonary capillary wedge pressure, global end diastolic volume and left ventricular end-diastolic area, indicating clinically relevant changes in preload. In the haemorrhage group, there was a significant reduction in the myocardial performance index (P < 0.05) independent of tidal volume applied and this was reversed after fluid loading. However, myocardial performance index was significantly impaired (P < 0.05) by high tidal volume ventilation (15 mL kg−1), while tidal volumes of 5 and 10 mL kg−1 had no effect.

The myocardial performance index is largely dependent on changes in preload. Moreover, high tidal volume ventilation significantly impaired the myocardial performance index.