Introduction Obstructive sleep apnea (OSA) affects 1%–10% of the pediatric population and is secondary to a diverse group of pathologies. The most commonly reported cause of pediatric OSA is adenotonsillar hypertrophy. Given the numerous sequela of persistent OSA, surgical treatment is usually recommended. Adenotonsillectomy (T&A) is one of the most common surgical procedures performed worldwide and the first line treatment of childhood OSA. Despite surgical advances, hemorrhage remains the most significant complication after T&A. The reported prevalence of hemorrhage after T&A ranges from 0.1% to 8.1%. Postoperative bleeding requiring transfusions occurs in ∼0.04% and fatal hemorrhage in ∼0.002. Treatment strategies for post-tonsillectomy hemorrhage range widely depending on bleeding severity; these include mechanical packing, oversewing of paratonsilar tissue, injection of vasoconstricting drugs, electrocautery, suture ligation, and, more recently, endovascular embolization. The reports to date which described management of bleeding via endovascular techniques were in the setting of delayed (hours to weeks) post-tonsillectomy hemorrhage, while the scenario of massive intraoperative hemorrhage was typically addressed by cut down and suture ligation of the external carotid artery. To our knowledge this is the first reported case of emergent, intraoperative endovascular sacrifice of a lingual artery during tonsillectomy for massive uncontrollable hemorrhage.

Initial presentation An 11-year-old female presented with persistent symptoms of OSA including snoring, choking following oral intake and tongue mass.

Operation During the course of the tonsillectomy the surgeons' encountered sudden uncontrollable arterial bleeding and despite repeated attempts to anatomically localize the source of the bleeding, the rate of bleeding was too brisk. As such a decision was made to immediately pack the oropharynx with sponges and pursue an endovascular modality to address the bleeding. A mobile C-arm fluoroscopy machine was positioned around the patient's bed for imaging during angiography. Uniplane arteriography of the right common carotid artery revealed obvious injury and extravasation from the right lingual artery. Next, a microcatheter was transnavigated into the lingual artery and Onyx-18 liquid embolic agent was injected under fluoroscope guidance until angiographic occlusion of the injured lingual artery. Further angiographic runs did not reveal any other abnormalities or sources of bleeding. The patient's oropharyngeal packing was removed and detailed laryngoscope examination/interrogation did not produce and further bleeding and confirmed a stable wound.

Postoperative course After observation in the ICU she was transitioned to normal care on postoperative day 3 and subsequently discharged at her functional neurological baseline on postoperative day 7.

Conclusion Operative bed bleeding following either conventional T&A or LT is common; however severe hemorrhage (requiring blood transfusions or emergent surgical intervention) is rare. In the setting of large volume hemorrhage, traditional surgical carotid cut down with exposure and suture ligation of external carotid artery can be a lifesaving maneuver but requires an additional incision and concomitant risks. Angiography allows for direct visualization of the bleeding vessel, enabling for a more targeted treatment strategy. Advances in endovascular techniques and embolization materials complimented by the increased availability of qualified interventional specialists present a fast, safe and viable alternative option in these emergent circumstances.

Competing interests None.