Aim: We report a case of spontaneous tonsillar hematoma in a 15-year-old male with adenotonsillitis and underlying immune thrombocytopenia (ITP). Introduction: Immune thrombocytopenia is an acquired autoimmune disorder characterized by isolated thrombocytopenia without other discernible etiology. Reported intraoral manifestations included petechiae, purpura, ecchymosis, and hematoma at trauma-prone site. Spontaneous tonsillar hematoma is rarely encountered. Case description: A 15-year-old male with underlying ITP presented with fever and sore throat for 2 days with odynophagia, dysphagia, and a change of voice. Examination revealed two large hyperemic masses occupying the oropharynx. Flexible endoscopy showed bilaterally enlarged tonsils. The patient developed spontaneous bilateral epistaxis requiring nasal packing. A blood test showed elevated leukocytes count and thrombocytopenia. Contrast-enhanced computed tomography (CECT) scan revealed adenoid and palatine tonsils hypertrophy with bilateral cervical lymphadenopathy causing oropharyngeal airway narrowing. He was admitted for observation and started on intravenous antibiotics, corticosteroids, and co-managed with the medical team. Nasal packing was removed after 4 days following platelet transfusion. Patient was discharged after 7 days with full resolution of symptoms. Conclusion: High index of suspicion should be practiced when encountering patients with erythematous oropharyngeal mass. The bleeding disorder should be excluded if the hematoma is suspected. Clinical significance: Spontaneous tonsil hematoma is a possible manifestation of ITP. Symptomatic ITP should be managed with a multidisciplinary team approach for the best outcome.