Journal List > Int J Thyroidol > v.8(2) > 1082722

Int J Thyroidol. 2015 Nov;8(2):187-189. English.
Published online November 30, 2015.  https://doi.org/10.11106/ijt.2015.8.2.187
Copyright © 2015. the Korean Thyroid Association. All rights reserved.
Life-Threatening Upper Airway Obstruction Caused by Delayed Hematoma Occurring 8 Days Post-Thyroidectomy
Kyeung A Ryu, Sung Tae Seo, Ki-Sang Rha and Bon Seok Koo
Department of Otolaryngology-Head and Neck Surgery, Cancer Research Institute, Research Institute for Medical Sciences, Chungnam National University College of Medicine, Daejeon, Korea.

Correspondence: Bon Seok Koo, MD, PhD, Department of Otolaryngology-Head & Neck Surgery, Chungnam National University College of Medicine, 282 Munhwa-ro, Jung-gu, Daejeon 301-721, Korea. Tel: 82-42-280-7695, Fax: 82-42-253-4059, Email: bskoo515@cnuh.co.kr
Received January 05, 2015; Revised February 10, 2015; Accepted February 16, 2015.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Abstract

Due to modern methods, thyroid surgery is generally considered quite safe. However, post-thyroidectomy hematomas, although rare, can be life-threatening and unpredictable complications of thyroid surgery. Most postthyroidectomy hematomas occur within 24 hours of surgery, with delayed hematomas occurring after one post-operative week being exceedingly rare. Herein, we report a case of delayed post-thyroidectomy hematoma with respiratory distress occurring on the eighth post-operative day in a patient who was not taking anticoagulants and had no hematologic diseases. Although most bleeding occurs within 24 hours, caution should be used even in such patients who are considered low-risk.

Keywords: Thyroidectomy; Hematoma; Postoperative complication

Introduction

Better preoperative preparation and proper surgical techniques have decreased the rate of complications to less than 2-3% in thyroid surgery. The most disturbing complications of thyroid surgery include recurrent laryngeal nerve injury and permanent hypoparathyroidism. Post-thyroidectomy hematomas, although rare, are potentially life-threatening and unpredictable complications of thyroid surgery reported at an incidence of 0.1-1.1%.1)

Relatively few studies have focused on prevention of and risk factors for postoperative hemorrhage and hematoma after thyroidectomy. Most authors are unable to definitively identify perioperative risk factors for the development of hematoma.2, 3, 4) Most post-thyroidectomy hematomas occur within 24 hours and delayed hematomas forming in the first post-operative week are exceedingly rare. We report a rare case of delayed post-thyroidectomy hematoma with respiratory distress occurring on the eighth postoperative day in a patient who was not on anticoagulants and had no hematologic disease.

Case Report

A 52-year-old female presented to our department for surgical treatment of thyroid cancer. She had no notable medical history and her coagulation tests were normal. On surgery, the vessels were ligated by Harmonic scalpel. The specimen size was 4×2×1.5 cm to right lobe, 4.5×1.5×1.5 cm to left lobe, 2.5×1 cm to isthmus. Surgical drain was not inserted because the blood loss was not significant and hemostasis was well achieved by absorbable hemostat. The duration of the surgery was about 60 min. Postoperative vocal cord movements were normal and there was no laryngeal edema. The incision appeared to be healing well with no swelling 3 days post-operatively, so the patient was discharged.

On the eighth postoperative day, the patient was rushed to the emergency room with a rapidly progressive anterior neck swelling and acute respiratory distress. Her respiratory rate was 30 breaths/min and the SpO2 was 59%. The patient was intubated then a neck angio CT scan was conducted, which revealed a hematoma in the thyroidectomy bed and edematous changes in the retrovisceral space and upper mediastinum (Fig. 1). Her coagulation tests were normal.


Fig. 1
Neck angio-computed tomography (CT) scan of our patient. It showed a low-attenuating lesion with partial rim enhancement, suggesting a hematoma in the thyroidectomy bed.
Click for larger image

Bedside decompression was performed in emergency room and revealed a deep hematoma. After hematoma removal in the thyroidectomy bed, the bleeding focus was identified just above the cricoid cartilage as the cricothyroid artery, a branch of the superior thyroid artery. The artery was electrocauterized and hemostasis was achieved. The patient stated that the anterior neck hematoma occurred acutely over several minutes without vigorous coughing or sneezing or other obvious reason for hemorrhage.

After 5 days, the patient was discharged with no wound swelling.

Discussion

Hematoma following thyroid surgery is a rare but potentially life-threatening complication, with a reported rate of 0.1% to 4.7%.5) It is generally difficult to predict which patients are at risk for developing hematoma after thyroid surgery.6, 7) Post-thyroidectomy hematoma may have a multifactorial etiopathogenesis, including slipping of ligatures on major vessels, reopening of cauterized veins, increased blood pressure during recover. Coughing, the Valsalva maneuver, retching or vomiting can also increase venous pressure.1, 2, 3, 4)

While drains have long been used empirically in thyroid surgery, there are now many studies, including those of a randomized prospective nature, which fail to demonstrate benefits in preventing the formation of postoperative hematoma.8, 9, 10, 11) Based on this, it would appear that drains do not have to be used as a preventative measure.

Most post-thyroidectomy hematomas occur within 24 hours and in most cases, bleeding is likely due to post-surgical hypertension. Thus, very close monitoring of blood pressure during the first 24 hours after surgery and prompt appropriate treatment of any signs of hypertension is recommended. A study by Promberger et al.12) found that 80.6% of postoperative bleeds became symptomatic within 6 hours and 88.0% within 12 hours after the operation; only 10 (0.03%) patients demonstrated signs of bleeding after 24 hours. The occurrence of post-surgical complications has also been associated with anticoagulant agents or hematologic diseases such as von Willebrand disease, hemophilia and chronic renal failure.2) Two cases of very delayed bleeding occurring on the 13th postoperative day in patients who were taking anticoagulants have been reported.3) Our case is highly unusual because our patient was not taking anticoagulants and the hematoma was markedly delayed until 8 days post-thyroidectomy. However, we suppose that the blood clot sealing the partially damaged cricothyroid artery during surgery melted and some acute cause of increased blood pressure might have been present. Delicate surgical procedure, and although rare, mentioning the possibility of a delayed hematoma, and careful consideration in restarting anticoagulation therapy may prevent such delayed hematoma.

Cervical hematomas can lead rapidly to progressive airway obstruction due to pressure in the tight compartment below the strap muscles that impairs venous and lymphatic drainage, causing laryngopharyngeal edema.1) Patients may present with respiratory distress, pain, a pressure sensation in the neck, and dysphagia. As early recognition with immediate intervention is key to managing this complication, medical staff should be aware of these signs and symptoms.7)

We experienced a highly unusual case of acute post-thyroidectomy hematoma that caused life-threatening upper airway obstruction on the eighth postoperative day without hematologic diseases, anticoagulant medications, or other predisposing factors for acute hemorrhage. Although most bleeding occurs within 24 hours after thyroidectomy, caution should be used, even in patients considered to be low risk.

Acknowledgments

This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (No. 2012R1A1A2005393, 2013R1A2A2A01015281), and a grant from the National R&D program for Cancer Control, Ministry for Health, Welfare, and Family Affairs, Republic of Korea (0720560).

References
1. Savargaonkar AP. Post-thyroidectomy haematoma causing total airway obstruction-a case report. Indian J Anaesth 2004;48(6):483–485.
2. Rosenbaum MA, Haridas M, McHenry CR. Life-threatening neck hematoma complicating thyroid and parathyroid surgery. Am J Surg 2008;195(3):339–343.
3. Calo PG, Erdas E, Medas F, Pisano G, Barbarossa M, Pomata M, et al. Late bleeding after total thyroidectomy: report of two cases occurring 13 days after operation. Clin Med Insights Case Rep 2013;6:165–170.
4. Lee HS, Lee BJ, Kim SW, Cha YW, Choi YS, Park YH, et al. Patterns of post-thyroidectomy hemorrhage. Clin Exp Otorhinolaryngol 2009;2(2):72–77.
5. Abbas G, Dubner S, Heller KS. Re-operation for bleeding after thyroidectomy and parathyroidectomy. Head Neck 2001;23(7):544–546.
6. Calo PG, Pisano G, Piga G, Medas F, Tatti A, Donati M, et al. Postoperative hematomas after thyroid surgery. Incidence and risk factors in our experience. Ann Ital Chir 2010;81(5):343–347.
7. Burkey SH, van Heerden JA, Thompson GB, Grant CS, Schleck CD, Farley DR. Reexploration for symptomatic hematomas after cervical exploration. Surgery 2001;130(6):914–920.
8. Defechereux T, Hamoir E, Nguyen Dang D, Meurisse M. Drainage in thyroid surgery. Is it always a must? Ann Chir 1997;51(6):647–652.
9. Khanna J, Mohil RS, Chintamani, Bhatnagar D, Mittal MK, Sahoo M, et al. Is the routine drainage after surgery for thyroid necessary? A prospective randomized clinical study [ISRCTN-63623153]. BMC Surg 2005;5:11.
10. Schoretsanitis G, Melissas J, Sanidas E, Christodoulakis M, Vlachonikolis JG, Tsiftsis DD. Does draining the neck affect morbidity following thyroid surgery? Am Surg 1998;64(8):778–780.
11. Hurtado-Lopez LM, Lopez-Romero S, Rizzo-Fuentes C, Zaldivar-Ramirez FR, Cervantes-Sanchez C. Selective use of drains in thyroid surgery. Head Neck 2001;23(3):189–193.
12. Promberger R, Ott J, Kober F, Koppitsch C, Seemann R, Freissmuth M, et al. Risk factors for postoperative bleeding after thyroid surgery. Br J Surg 2012;99(3):373–379.