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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 4  |  Issue : 3  |  Page : 229-232

From neck swelling to abrupt compromised airway: A case of a hemorrhagic ruptured thyroid cyst


Department of ENT, Bahrain Defense Force Hospital, Ar-Rifaa, Kingdom of Bahrain

Date of Web Publication11-Aug-2016

Correspondence Address:
Muneera A Al-Khalifa
Bahrain Defense Force Hospital
Kingdom of Bahrain
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DOI: 10.4103/1658-631X.188250

PMID: 30787737

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  Abstract 

Here, we present a rare case of spontaneous hemorrhagic rupture of a benign thyroid cyst in an adult Indian female who had no history of thyroid gland disease, trauma or coagulopathies. The patient presented to the Emergency Department with a suddenly progressive left-sided neck swelling of short duration. A 36-year-old otherwise healthy female presented to our Emergency Department with a progressive swelling on the left side of her neck that had started 2 days before her visit. Initially, the clinical neck examination revealed a well-defined soft cystic lesion confined to the left side of the neck anteriorly, measuring around 4 cm × 4 cm, tender to touch and moving with deglutition. Preliminary flexible scope examination of her larynx was normal. Within a few hours of having undergone ultrasonography examination, the neck swelling became diffused with increased tenderness. However, the patient remained clinically stable with no signs of airway compromise. A repeat of the fiber optic flexible scope examination showed submucosal hematoma in the left aryepiglottic area that mildly pushed the patient's laryngeal inlet to the contralateral side. Shortly after, the patient's condition worsened with the progression of swelling leading to compression of the airway. This promoted the decision to intubate the patient, who was subsequently, managed conservatively with close monitoring in the intensive care unit. Postintubation ultrasonography and computer tomography scans showed diffused inflammatory changes on the left side of the neck in the superficial and deep planes, mainly confined to the infrathyroid. Spontaneous sudden hemorrhagic rupture of a thyroid gland cyst is a rare condition but should be considered in a massive abrupt neck swelling that could potentially be life threatening.

  Abstract in Arabic 

ملخص البحث :

يعرض الباحثون حالة نادرة لنزف تلقائي لكيس بالغدة الدرقية لمريضة هندية لم تكن تعاني من مرض أو إصابة في الغدة الدرقية، أو انسداد الممر الهوائي. بين الفحص وجود (Submucosal hematoma) بالجهة اليسرى .وقد تطورت حالة المريضة مما أدى إلى الضغط على الممر الهوائي ومن ثم وضع أنبوبه للقصبة الهوائية وعلاجها تحفظياً ومتابعة دقيقة في العناية المركزة . وخلصت الدراسة إلى أن أي نزف مفاجئ في الغدة الدرقية يجب أن يعامل بجدية كونه قد يهدد حياة المريض.

Keywords: Airway compromise, hemorrhagic rupture, thyroid cyst


How to cite this article:
Al-Khalifa MA, Sharif H, AlShehabi M. From neck swelling to abrupt compromised airway: A case of a hemorrhagic ruptured thyroid cyst. Saudi J Med Med Sci 2016;4:229-32

How to cite this URL:
Al-Khalifa MA, Sharif H, AlShehabi M. From neck swelling to abrupt compromised airway: A case of a hemorrhagic ruptured thyroid cyst. Saudi J Med Med Sci [serial online] 2016 [cited 2020 Aug 14];4:229-32. Available from: http://www.sjmms.net/text.asp?2016/4/3/229/188250


  Introduction Top


Spontaneous sudden onset of hemorrhagic rupture of thyroid gland cyst is remarkably uncommon but not unheard of. In current literature, only a limited number of cases have been reported.[1]

A rapid and immense swelling can swiftly occlude the airway and threaten the life of a patient.[2] Here, we present a patient who developed a sudden neck swelling that escalated and compromised her airway.


  Case Report Top


A 36-year-old healthy female presented to our Emergency Department with a progressive swelling on the left side of her neck that had started 2 days before presentation. There was no history of trauma, fever, cough, coagulopathies, recent medical procedures, medication intake or thyroid problems. The patient complained of pain and dysphagia on the side of the swelling.

The initial evaluation revealed a sick-looking nonetheless stable patient who was not in dyspnea or in respiratory distress. The neck examination revealed a well-defined soft cystic lesion confined to the left side of the neck anteriorly, measuring around 4 cm × 4 cm, extending from the left thyroid lobe levels III-IV. It was tender to the touch and moved with deglutition. Preliminary fiberoptic flexible scope examination of the larynx was normal.

Laboratory investigations showed a white blood cell count of 10.42 × 10 × 9/L, hemoglobin of 115 g/L and calcium levels of 2.32 mmol/L, which were all within the normal range. The thyroid function test was also within the normal range with elevated antithyroglobulin antibodies.

A preliminary ultrasound study of the neck showed posterior inferior left lobe hypoechoic thyroid nodule measuring 3 cm with ill-defined lateral border and echogenicity suggesting turbid fluid collection in the left neck spaces [Figure 1].
Figure 1: Ultrasound image of the neck showing hypoechoic nodule in left thyroid lobe

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A computer tomography scan showed diffused inflammatory changes of the superficial and deep facial planes mainly on the left side of the neck; however, they were confined to the infrathyroid region within the muscular and visceral facial planes of the intermediate deep cervical fascia [Figure 2]a and [Figure 2]b.
Figure 2: (a) Computed tomography coronal image showing left side soft tissues diffuse inflammation (arrow) pushing the airway to the opposite side. (b) Axial computed tomography image showing the thyroid gland with inferior posterior diffuse border of left thyroid lobe (arrow)

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Three hours after the initial assessment, the patient's condition suddenly changed. The swelling on the neck became engorged with increased tenderness. However, the patient remained clinically stable with no evidence of airway compromise or respiratory distress. Laryngeal flexible fiberoptic scope was repeated and revealed a left aryepiglottic submucosal hematoma compressing the airway and shifting the patient's laryngeal inlet to the right [Figure 3]a and [Figure 3]b.
Figure 3: (a and b) A direct flexible fiberoptic scope images of the larynx postextubation showing the regressing hematoma in left aryepiglottic area

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According to the findings of the flexible fiberoptic scope, the focus was on securing the airway. Therefore, the patient was electively intubated then transferred to the intensive care unit for observation. The patient was managed conservatively with intravenous antibiotics and steroids (dexamethasone). The following day, a, direct flexible fiberoptic scope was repeated which showed regression of the left sided submucosal swelling, and laryngeal inlet patency was visualized. The patient was then extubated and transferred from the intensive care unit to the ward where she gradually improved and discharged on the following day.

Thyroid ultrasound-guided fine needle aspiration (FNA) cytology showed normal sized thyroid gland with evidence of an oblong shaped, fairly well-defined hypoechoic nodule in the left thyroid lobe. Cytology was reported as Thy1 (Bethesda class I, nondiagnostic or unsatisfactory). In relation to previous imaging studies and cytology report, a diagnosis of ruptured thyroid cyst and hematoma was established.


  Discussion Top


Sudden abrupt neck swelling is both a life threatening condition and a surgical emergency that may result from traumatic causes, such as FNA, rupture aneurysm, or in rare circumstances, a spontaneous bleed into the thyroid gland nodule or parathyroid adenoma.[2],[3] One of the early publications was by Capps, who reported a fatal spontaneous massive swelling in 1934. The 50-year-old patient died of acute dyspnea and postpartum autopsy showed a cervicothoracic hematoma due to a parathyroid hemorrhage.[4]

In the current case, the initial physical examination of the neck swelling that mobilized with deglutition favored the endocrine glands of the neck (thyroid or parathyroid) as a preliminary source of the swelling. Furthermore, infectious causes were considered unlikely due to the absence of clinical signs of inflammation and normal white blood count. Moreover, the normal calcium level pushed back the parathyroid glands as a cradle of the swelling.

The initial ultrasound of the neck showed a hypoechoic nodule in the left thyroid lobe; this further supported the primary diagnosis of thyroid gland cyst. The subsequent computer tomography scan and direct visualization of the submucosal hematoma with the flexible fiber optic scope helped in constructing the diagnosis of ruptured hemorrhagic thyroid gland cyst.

Numerous authors postulated that the cause of sudden intrathyroid gland spontaneous bleeding can be due to sudden increase in intravenous pressure in certain activities such as cough or valsava.[5] However, the majority of cases lacked a clear triggering event. Interestingly, in our case, the only events that can be somehow considered as triggers were the ultrasound and the cyst palpitation during clinical examination.

The management approaches for such cases were all tailored according to the cause. However, the first and foremost mainstay in all reported cases was securing the airway.[1],[2],[3],[4],[6] The same was implemented with our patient, who was immediately intubated when the swelling increased and the laryngeal inlet was directly visualized to be compromised and shifted to the right.

Furthermore, planned management in such reported cases ranged from conservative management to surgical exploration and occasionally emergency partial thyroidectomy.[2] Conservative management was reported to be useful in cases of intrathyroid nodule haemorrhage.[5],[6] This was applicable in our case where repeated flexible fiberoptic scope examination of the larynx and ultrasound displayed regression of the hematoma, thereby diminishing the need for surgical intervention.

Taking in consideration the possibility of malignancy, a FNA biopsy was done and reported as a nondiagnostic or inconclusive. Anderson et al. reviewed 393 patients with a single nodule with nondiagnostic biopsy results.[7] Repeated FNA was obtained on 336 nodules, 18 of which were considered to be possibly cancerous, for which surgical removal and pathologic examination was done. This lead to a diagnosis of cancer in two patients. Anderson et al. recommended that nodules with a nondiagnostic cytology result, those that are lacking other risk factors and having benign appearance at ultrasound, could be followed with serial ultrasound examinations without a repeated biopsy.[7]

This recent recommendation was followed and our patient underwent several ultrasonographies over a period of a few months. The latest ultrasound on the neck was done approximately 9 months after initial presentation and revealed a normal thyroid gland with no evidence of abnormalities.


  Conclusion Top


Only a limited number of neck swellings attributed to spontaneous hemorrhagic ruptured thyroid gland cyst have been reported. Our case is unusual in terms of the sudden progressive swelling compromising the airway despite of no previous underlying thyroid gland disease or clear trigger of the hemorrhage. Hence, any sudden progressive neck swelling should promote hemorrhagic cyst as a differential diagnosis taking into consideration the necessity of securing the airway.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Amadei EM, Benedettini L, Piccin O. Two cases of cervical hemorrhage with upper airway obstruction: A life-threatening condition. Case Rep Med 2014;2014:674176.  Back to cited text no. 1
[PUBMED]    
2.
Hobbs HA, Bahl M, Nelson RC, Eastwood JD, Esclamado RM, Hoang JK. Applying the society of radiologists in ultrasound recommendations for fine-needle aspiration of thyroid nodules: Effect on workup and malignancy detection. AJR Am J Roentgenol 2014;202:602-7.  Back to cited text no. 2
[PUBMED]    
3.
Zhang J, Niu Z, Liang L, Shougen C, Zhou Y. Parathyroid adenoma presenting as spontaneous cervical-mediastinal and retropleural hematoma: A case report and review of the literature. J Clin Case Rep 2014;4:6-8.  Back to cited text no. 3
    
4.
Capps RB. Multiple parathyroid tumors with massive mediastinal and subcutaneous hemorrhage. Am J Med Sci 1934;188:801-4.  Back to cited text no. 4
    
5.
Sahin S, Belice T, Ogullar S, Ayaz T, Cure E. Syncope in a patient with spontaneous hemorrhage into a thyroid nodule. Hippokratia 2014;18:177-9.  Back to cited text no. 5
[PUBMED]    
6.
Vijapurapu R, Kaur K, Crooks NH. Case report. A case of airway obstruction secondary to acute haemorrhage into a benign thyroid cyst. Case Reports in Critical Care, Article ID 372369,2014;2014:3-6.  Back to cited text no. 6
    
7.
Anderson TJ, Atalay MK, Grand DJ, Baird GL, Cronan JJ, Beland MD. Management of nodules with initially nondiagnostic results of thyroid fine-needle aspiration: Can we avoid repeat biopsy? Radiology 2014;272:777-84.  Back to cited text no. 7
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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