Central JSM Clinical Case Reports

Cite this article: Marta Pérez NM, Enjuto D, Molero SS, Merino NH, García RS, et al. (2014) Cervical Hematoma Secondary to Spontaneous Rupture of a Thyroid Nodule. JSM Clin Case Rep 2(6): 1064.

*Corresponding authorMarcelin Necial, Department of Public Health and Epidemiology, University Rey Juan Carlos, Madrid, Spain, Tel: 34622827680, 34633540450; Email:

Submitted: 25 July 2014

Accepted: 07 October 2014

Published: 09 October 2014

Copyright© 2014 Marta Pérez et al.

OPEN ACCESS

Keywords•Neck hematoma•Neck tumor•Thyroid nodule•Thyroid hemorrhage

Case Report

Cervical Hematoma Secondary to Spontaneous Rupture of a Thyroid NoduleNecial Marcelin, Marta Pérez, Diego Enjuto, Soraya Sánchez Molero, Norberto Herrera Merino, Rosa Serrano García, Rafael Sánchez Estella, Javier Martin Ramiro, Fernández Merino Javier, Mariano Salvador Fernández and Jorge De Luis YanesDepartment of general surgery unit of the University Hospital Severo Ochoa, Madrid, Spain

Abstract

We present a case of intrathyroid hemorrhage of a thyroid no-dule which presented as a progressive cervical mass asso-ciated with anterior neck discomfort, anterior neck malaise, dysphagia and mild dyspnea which was controlled with rest. Ultrasound and CT scan allowed diagnosis and staging.

CASE PRESENTATIONA 44-year-old Male with a known thyroid nodule, and gastroe-

sophageal reflux disease (GERD) arrived to the Emergency Room with a right-sided cervical tumor with pain, dysphagia and mild respiratory difficulties (Figure 1). Symptoms and signs appeared while the patient was performing his regular weight- lifting. Physical examination showers a difficulty swallowing afebrile, eupneic and stable patient. On neck exam, an anterior cervi-cal mass was palpated, predominantly on the right side with upward shift with swallowing. No ecchymosis or crepitation was notice. Lab tests showed: Hemoglobin 13.5 g/dL. Coa-gulation profile serum chemistries and thyroid function were unremarkable. An urgent cervical ultrasound revealed a subs-capular thyroid hematoma (Figure 2). Further staging with a cercivothoracic CT scan with and without IV contrast confirmed the diagnosis of subscapular hematoma secondary to a hemorrhagic thyroid nodule (Figure 3).

Figure 1 Spontaneous anterior cervical hematoma in a 54-year old patient.

Figure 2 Thyroid ultrasound. A) Increase of the size of the gland with subscapular thyroid hematoma, shown as a mass with hypoechoic areas, most evident in low right thyroid lobe of. B) Healthy thyroid tissue. C) Traqueal deviation caused by the hematoma.

Figure 3 Cervicothoracic Scan. A) Subcapscular hematoma of the right thyroid lobe, most evident in the lower pole. B) Healthy thyroid tissues with an intact thyroid lobe. C) Left displacement of the traqueal.

Central

Marta Pérez et al. (2014)Email:

JSM Clin Case Rep 2(6): 1064 (2014) 2/2

Marta Pérez NM, Enjuto D, Molero SS, Merino NH, García RS, et al. (2014) Cervical Hematoma Secondary to Spontaneous Rupture of a Thyroid Nodule. JSM Clin Case Rep 2(6): 1064.

Cite this article

The patient was placed on observation. The size of hematoma decreased and the patient was discharged on the 3rd day.

DISCUSSIONThe first cervical hematoma secondary to an extracapsular

hemorrhage of the thyroid was diagnosed by Capps in 1934. The patient was a 50-year-old female who died of acute dyspnea and dysphagia. An autopsy showed a cervicothoracic hematoma due to a parathyroid hemorrhage [1,2]. In 1981 Jordan diagnosed a similar case [3]. Intranodular hemorrhage of the thyroid gland is rare, usually limited to the gland and in most cases secondary to hemodynamic changes in the setting of hemodialysis and the use of Heparin or warfarin [4]. Trauma or maneuvers that increase the intravascular pressure, like cough and Valsalva maneuver are other causes. The most plausible explanation of the thyroid hemorrhage is physical activity and possibly venous bleeding due to the increase of intravenous pressure. The thyroid nodules are vascularized by small lobular arteries with large blood vessels and arteriovenous fistulae [5]. Those features explain the susceptibility to bleeding upon physical activity. There no clear explanation of a spontaneous hemorrhage in a thyroid nodule. Some authors try to explain the increase of the intravenous pressure due to certain maneuvers like Valsalva maneuver while many cases lack a triggering event. Clinically the cervical hematoma secondary to a thyroid hemorrhage presents with spontaneous cervical pain or dysphagia. The management depends on the patient’s general condition. If the patient is stable clinically, the best treatment is rest and deferred surgery. This would allow time for a better preoperative preparation and also would give time for reabsorption of the hematoma before surgery. Dyspnea and dysphonia are indications for a surgical intervention according to Massard & Roma. The lack of severe

respiratory compromise in our patient allowed deferring surgery, which finally was deemed unnecessary [6,7].

CONCLUSIONSpontaneous cervical hematoma of thyroid gland can be

conservatively managed, although acute clinical manifestations such as sever dyspnea or dysphagia may require urgent surgical intervention. To Image studies like cervical ultrasound and cervicothoracic CT scan establish the diagnosis, allow differential diagnosis and stage extension for management.

REFERENCES1. Maweja S, Sebag F, Hubbard J, Misso C, Henry JF. [Spontaneous cervical

haematoma due to extracapsular haemorrhage of a parathyroid adenoma: a report of 2 cases]. Ann Chir. 2003; 128: 561-562.

2. Chang CC, Chou YH, Tiu CM, Chiou HJ, Wang HK, Chiou SY, et al. Spontaneous rupture with pseudoaneurysm formation in a nodular goiter presenting as a large neck mass. J Clin Ultrasound. 2007; 35: 518-520.

3. Jordan FT, Harness JK, Thompson NW. Spontaneous cervical hematoma: a rare manifestation of parathyroid adenoma. Surgery. 1981; 89: 697-700.

4. Handa SP, Colwell B. Spontaneous retropharyngeal bleeding in a patient on chronic hemodialysis. Nephron. 1993; 64: 485-486.

5. Jougon J, Zénnaro O. [Acute cervico-mediastinal hematoma of parathyroid origin]. Ann Chir. 1994; 48: 867-869.

6. Kozlow W, Demeure MJ, Welniak LM, Shaker JL. Acute extracapsular parathyroid hemorrhage: case report and review of the literature. Endocr Pract. 2001; 7: 32-36.

7. Korkis AM, Miskovitz PF. Acute pharyngoesophageal dysphagia secondary to spontaneous hemorrhage of a parathyroid adenoma. Dysphagia. 1993; 8: 7-10.