Early CT scan prevents airway obstruction in a thyroidectomy case complicated by postoperative hematoma: A case report

Abstract

Introduction

Among patients undergoing thyroid or head and neck surgery, the incidence of postoperative hemorrhage is reported to range between 0.36 % and 4.2 %. Postoperative bleeding in the neck can lead to severe complications if not promptly addressed.

Presentation of case

The patient in this case was a man in his 50s, who was being treated for T3-dominant Basedow's disease with medication at the endocrinology department of our hospital. However, owing to the ineffectiveness of drug therapy in controlling the condition, the patient was referred to our department for surgery. Approximately 18 h after undergoing a thyroidectomy, the patient suddenly complained of dyspnea. Laryngeal fiberoptic examination showed no signs of laryngeal edema or recurrent nerve palsy. However, a neck CT scan revealed a hematoma at the surgical site, necessitating emergency surgery. During the operation, hematomas were found in both the superficial and deep layers of the surgical area. Arterial bleeding from the left side of the thyroid cartilage was confirmed, and the branches of the superior laryngeal artery were ligated to stop the bleeding.

Discussion

Hematoma formation in a narrow space, particularly in the neck, can obstruct large vessels such as the internal jugular veins, compromising venous return. This may result in laryngeal edema, asphyxia, and, in the worst-case scenario, death.

Conclusion

An early neck CT scan revealed a subcutaneous neck hematoma caused by postoperative bleeding, leading to emergency hematoma removal, hemostasis, and tracheotomy, which successfully prevented airway obstruction.

Highlights

• •Postoperative cervical bleeding can lead to serious complications.
• •Wound hematomas may occlude large blood vessels and impair venous return.
• •Neck postoperative bleeding can lead to laryngeal edema, asphyxiation, and death.
• •Early neck CT scan can detect subcutaneous cervical hematomas.
• •Early treatment can prevent airway obstruction.

1. Introduction

Cervical surgery includes various procedures, such as thyroidectomy performed for thyroid disorders, anterior cervical fusion for cervical spine conditions, and cervical lymph node dissection for head and neck cancers [1]. Anatomically, unlike the thorax and abdomen, which contain the thoracic and abdominal cavities, respectively, the neck has no cavity and contains closely packed tissues with little to no space between them. When postoperative bleeding occurs in this narrow space, it can lead to the formation of a hematoma, potentially obstructing large vessels such as the internal jugular veins. This obstruction may impair venous return, leading to laryngeal edema, asphyxia, and, in the worst cases, death [1].

In the current case, the patient developed sudden dyspnea approximately 18 h after a thyroidectomy. An early neck CT scan revealed a subcutaneous neck hematoma due to postoperative bleeding. Emergency intervention, including hematoma removal, hemostasis, and tracheotomy, was performed to prevent airway obstruction. This case was presented in accordance with the updated consensus Surgical Case Report (SCARE) 2023 guidelines [2].

2. Presentation of case

The patient was a man in his 50s who was undergoing drug treatment for T3-dominant Basedow's disease in the endocrinology department of our hospital. Owing to the ineffectiveness of drug therapy in controlling his condition, he was referred to our department for surgical intervention. Physical examination revealed a height of 159.1 cm, a weight of 87.6 kg, and a diffuse, elastic swelling in the anterior neck. A preoperative neck CT scan revealed diffuse thyroid enlargement (Fig. 1A). The patient was deemed suitable for surgery, and the procedure was performed under general anesthesia on the X day.

Fig. 1.

(A)Preoperative CT image of the neck shows diffuse enlargement of the thyroid gland (arrowhead). (B),(C) Endoscopic view of the larynx after the onset of respiratory distress on X + 1 Day shows no laryngeal edema during (B) inhalation and (C) exhalation.

3. Progress

3.1. X Day

A total thyroidectomy was performed, with the surgery lasting 4 h and 28 min. Intraoperative bleeding was minimal, and one drain was inserted into each side of the neck. After the surgery, the patient was successfully extubated and removed from the ventilator. The surgery ended at 17:28.

At 17:59, the patient was transferred back to his room, with clear consciousness and no signs of respiratory distress. Oxygen saturation (SpO₂) was maintained between 92 % and 95 % with 5 L of oxygen administered.

At 18:30, bleeding was observed from the surface of the left wound, after which the doctor was called. At this time, the drainage volume was small, and the patient showed no signs of respiratory distress.

3.2. X+1 Day

10:20: At the time of the routine check-up, the draining volume was measured at 104 mL from the right drain and 103 mL from the left drain. Laryngeal fiberscopy was performed, revealing no signs of laryngeal edema, vocal cord paralysis, or laryngeal submucosal hematoma. The patient was able to walk and converse independently, and no signs of subcutaneous hematoma were observed in the neck.

11:48 (approximately 18 h and 20 min after surgery): The patient complained of difficulty breathing while in a sitting position and expressed discomfort when lying down. His respiratory rate was 20 breaths/min, with an SpO₂ of 99 % on 1 L of oxygen. A repeat laryngeal endoscopy showed no laryngeal edema, vocal cord paralysis, laryngeal submucosal hematoma, or saliva retention (Fig. 1B,C).The imaging showed no obvious abnormalities in the lung fields (Fig. 2A).

Fig. 2.

(A) X + 1 Day: Simple chest radiograph after the onset of respiratory distress shows no congestion in the lung fields.

(B) X + 1 Day: Simple CT image of the neck after the onset of respiratory distress shows a hematoma in both the shallow surgical layer and the deep surgical wound (arrowhead).

12:17: At the time of neck CT, the ecchymosis in the neck in Fig. 3A was not confirmed. We determined that a CT scan was warranted to guide early therapeutic management and confirm the presence of a compressible neck hematoma. A plain CT scan of the neck and chest was performed to assess the surgical wound. A deposit suggestive of a hematoma was found in the superficial and deep layers of the subcutaneous tissue of the anterior neck, and a gas image suggestive of a postoperative change was also found. The fat concentration in the superior posterior cavity had also increased slightly, suggesting the progression of the hematoma (Fig. 2B).

Fig. 3.

X + 1 Day: Images show the surgical field at the time of hematoma removal.

The sutures at the skin and platysma muscle were removed, and the superficial wound was opened (Fig. 3A and B). A blood clot weighing at least 264 g was found just below the platysma muscle and was removed by irrigation. Next, the sutures at the anterior cervical muscles were removed, revealing the deep wound. A blood clot was found in the cavity where the thyroid gland had been, extending from the larynx to the trachea (Figs. 3C–3E). Arterial bleeding from the left side of the left thyroid cartilage was confirmed (Fig. 3F), and the branches of the superior laryngeal artery were ligated to stop the bleeding (Fig. 3G). After confirming that the wound had stopped bleeding (Fig. 3H), a tracheotomy was performed. One drain was inserted on each side, and the surgery was completed. Images (A)–(E) show the hematoma (arrowhead), and image (F) shows arterial hemorrhage (arrowhead).

Given these findings, we determined that emergency surgery was necessary and promptly contacted all relevant authorities.

15:54: The patient underwent an emergency procedure under general anesthesia, including an examination, hemostasis, and tracheotomy. No laryngeal edema was observed, and tracheal intubation was performed without any complications.

The sutures at the skin and platysma muscle were removed, and the superficial wound was opened (Fig. 3A and B). Fig. 3A is a photo taken immediately before surgery. A blood clot weighing at least 264 g was found just below the platysma muscle and was removed by irrigation. Next, the sutures at the anterior cervical muscles were removed to expose the deeper wound. A blood clot was found in the cavity where the thyroid gland had previously been, extending from the larynx to the trachea (Figs. 3C–3E). Arterial bleeding from the left side of the left thyroid cartilage was confirmed (Fig. 3F). The branches of the superior laryngeal artery were ligated to control the bleeding (Fig. 3G). After confirming that the bleeding had stopped (Fig. 3H), a tracheotomy was performed. One drain was inserted on each side, and the surgery was completed. Postoperatively, the patient developed anemia, with his hemoglobin levels dropping from 15.5 g/dL before surgery to 11.3 g/dL by postoperative X+3 Day. However, following hemostasis, there were no further issues with the wound.

The tracheal cannula was removed on X+2 Day, all drains were removed on X+4 Day, and the postoperative course was uneventful, with the wound healing well and no further complications observed on Day X+6.

4. Discussion

Postoperative bleeding associated with head and neck surgery can be a life-threatening complication, and care must be taken to avoid it. It is important to understand the frequency, timing, clinical signs, and risk factors associated with postoperative bleeding, as well as the importance of vigilant postoperative management to mitigate the risks. Approximately 85 % of re-bleeding incidents occur within the first 24 h of the initial procedure, with the majority happening in the first 8 h. However, late bleeding has been reported up to 20 days postoperatively [1,[3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]]. The larynx is located at the center of the respiratory tract, extending from the oral and nasal cavities to the trachea, and is located anterior to the 4th to 6th cervical vertebrae. It is surrounded by a framework of cartilage and its cavity is lined by a mucous membrane. Since cervical surgery can disturb the return of the venous blood around the larynx, laryngeal edema is likely to occur after such surgery. Furthermore, if postoperative bleeding occurs and hematoma is formed, the blood flow of the vein, including the internal jugular vein, is disturbed. This disturbance can aggravate edema in the glottis, the narrowest part of the larynx, potentially leading to airway obstruction [1,[3], [4], [5], [6], [7], [8], [9], [10]].

Discrete signs, such as cervical pressure and tightness, coughing, difficulty in swallowing, change in voice, sensations of heat and/or cold, and restlessness, may be early indicators of impending neck swelling, which can be preceded by a blood-soaked dressing, rapid wound filling, or occlusion of wound drainage [1,3,4,[9], [10], [11], [12]] (Table 1). While cervical swelling is not necessarily a sign of relevant bleeding, it may occur owing to hemorrhage between the platysma muscle and anterior cervical muscles. Conversely, significant hemorrhage in a deeper region of the neck may occur even without noticeable neck swelling, especially if the midline is completely closed. Symptoms such as cervical pressure and tightness, difficulty swallowing, and a subjective feeling of shortness of breath are potential indicators of bleeding. More severe signs, including shortness of breath, stridor, tachycardia, and hypotension suggest significant bleeding that demands immediate reintervention [1,3,4,[8], [9], [10], [11], [12], [13]].

Table 1.

Clinical signs of postoperative neck rebleeding and airway stenosis

(A)Subjective symptoms. (B)Objective symptoms.

(A)
Subjective symptoms	Publication
Cervical pressure sensation	Burkey et al.2001, Lee et al.2009
Uncomfortable feeling in the throat	Japan Medical Safety Research Organization 2022
Pain cervical region	Burkey et al.2001, Lee et al.2009, Japan Medical Safety Research Organization 2022
Difficulties swallowing	Burkey et al.2001, Promberger et al.2012, Japan Medical Safety Research Organization 2022
Shortness of breath	Burkey et al.2001, Promberger et al.2012, Japan Medical Safety Research Organization 2022

(B)
Objective symptoms	Publication
Cervical swelling	Lee et al.2009, Promberger et al.2012, Japan Medical Safety Research Organization 2022
Bleeding from the wound	Lee et al.2009, Promberger et al.2012
Subcutaneous bleeding	Japan Medical Safety Research Organization 2022
Notable amount of bloody fluid emerging from the neck drain	Burkey et al.2001, Promberger et al.2012, Japan Medical Safety Research Organization 2022
Increased neck circumference	Japan Medical Safety Research Organization 2022
Wheezing and stenotic sound detected by auscultation of the neck	Japan Medical Safety Research Organization 2022
Labored breezing (shoulder breathing, retractive breathing, etc.)	Japan Medical Safety Research Organization 2022
Orthopnea	Japan Medical Safety Research Organization 2022
Increased respiratory rate	Japan Medical Safety Research Organization 2022
Frequent postural changes or rolling-over	Japan Medical Safety Research Organization 2022
Restlessness	Japan Medical Safety Research Organization 2022
Anguished expression on the face	Japan Medical Safety Research Organization 2022
Cold sweat	Japan Medical Safety Research Organization 2022

The patient’s symptoms, which indicated potential airway stenosis, included subjective symptoms such as increased phlegm, difficulty swallowing saliva, and sore throat.

In addition, such a patient may find it difficult to lie supine and might prefer to lie on their side, with their head elevated, or remain in a sitting position. As the airway narrows, the patient may want to change positions to make breathing easier, potentially becoming restless or agitated, as if unable to find a comfortable position. If a patient complains of “phlegm,” “changing positions,” “shortness of breath,” or “wound pain” after neck surgery, it is important to recognize these as potential signs of airway stenosis and to observe symptom progression and changes to avoid missing these critical signs. Wound observation is also important in the postoperative care of patients undergoing neck surgery. Key aspects that should be monitored are neck swelling or induration, the presence or absence of subcutaneous hematoma, the amount of drainage fluid, and the characteristics of the drainage fluid.

In this case, the neck and laryngeal findings at the time the patient complained of dyspnea at 11:48 had not changed significantly from those 1 h and 28 min before the onset of symptoms. Therefore, the patient's subjective symptoms and the objective symptom of orthopnea were clues for early detection of postoperative bleeding in the neck, and postoperative bleeding was diagnosed by neck CT. A past report looked at 10 cases of fatal accidents reported to the Medical Accident Investigation and Inspection Center over a 5-year 6-month period. In these 10 cases, the time from returning to the room to the sudden change in condition ranged from 1 to 32 h, with a median of 4.5 h, and the time from the doctor's arrival to securing the airway ranged from 5 to 60 min, with a median of 25 min [1]. Behind these cases, it is believed that there may have been cases that did not result in death, but in which delayed response led to serious complications such as hypoxic encephalopathy, which are not reported in the table [1]. We believe that neck CT scans performed when subjective or objective symptoms appear are useful for diagnosing early postoperative bleeding before the condition suddenly worsens.

5. Conclusion

Bleeding after neck surgery is a complication that can lead to serious consequences if not promptly managed. Early diagnosis and treatment of postoperative hemorrhage are crucial to prevent the development of laryngeal edema. We believe that neck CT scans are a valuable tool for evaluating postoperative bleeding and ensuring timely intervention.

CRediT authorship contribution statement

YT drafted the manuscript. TS, TS, AY, and NO provided academic advice. All the authors have read and approved the final version of the manuscript.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

This case study was approved by the Research Ethics Committee.

Funding

This study did not receive any specific funding grants.

Declaration of competing interest

The authors declare no conflicts of interest.