A rare event of a fall causing delayed intrathyroidal hematoma and respiratory distress is reported here. A 75-year-old woman with symptoms of vertigo causing syncope and fall 24 h earlier was seen and discharged from our emergency department after an unremarkable physical exam and 6-h observation period. Within 3 h of discharge, the patient was transported back by Emergency Medical Services with an enlarging neck mass and subjective respiratory distress. CT scan demonstrated a large, expanding hematoma, and the patient underwent an emergency hemithyroidectomy. Hürtle cell adenoma was found on pathologic specimen examination. A review of the literature of similar cases is presented, emphasizing the notion that concurrent thyroid pathology is a risk factor for airway compromise after seemingly benign trauma and that airway compromise can present in a delayed fashion

A Wendel

H Rupprecht

Joel P. Turner

Lucas B. Chartier

M Blaivas

M Sobrinho-Simões

N Hirshoren

PBS Fowler

R Phitayakorn

RH Grace

RL Behrends

WI Terry

WJ Ryan

Y Oka

International Journal of Emergency Medicine

English

PubMed

Abstract
              A rare event of a fall causing delayed intrathyroidal hematoma and respiratory distress is reported here. A 75-year-old woman with symptoms of vertigo causing syncope and fall 24 h earlier was seen and discharged from our emergency department after an unremarkable physical exam and 6-h observation period. Within 3 h of discharge, the patient was transported back by Emergency Medical Services with an enlarging neck mass and subjective respiratory distress. CT scan demonstrated a large, expanding hematoma, and the patient underwent an emergency hemithyroidectomy. Hürtle cell adenoma was found on pathologic specimen examination. A review of the literature of similar cases is presented, emphasizing the notion that concurrent thyroid pathology is a risk factor for airway compromise after seemingly benign trauma and that airway compromise can present in a delayed fashion

Chartier, Lucas B

Turner, Joel P

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Delayed intrathyroidal hematoma causing respiratory distress after a seemingly benign fall: a case report

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CASE REPORT
Delayed intrathyroidal hematoma causing respiratory
distress after a seemingly benign fall: a case report
Lucas B. Chartier & Joel P. Turner
Received: 27 March 2010 /Accepted: 30 May 2010 /Published online: 8 July 2010
# Springer-Verlag London Ltd 2010
Abstract A rare event of a fall causing delayed intra-
thyroidal hematoma and respiratory distress is reported
here. A 75-year-old woman with symptoms of vertigo
causing syncope and fall 24 h earlier was seen and
discharged from our emergency department after an
unremarkable physical exam and 6-h observation period.
Within 3 h of discharge, the patient was transported back by
Emergency Medical Services with an enlarging neck mass
and subjective respiratory distress. CT scan demonstrated a
large, expanding hematoma, and the patient underwent an
emergency hemithyroidectomy. Hürtle cell adenoma was
found on pathologic specimen examination. A review of the
literature of similar cases is presented, emphasizing the
notion that concurrent thyroid pathology is a risk factor for
airway compromise after seemingly benign trauma and that
airway compromise can present in a delayed fashion.
Keywords Trauma . Thyroid . Hematoma .
Respiratory distress
Introduction
Although hemorrhage into the thyroid gland is well
recognized, massive bleeding into the thyroid gland after
trauma is rare. Given the anatomical location of the thyroid
gland and the potential for airway compromise secondary to
external compression, this is an issue that emergency
physicians (EPs) must not overlook. We report the case of
a patient presenting to the emergency department (ED) with
a spontaneously expanding neck hematoma, approximately
24 h after a seemingly benign fall.
Case report
Mrs. C, a 75-year-old female, had been experiencing 4 days
of dizziness before sustaining an unwitnessed syncopal
episode at home after getting up from bed. She called the
Emergency Medical Services (EMS), which transported her
to a local ED. Except for a mild bradyarrhythmia, the
patient was stable and was transferred to our hospital ED
for further evaluation. She was known for benign paroxys-
mal positional vertigo (BPPV), atrial fibrillation and
hypertension. Her medications included warfarin, spirono-
lactone and telmisartan. On further questioning, the patient
remembered experiencing vertigo prior to the fall. In the
ED, she continued to complain of vertigo, nausea, mild
headache and tinnitus. She had one episode of vomiting
while in the ED, which was managed with 50 mg of
dimenhydrinate intravenously. The patient appeared in no
apparent distress. Her vital signs included a blood pressure
of 175/85, an irregular pulse of approximately 75 and an
oxygen saturation of 96% with a respiratory rate of 14. She
was afebrile. Her physical exam, including a complete
musculoskeletal exam, was unremarkable except for bilat-
L. B. Chartier (*)
Division of Emergency Medicine, Department of Medicine,
University of Toronto,
2075 Bayview Ave., Rm. C753,
Toronto, ON, Canada M4N 2M5
e-mail: lucas.chartier@utoronto.ca
J. P. Turner
Department of Emergency Medicine,
Sir Mortimer B. Davis Jewish General Hospital,
3755, Côte-Ste-Catherine Road, Room D-027,
Montreal, QC, Canada H3T 1E2
Int J Emerg Med (2010) 3:431–433
DOI 10.1007/s12245-010-0196-6
eral chronic pedal edema. Of note, there was no neck pain,
tenderness or mass. An electrocardiogram revealed atrial
fibrillation with a ventricular rate of 66 to 75 beats per
minute. Laboratory tests revealed a hemoglobin of 142 g/l,
a white blood cell count 10.3×109/l, a platelet count of
185×109/l and a blood glucose of 8.6 mmol/l (all within
normal limits). The international normalized ratio (INR)
was subtherapeutic at 1.6. The patient was given a
diagnosis of “fall secondary to BPPV,” and was discharged
home asymptomatic and in stable condition after a
6-h observation period. She was instructed to return to the
ED if her symptoms persisted.
Within 3 h of discharge, the patient called EMS complain-
ing of vomiting and of an enlarging neck mass. She was
immediately transported back to our hospital ED where a new
team of EPs assessed her. The patient stated that the mass had
been enlarging for the past hour and that it was accompanied
by a sensation of fullness in her neck, dysphagia and some
mild respiratory difficulties. After obtaining a history of a
trauma 24 h earlier, cervical spine immobilization was
immediately initiated. The patient had a blood pressure of
150/75, an irregular pulse of approximately 68 and an oxygen
saturation of 99% on 4 l of oxygen by nasal prong. She was
noted to be in minimal respiratory distress, with a respiratory
rate of 22. On examination, the patient was found to have a
large swelling in the right anterior triangle of the neck, at the
level of the thyroid gland. The trachea was displaced to the
left, but the patient displayed no stridor. She also had
tenderness in the region of the cervical paraspinal muscles.
A bedside ultrasound performed by the EP confirmed a large
fluid-filled structure adjacent to the thyroid gland. A provi-
sional diagnosis of “neck hematoma causing potential airway
compromise” was given. Computed tomography scan (CT) of
the patient’s head, neck and cervical spine was immediately
ordered. Four units of fresh frozen plasma were ordered to
correct the patient’s anticoagulation. The ear, nose and throat
specialists (ENT), already in the ED, were consulted and
immediately assessed the patient.
The CT of the patient’s head and cervical spine showed
no fracture or abnormality. The CT of her neck revealed a
large hematoma, centered in the right thyroid lobe
measuring 7.2×5.0×6.9 cm. The trachea was moderately
deviated towards the left but without significant reduction
in the cross-sectional area. While ENT was establishing a
course of action, the patient complained of a subjective
increase in respiratory distress in the ED. Mrs. C was
immediately transferred to the operating room, successfully
intubated and had her neck mass explored. A large
hematoma resulting from the torn right infrathyroid artery
was discovered. Hemostasis was established, and the
patient finally underwent a right hemi-thyroidectomy. The
patient did very well postoperatively and was discharged
from the hospital 2 days later. She was doing well at her
follow-up appointment 2 weeks later. Pathologic examina-
tion of the resected specimen revealed an intrathyroidal
hematoma involving a Hürthle cell adenoma.
Discussion
Spontaneous hemorrhage in the thyroid gland, although not
frequent, is not an uncommon phenomenon [1, 2]. Blunt
traumatic etiologies, however, are much more rare. Reported
cases include direct blunt trauma to the neck from a motor
vehicle steering wheel [3], bicycle handlebars [4], secondary
to airbag deployment [5] as well as a fall on the neck [6].
Rare cases of thyroid hemorrhage following indirect trauma
(trauma near the neck but not directly to the thyroid gland)
[1, 7], and excessive Valsalva maneuvers [2, 8] have also
been described. The symptoms displayed by the patients
ranged from a painless neck lump [2] to sudden respiratory
collapse [8]. The time to presentation to a physician ranged
from immediate [2, 3, 8] to more than 24 h [6, 7]. All but
one [8] survived. In seven of the eight cases, a concomitant
thyroid pathology was either known or subsequently
discovered on pathologic examination [1–3, 5–8].
Thyroid pathology seems to be an important risk factor
in causing neck hematoma following blunt trauma. This
was illustrated as early as in 1922 by Terry’s experimental
work, in which he showed that in pathological states,
coughing or straining raises the patient’s central venous
pressure sufficiently to cause thyroid vessel bleeding [9]. It
is believed that many thyroid pathologies, including
adenomas, induce angiogenesis of immature, fragile blood
vessels that are prone to rupture [10, 11]. This vulnerability
is compounded by the fact that blood flow increases in
diseased states [12], potentially causing vessel rupture with
major bleeding after seemingly benign trauma. One
important contributing factor unique to the present case
was the fact that the patient was taking warfarin for atrial
fibrillation. While no single cause seems sufficient to
account for Mrs. C’s intrathyroidal hemorrhage, the
combination of different factors might have been enough
to account for her significant hematoma. These may include
a possible trauma to the neck during her fall, the action of
warfarin and the presence of a Hürthle cell adenoma.
In light of the diverse nature of presentations in patients
with trauma-related intrathyroidal hemorrhages illustrated
here, a few points are noteworthy. All patients with obvious
direct trauma to the neck and thyroid gland require close
observation with respect to possible airway compromise.
However, in patients with known or suspected thyroid
pathology, even minor trauma can pose a risk for delayed
intrathyroidal hemorrhage. These patients may require a
prolonged period of observation before being safely dis-
charged from the ED. Given that the currently discussed
432 Int J Emerg Med (2010) 3:431–433
case is only the ninth reported in the literature, it is difficult
to suggest any specific duration for monitoring. Since very
delayed complications may still occur, patients and/or their
caregivers should receive, upon discharge, appropriate and
detailed information regarding indications to return to the
ED. Luckily, most hemorrhages into thyroid adenomas are
usually gradual and generally respond to conservative
treatment. As opposed to previous recommendations [7],
we do not recommend serial neck circumference measure-
ments. We believe that given the different compressive
nature of soft tissue masses, this measure would be
ineffective at detecting and preventing airway compromise
before it is subjectively or objectively apparent.
Conclusion
We illustrated the case of a patient presenting with an
intrathyroidal hemorrhage causing respiratory distress approx-
imately 24 h after a seemingly benign fall. It is important to
recognize the potential for such complications, especially in
the presence of thyroid pathology. The greatest challenge for
the emergency physician is to recognize this risk factor and to
consider the possibility of delayed airway compromise when
deciding on the final disposition of the patient.
Conflicts of Interest The authors have no financial or other
conflicts of interest related to this submission.
References
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Crossref

University of Toronto Research Repository

Acute bleeding caused by rupture of the thyroid gland following blunt neck trauma: case report.

Acute goiter hematoma following blunt neck trauma.

Acute haemorrhage into the thyroid gland following trauma and causing respiratory distress.

Blunt thyroid trauma with acute hemorrhage and respiratory distress.

Fetal adenoma with hemorrhage.

Follicular and Hürthle cell carcinoma of the thyroid gland.

Hemorrhage into the thyroid gland resulting from muscular effort.

Isolated traumatic thyroid hemorrhage secondary to air bag deployment. Otolaryngol Head Neck Surg 130:791–793

Radium emanations in exophtalmic goiter-blood vessels of adenomas of thyroid.

Thyroid gland hematoma after blunt cervical trauma.

Thyroid, blood flow and atheroma.

Vieira de Castro I et al (2005) Hürthle (oncocytic) cell tumors of thytroid: etiopathogenesis, diagnosis and clinical significance.

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Delayed intrathyroidal hematoma causing respiratory distress after a seemingly benign fall: a case report

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