Overview
Definition:
Neck hematoma evacuation after thyroidectomy refers to the surgical intervention to remove a collection of blood in the neck tissues following thyroid gland removal
This is a critical emergent procedure often necessitated by rapid expansion of the hematoma, leading to airway compromise.
Epidemiology:
Post-thyroidectomy hematomas occur in approximately 0.1% to 1% of cases, with a subset developing rapidly and requiring urgent intervention
Factors increasing risk include coagulopathy, aggressive dissection, and uncontrolled hypertension
Rapidly expanding hematomas are a surgical emergency.
Clinical Significance:
This complication is of paramount importance as it directly threatens the airway, leading to potential suffocation and death if not managed promptly
Early recognition and definitive management are crucial for patient survival and preventing neurological sequelae from hypoxia.
Clinical Presentation
Symptoms:
Sudden onset of neck pain or tightness
Dyspnea, stridor, or hoarseness
Feeling of impending doom
Difficulty swallowing (dysphagia)
Sensation of lump or fullness in the throat
Swelling of the neck, rapidly increasing in size
Restlessness and anxiety.
Signs:
Visible and palpable neck swelling, often tense and ecchymotic
Tracheal deviation
Jugular venous distension
Tachypnea and tachycardia
Accessory muscle use for breathing
Cyanosis in severe cases
Decreased breath sounds on auscultation
Palpable thrill or pulsatile mass may be absent or present.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the rapid onset of neck swelling and symptoms of airway compromise in a patient post-thyroidectomy
Imaging is often not feasible in emergent situations but can confirm hematoma if the patient is stable enough.
Diagnostic Approach
History Taking:
Detailed inquiry about the time of surgery, any intraoperative bleeding, patient's current medications (especially anticoagulants), and history of bleeding disorders
Assess for onset and progression of symptoms
Note any recent trauma to the neck.
Physical Examination:
Focused assessment of the neck for swelling, tenderness, and ecchymosis
Assess for tracheal position and mobility
Auscultate for stridor or diminished breath sounds
Assess for signs of airway compromise including respiratory rate, use of accessory muscles, and cyanosis
Palpate the surgical wound for drainage or dehiscence.
Investigations:
In emergent cases, investigations are secondary to immediate airway management
If time permits and the patient is stable, ultrasound of the neck can confirm the presence and extent of a hematoma
CT scan of the neck may be considered for better delineation but is often delayed
Coagulation profile (PT, INR, aPTT) is essential to identify underlying coagulopathy.
Differential Diagnosis:
Seroma formation (usually slower onset, less tense)
Abscess formation (fever, purulent discharge)
Edema from lymphatic disruption
Surgical emphysema
Laryngeal edema
Pre-existing neck masses
Inflammatory conditions of the neck.
Management
Initial Management:
Immediate airway assessment and securing the airway are paramount
This may involve intubation or tracheostomy
Continuous monitoring of vital signs and oxygen saturation
Mobilize surgical team for prompt evacuation
Administer oxygen
If coagulopathy is suspected, administer fresh frozen plasma (FFP) or other blood products.
Medical Management:
Primarily supportive and focused on reversing coagulopathy if present
Transfusion of blood products (platelets, FFP, prothrombin complex concentrate) based on laboratory findings and active bleeding
Electrolyte and fluid management.
Surgical Management:
Urgent surgical evacuation of the hematoma
This typically involves opening the existing surgical incision, releasing the clot, identifying and ligating any bleeding vessels, and achieving hemostasis
Thorough irrigation and placement of a drain are essential
The procedure may require general anesthesia or local anesthesia with sedation depending on the patient's airway status.
Supportive Care:
Post-evacuation, close monitoring of the airway and vital signs
Pain management
Antibiotics may be initiated if there is concern for infection or wound contamination
Regular wound care and drain management
Adequate hydration and nutrition
Early mobilization as tolerated.
Complications
Early Complications:
Airway obstruction leading to hypoxia and cerebral damage
Recurrent bleeding
Wound infection
Seroma formation
Damage to recurrent laryngeal nerve or superior laryngeal nerve (causing vocal cord paralysis).
Late Complications:
Chronic neck stiffness or pain
Scarring and keloid formation
Persistent dysphagia or hoarseness
Hematoma organizing into a fibrotic mass
Granuloma formation around drains.
Prevention Strategies:
Meticulous hemostasis during surgery
Careful ligation of vessels
Avoidance of unnecessary dissection
Preoperative correction of coagulopathies
Judicious use of anticoagulants post-operatively
Postoperative monitoring for wound swelling and patient symptoms
Prompt identification of even minor neck swelling.
Prognosis
Factors Affecting Prognosis:
Timeliness of intervention
Severity of airway compromise
Presence and severity of coagulopathy
Presence of associated nerve injury
General health status of the patient.
Outcomes:
With prompt and effective evacuation and airway management, the prognosis is generally good, with most patients recovering fully
Delayed intervention can lead to significant morbidity and mortality
Persistent nerve deficits can impact long-term quality of life.
Follow Up:
Close follow-up is required to monitor wound healing, drain output, and resolution of airway symptoms
Assessment for recurrent bleeding, infection, or seroma
Speech and swallowing evaluation may be necessary if vocal cord function or swallowing is affected
Regular assessment for thyroid hormone levels is important.
Key Points
Exam Focus:
Recognize neck hematoma as a surgical emergency post-thyroidectomy due to airway risk
Immediate airway management is the priority
Prompt surgical evacuation is definitive
Coagulopathy is a significant contributing factor and needs urgent correction.
Clinical Pearls:
Always have tracheostomy equipment readily available in the operating room during thyroidectomy
Educate patients to report any neck discomfort or swelling immediately postoperatively
A tense, rapidly expanding neck mass in a post-thyroidectomy patient is highly suspicious for a hematoma compromising the airway.
Common Mistakes:
Delaying surgical evacuation due to preoccupation with imaging
Underestimating the rapidity with which a hematoma can compromise the airway
Failing to adequately assess and secure the airway first
Inadequate hemostasis during evacuation
Neglecting to correct underlying coagulopathies.