Airway compromise caused by the spontaneous thyroid hemorrhage

A 44-year-old man presented to emergent department due to sudden onset of left neck pain with a rapidly enlarging mass and dysphagia for less than 30 min after giving a lecture. An urgent computed tomography disclosed a hematoma surrounded by a capsule in the left lobe of the thyroid gland and tracheal deviation with luminal narrowing. Endotracheal intubation via flexible fiberoscopy and emergent left lobectomy of the thyroid were performed and the patient recovered uneventfully and was discharged 4 days after surgery. In this case, the time elapse between onset of symptoms and airway compromise is even shorter as only 1 h. Securing the airway in such emergent situation is very important.

A 44-year-old man presented to emergency department due to sudden onset of left neck pain with a rapidly enlarging mass, dysphagia and felt someone to squeeze his throat for less than 30 min before admission. He had a past history of hypertension without regular medication, and thyroid goiter with euthyroidism status without body weight loss, heat intolerance or hand tremor in recent 6 months. He denied any history of trauma, symptoms of an upper respiratory tract infection, ingestion of foreign objects, taking antiplatelet and anticoagulant agents, or a bleeding diathesis. Vital signs included a body temperature of 37.2 °C, pulse rate of 128 beats/min, respiratory rate of 20 breaths/min, blood pressure of 183/105 mmHg and pulse oxygen saturation of 99%. The tachycardia and elevated blood pressure were thought to be secondary to an increase in sympathetic tone. On physical examination, the patient had a large, firm, non-fluctuant, and tender mass on the left side of neck. An urgent computed tomography disclosed a hematoma surrounded by a capsule in the left lobe of the thyroid gland and tracheal deviation with luminal narrowing (Fig. 1). The patient was agitation and difficult to breathe even under non-rebreather mask with pulse oxygen saturation of 98%. Owing to the concern of his acute airway obstruction with impending respiratory failure, the awake flexible fiberoscopy-aided intubation was done with a size 7.5 French nasal cuffed endotracheal tube. Emergent left lobectomy of the thyroid was performed after establishing definite airway. A nodular goiter with parenchyma hemorrhage was found during surgery and confirmed on pathologic examination. The patient recovered uneventfully and was discharged 4 days after surgery.

Nodular goiter affects 4% of the general population in the United States. In Taiwan, the prevalence of goiter in school children is 4.3%. The causes of thyroid goiter hemorrhage may result from trauma, fine needle aspiration, coagulopathy, or even spontaneously. The incidence rate of spontaneous thyroid goiter hemorrhage is very rare; however, acute airway compromise caused by thyroid goiter hemorrhage could be life-threatening and may occur within hours to days. In this case, the time elapse between onset of symptoms and airway compromise is even shorter as only 30 min. Securing the airway in such emergent situation is very important. Complex diagnostic and treatment procedures should only be undertaken after securing the airway.