Traumatic thyroid hemorrhage is a rare but potentially life-threatening condition that needs further airway management or surgical intervention under most circumstances. Most traumatic thyroid hemorrhages occur in patients with preexisting goitrous thyroid glands for its increased vascularity. Symptoms and signs of the traumatic thyroid injury include pretracheal swelling and tenderness, neck swelling, dysphagia, airway obstruction, and respiratory distress. Due to potential airway compromised of the traumatic thyroid hemorrhage, surgical intervention is often needed. Bilateral thyroid hemorrhage is even rarer, and the airway should be more intensively monitored because of the severe mass effect. Herein, we report a case of traumatic bilateral thyroid hemorrhage treated with nonoperative management.
A 49-year-old woman with a history of goiter was admitted to the emergency department after a traffic accident 30 min before this presentation. According to the patient and medical records, the preexisting goiter was Grade I and she received no medications for euthyroid status of the goiter. This time, she was riding a motorcycle at night and fell to the ground. Her neck was hit to the motorcycle stem after a hard brake to dodge from a taxi. Upon arrival, the patient was alert and oriented. She complained of neck swelling and pain but denied loss of consciousness throughout the incident. The temperature was 35.8°C, the heart rate 85 beats per minute, the blood pressure 120/78 mmHg, the respiratory rate 18 breaths per minute, and the oxygen saturation 97% under ambient air. She had neck swelling and tenderness with erythematous change; however, no stridor or respiratory distress was noted. Laboratory data revealed that her hemoglobin was 9.4 g/dL. The computed tomography (CT) of the head and neck revealed bilateral thyroid hemorrhage and mild tracheal deviation to the right [Figures 1 and 2] without intracranial hemorrhage or cervical spine deformity. The hematoma was larger in the left lobe of the thyroid (5.2 cm × 4.0 cm × 7.2 cm) and smaller in the right lobe of the thyroid (3.6 cm × 2.0 cm × 6.0 cm). The CT scan of the chest, abdomen, and pelvis demonstrated no signs of internal bleeding or other organ damage.
She was admitted to the trauma intensive care unit and received nonoperative treatment with continuous vital signs monitoring. Repeated blood test showed no decline in her hemoglobin level. Her voice was as usual and had no hoarseness or stridor. Smooth respiratory pattern without the need of supplemental oxygen use was noted throughout her entire course of hospitalization. The patient was discharged after 5 days of hospital stay uneventfully. Follow-up laboratory test revealed normal thyroid function at 1, 3, and 6 months after the event.
Traumatic bilateral thyroid hemorrhage was rarer than the one-side thyroid hemorrhage. To our review and knowledge, guideline or consensus for management of the traumatic thyroid hemorrhage was lacking due to rarity of the case. The treatment of choices between conservative treatment and surgical intervention depends mostly on the clinical symptoms of the patients. Although most of the patients underwent surgical interventions of total or hemithyroidectomy in literatures, the nonoperative treatment would work for selective patients without airway compression and respiratory distress. Heizmann etal. have proposed an algorithm for diagnosis and management of thyroid gland injury. In the algorithm, hemodynamically stable patients who presented with associated thyroid pathology, including adenoma, cysts, or goiter, should undergo elective neck exploration and resection of the diseased thyroid gland. Our case had a history of goiter, and presented as traumatic bilateral thyroid hemorrhage, but also managed successfully under nonoperative treatment. This case emphasized that clinical symptoms as well as intensive monitoring should still be prioritized in blunt neck injury with conservative treatment.
Furthermore, delayed onset of the airway compression up to 24 h or even longer would occur, so intensive monitoring for more than 24 h may be warranted. Our case underwent a 5-day intensive monitor during hospital.
To our knowledge, no case of bilateral thyroid hemorrhage after blunt neck trauma managed with nonoperative treatment has been reported. In our patient, nonoperative management and continuous vital signs monitoring were given because she presented with clear consciousness without respiratory distress or dyspnea after the accident. No progression of the thyroid hemorrhage or delayed onset of the airway compression was noted afterward. Follow-up laboratory test revealed normal thyroid function at 1, 3, and 6 months after the event. The overall clinical course and further follow-up of the thyroid gland function suggested that traumatic bilateral thyroid hemorrhage may be managed nonoperatively in a selective case.
This rare case demonstrated successful nonoperative management on the blunt injury of the neck, complicated with bilateral thyroid hemorrhage in a 49-year-old woman with a preexisting goiter.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Research quality and ethics statement
The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.
Financial support and sponsorship
the Ministry of Science and Technology, Taiwan (MOST 110-2511-H-002-009-MY2).
Conflicts of interest
There are no conflicts of interest.
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