A 53-year-old woman is evaluated in the postanesthesia care unit following thyroid surgery. She underwent a total thyroidectomy for a retrosternal goiter that was causing dysphagia from esophageal compression. The patient states her neck feels a little "tight" but has no significant pain or difficulty breathing. Medical history is otherwise unremarkable. Temperature is 37 C (98.6 F), blood pressure is 126/86 mm Hg, and pulse is 100/min. Oxygen saturation is 99% on room air. On physical examination, the patient appears comfortable, with no distress. Pupils are equal, round, and reactive. Voice is normal. Neck incision is well-approximated, and there is a 4-cm ballotable swelling under the incision. The lungs are clear to auscultation. Heart sounds are normal. The neck swelling increases in size during the examination. Which of the following is the best next step in management?

Question

A 53-year-old woman is evaluated in the postanesthesia care unit following thyroid surgery.  She underwent a total thyroidectomy for a retrosternal goiter that was causing dysphagia from esophageal compression.  The patient states her neck feels a little "tight" but has no significant pain or difficulty breathing.  Medical history is otherwise unremarkable.  Temperature is 37 C (98.6 F), blood pressure is 126/86 mm Hg, and pulse is 100/min.  Oxygen saturation is 99% on room air.  On physical examination, the patient appears comfortable, with no distress.  Pupils are equal, round, and reactive.  Voice is normal.  Neck incision is well-approximated, and there is a 4-cm ballotable swelling under the incision.  The lungs are clear to auscultation.  Heart sounds are normal.  The neck swelling increases in size during the examination.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

This patient with an enlarging fluid collection (ballotable neck swelling) developing after thyroidectomy likely has an expanding neck hematoma. An expanding neck hematoma is life-threatening due to the potential for airway obstruction, either from direct airway compression or from vascular compression causing venous congestion leading to laryngeal edema. Stridor, dysphagia, voice changes, and "tripod positioning" are all signs of increasing upper airway obstruction; however, patients can initially have few or no symptoms (as in this patient with only mild neck tightness). Notably, patients often maintain their peripheral blood oxygenation concentration until rapid (<1 min) decompensation. The most important step in management is to decompress the airway by immediately evacuating the hematoma (including at the bedside if necessary). This is done by reopening the incision and removing the blood collection. The wound should then be explored in the operating room to control the source of bleeding, and the patient's airway should be evaluated to assess for laryngeal edema and need for protective endotracheal intubation (until the edema subsides). (Choice A) Compression via direct pressure or with a compressive dressing is often used to control bleeding at many sites. However, when bleeding is in the neck, compression can worsen the airway obstruction. (Choice B) A CT scan of the neck is not needed to diagnose an expanding neck hematoma and would delay potentially life-saving treatment. (Choice C) A fluoroscopic swallowing study may be used to assess for pharyngeal or esophageal injury (which would not cause rapidly expanding neck swelling) or to evaluate swallowing function if there is concern that a regular diet may be unsafe (eg, in some patients with head and neck tumors). (Choice E) Urgent cricothyrotomy involves an incision through the cricothyroid membrane to secure an airway for a patient in distress when other forms of airway management are unsuccessful, unavailable, or contraindicated. This patient's airway is threatened by a hematoma; removal may be sufficient to improve the airway. Educational objective: A postoperative neck hematoma should be recognized promptly and drained to avoid potentially lethal upper airway obstruction. References: Risk factors for hematoma after thyroidectomy: results from the nationwide inpatient sample. (http://www.ncbi.nlm.nih.gov/pubmed/24947642) Risk factors for neck hematoma after thyroid or parathyroid surgery: ten-year analysis of the nationwide inpatient sample database. (http://www.ncbi.nlm.nih.gov/pubmed/25663203) Airway management of a life-threatening post-thyroidectomy hematoma. (http://www.ncbi.nlm.nih.gov/pubmed/26670901)

A 53-Year-Old Woman Is Evaluated in the Postanesthesia Care Unit