Post thyroidectomy haematoma

Question 1

A 56 year old man has a total thyroidectomy. 12 hours later he complains of difficulty breathing. He has stridor and there is swelling at his wound site. How would you manage him?

Answer 1

Impression
Given the recent thyroidectomy with swelling and difficulty breathing, I am most concerned about a post-thyroidectomy haematoma having formed and causing airway obstruction. This is a surgical emergency which demands urgent attention. This can cause venous and lymphatic obstruction to drainage of the larynx, making intubation difficult post-evacuation of the haematoma.

Number of important post-thyroidectomy complications to consider;

• Haematoma (immediate)
• thyroid storm (if not euthyroid pre-surgery)
• hypocalcaemia (usually in first 30 days)

Other DDx

• anaphylaxis
• foreign body inhalation

Goals

• conduct rapid primary survey, alerting senior on call surg registrar whilst releasing sutures as a temporising measure for airway management
• arrange for definitive management with ETT insertion if appropriate or surgical cricothyroidotomy, then surgical exploration of haematoma

Question 2

Post-thyroidectomy haematoma - Assessment

Answer 2

Assessment
Start ABCDE assessment after calling for help, including anaesthetics for intubation and gen surg registrar. Notify treating team of surgical emergency

A - Assess for degree of obstruction, release sutures, remove bandaging and wound dressings, then immediate airway management with basic manoeuvres (chin lift, jaw thrust), utilisation of any supraglottic adjuncts for airway securing (LMA, + bag/mask), then escort patient to theatre for further exploration. Ultimately require RSI and intubation as soon as possible.

B - RR, SP02, - administer supplemental 02 as required
C - as per
D - GCS
E - look for alternative bleeds

Question 3

Post-thyroidectomy haematoma - history + examination

Answer 3

History

• review op report notes, screen for any risk factors (difficult closure/procedure, large mass, etc)
• sx of airway obstruction; hoarse voice, stridor
• Medications: anticoagulants, steroids (poor wound healing)

Examination

• general appearance + vitals
• as per A to E
• regular obs and GCS prior to theatres

Investigations
- consider FBC for Hb

Question 4

Post-thyroidectomy haematoma - management

Answer 4

Management
- Call surg reg and anaesthetics, organise OT

Supportive

• NBM
• pre-op bloods

Definitive

• Transfer to OT for definitive surgical exploration (AS there may be additional haematoma under muscle that has not yet been released)
• interventions such as irrigation, cautery of any bleeding signs, drainage and closure
• further interventions such as intubation to secure airway in setting of laryngeal oedema, if this fails then surgical cricothyroidotomy to secure the airway
• ICU admission for 1 to 1 observation
• only extubatne once supraglottic oedema has subsided
• regular obs of wound site, and for any evidence of reaccumulation.

Question 5

Complications of Thyroidectomy

Answer 5

Complications:

• Hypothyroidism
• Hypocalcaemia
• Haematoma/seroma
• Chyle leak
• Infection
• Recurrent laryngeal nerve injury
• Horner’s syndrome