Muhamad Na'im B Ab Razak (jacknaim) is a fresh graduate Muslim Doctor from Universiti Sains Malaysia and waiting for the enrollment into the housemanship program. Ambitious in pursuing master program in emergency and traumatology medicine and loves to spent his free time joining humanitarian missions, writing and speaks as an amateur public speaker in motivation and comparative religion. [HOME]

Stridor in 34 Years Old Gentleman, 5 hours post total thyroidectomy


Answers


1) Complications of thyroidectomy

a) Intra operative
- Recurrent laryngeal nerve injury
- iatrogenic parathyroid injury
- damage to the sympathetic trunk and trauma to the Internal jugular vessel (Rare)
- Thyroid storm
- Injury to the Superior Laryngeal Nerve


Early post operative complication
- Complication related to general anesthesia
- Thyroid storm
- Postoperative surgical site seromas
- Postthyroidectomy infection


b) Late post operative complication
- Transient hypocalcaemia
- Permanent hypo parathyroidism
- Hypothyroidism
- Poor scar formation


2) This patient develops upper airway obstruction secondary to delay post total thyroidectomy bleeding/ hematoma.


3) Possible causes of this complication
- Slipping of the ligature on major vessels
- Re opening of the cauterized veins
- Retching, vomiting, bucking during recovery
- Valsalva maneuver, increased blood pressure during recovery and oozing from cut area of thyroid


4) Outline of management
- Immediate intubation to protect the airway
- If not possible, do the emergency bedside decompression of the wound (evacuate the hematoma and compress with gauze or gamgee)
- Secure the airway
- Prepare patient for the emergency exploratory operation.
- Blood investigation (PT/aPTT, GSH, GXM, FBC, RFT/LFT)
- IV hydrocortisone to relieve edema (some thought the obstruction is due to edema of the epiglottis. Furthermore, even though this patient has bleeding, it is also associated with swelling.)


Discussion


Time for Post thyroidectomy hemorrhage

Prospective study on 918 patients undergoing thyroidectomy or parathyroidectomy from 1995-1999 by Abbas et al, 2001 shows that 6/918 (0.7%) post thyroidectomy patient required re operation for bleeding. two of them required emergency opening of the surgical scar by the bedside for hematoma evacuation because of worsening airway obstruction. from his study, post operative bleeding may occur from 2 to 48 hours with median being 16 hours. this data was after excluding one patient who bleed five days post operatively


Source of bleeding
- Superficial to strap muscle
- Deep to strap muscle


Reference

i. Anjali P. Savargaonkar, "Post-Thyroidectomy Haematoma Causing Total Airway Obstruction - A Case Report", Indian Journal Of Anaesthesia, December 2004.
ii. Hyoung Shin Lee, Bong Ju Lee,Sung Won Kim et al, "Patterns of Post-thyroidectomy Hemorrhage", Clin Exp Otorhinolaryngol. 2009 June; 2(2): 72–77.
iii. G Abbas, S Dubner, KS Heller. “Re-operation for bleeding after thyroidectomy and parathyroidectomy.” Head & Neck, 2001.
iv. Pramod K Sharma & Lucy J Barr, "Complications of Thyroid Surgery", eMedicine
http://emedicine.medscape.com/article/852184-overview