The patient, a 69-year-old female, fell in the bathroom on a slippery floor and struck her anterior neck. About three hours after the event, she was admitted by ambulance to the emergency department (ED) of our hospital. On admission, she was conscious and did not appear unduly distressed. There were no signs of emphysema, stridor or dyspnea. Her breath sounds were equal. The patient didn’t suffer any kind of aspiration or cough. Her vital signs were normal, showing a blood pressure of 130/80 mmHg, a heart rate of 66 bpm and a respiratory rate of 20 breaths per minute. Her arterial blood gas was normal, with an O2 saturation of 98% on room air. Although the vital signs were stable and she was not in respiratory distress, her voice was hoarse immediately following the injury. The patient was only able to speak in a whisper. On examination, her neck was swollen and was tender to palpation. No carotid bruits were auscultated. Plain films of the neck revealed a normal cervical spine with mild tracheal deviation toward the right. Because of the suspicion of a muscular hematoma, the patient underwent a sonographic examination of the neck. The neck ultrasound revealed a moderately hypoechoic, diffuse, infiltrative process presumed to be a hematoma surrounding the left thyroid lobe and extending into the anterior cervical muscular strap.
Computed tomography (CT) scan without contrast was performed to better evaluate the extent of the hematoma and the possible compromise of neighboring structures. However, neck CT scan demonstrated fragmentation and hematoma within the left lobe of the thyroid gland (Figure 1), as well as tracheal deviation to the right without evidence for laryngotracheal trauma. This study revealed a mass, felt to be a hematoma, in the left neck, measuring 4.7 × 5 × 5 cms. The left lobe of the thyroid was indistinguishable from the hematoma, and luminal narrowing was noted in the lower neck. A thyroid functional profile showed a moderate thyroid hormone disorder: free thyroxine, 1.05 pg/ml (reference range, 0.70–1.48 ng/dL), free triiodothyronine, 3.95 pg/mL (reference range, 1.71–3.71 pg/mL), and thyrotropin, 1.78 uIU/mL (reference range, 0.35–4.94uIU/mL). Hematologic analysis showed a WBC of 14 K/uL (normal: 4,4 to 11,3), with no other significant abnormalities.
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Because the patient was hemodynamically stable with excellent oxygen saturations upon examination in the ED, further evaluation by means of cervical angiography and indirect laryngoscopy were planned. No signs of active bleeding or expanding hematoma were noted; however, cervical angiography was performed to rule out vascular injury. No vascular injury was found. Otolaryngology was consulted to perform indirect laryngoscopy for evaluation of possible laryngeal injury. Fiberoptic laryngoscopy performed by the consulting otolaryngologist revealed a patent supralaryngeal airway with ecchymoses and mild bilateral vocal-cord edema with an otherwise normal airway.
The patient was admitted to the surgical intensive care unit for close airway observation, reverse Trendelenberg and monitoring for progression of her neck hematoma. Over the ensuing four days, the size of the patient’s neck hematoma remained stable, no stridor or respiratory distress developed, and the patient’s voice weakness resolved. Follow-up sonography performed two months later showed a normal left thyroid lobe.