By Delikoukos, Stylianos Mantzos, Fotios
Isolated thyroid gland injury due to blunt neck trauma is uncommon and rarely complicated by thyroid storm in patients without known hyperthyroidism. The aim of this study was to report our experience on blunt thyroid gland injury followed by massive gland hemorrhage, acute airway obstruction, and symptoms of thyroid storm. Among 231 patients with neck trauma, four patients appeared with isolated thyroid gland injury. In two of them, the diagnosis of simultaneous thyrotoxic crisis was made on the basis of clinical findings and confirmed on emergency laboratory tests. The diagnosis of thyroid gland injury was supposed by the history and physical examination and established after neck exploration. Therapy was directed at stabilizing the patients by correcting the hyperthyroid state, followed by operative treatment. Left lobectomy and total thyroidectomy were performed and, along with postoperative medical measures, led to uneventful recovery. This study demonstrates that thyroid gland injury due to blunt neck trauma, although uncommon, may result in potentially life-threatening thyroid storm due to rupture of acini and liberation of thyroid hormones into the bloodstream. This may occur in patients without known hyperthyroidism. BLUNT NECK TRAUMA is commonly encountered in cases of vehicle crashes, but isolated thyroid gland injury is rare. ‘ The frequency of thyroid gland injury due to blunt neck trauma is about one to two per cent.1-3 According to most of the reported cases, posttraumatic thyroid gland hematoma occurred in patients with a history of pre-existing goiter.2-4 Hemorrhage into a normal thyroid gland, caused by blunt neck trauma, is extremely rare.4 On the other hand, thyroid storm after trauma has rarely been reported and usually occurs in patients with known hyperthyroidism.5, 6 Thyroid storm induced by direct thyroid gland trauma has not been published in the literature. The aim of this study was to report our experience on isolated blunt thyroid gland injury followed by massive hemorrhage, acute airway obstruction, and symptoms of thyroid storm. The diagnosis of gland injury was proved by neck exploration. Thyrotoxic crisis was initially suspected on the basis of clinical findings and established by laboratory tests.
Patients and Methods
Between 1988 and 2005, 231 patients (175 men) presented to the emergency department complaining of blunt neck trauma due to traffic or other injury. Four appeared with isolated thyroid gland injury. In two patients, (women, 29- and 65-years-old) the trauma led to thyroid crisis. The two patients denied a previous history of goiter or symptoms of hyperthyroidism.
The first patient sustained neck trauma due to a motor vehicle accident. The patient, seated behind the driver without a fastened seat belt, struck her neck on the front seat. She arrived at the hospital 60 minutes after the crash. The patient was awake, normotensive, and free of respiratory problems. She manifested low grade fever (37.8[degrees] C), tachycardia (140 pulses/min), nervous system disorders (tremor and facial abrasions), and gastrointestinal dysfunction (nausea and vomiting). On physical examination, other than some smooth enlargement on the left anterior neck region, no signs of injury were visible.
The second patient fell in the bathroom due to a slippery floor and struck her neck on the wash-basin. She developed the sensation of having a lump in her throat and she had difficulties in swallowing. She was transferred to the hospital 12 hours after the accident because of increasing neck pain and worsening respiratory distress. She manifested high fever (39.2[degrees] C), supraventricular arrhythmias, central nervous system symptoms (tremor), and gastrointestinal dysfunction (vomiting and diarrhea).
The diagnosis of thyrotoxic crisis was supposed in both patients based on their clinical findings. Emergency laboratory tests were ordered (T^sub 3^, T^sub 4^, TSH) and initial medical and supportive therapies, directed at stabilizing the patients and correcting the hyperthyroid state, were applied. Cooling blanket, cold fluid infusion, flurbiprofen, diltiazem, and verapamil were used to decrease body temperature and heart rate. Radiological examinations (ultrasonography or computed tomography) were omitted due to the patients’ crucial condition. The laboratory test results, several hours later, revealed the total T^sub 4^ equaled 28 [mu]g and 26 [mu]g for the two patients respectively, [normal ranges (nr) 4-11 [mu]g/100mL], free T^sub 3^ equaled 330 mg and 325 mg, (nr = 160- 320 mg/100 mL), free T^sub 4^ equaled 4.3 mg and 4.1 mg, (nr = 0.8- 2.9 mg/100 mL), TSH equaled 0.2 ng and 0.3 ng, (nr = 1-10 ng/mL), and confirmed the diagnosis of acute thyroid storm.
Soon after the diagnosis of possible thyroid gland injury was confirmed in the first patient, the initial swelling in her left neck became extensive and congestion of the jugular veins developed. Acute respiratory distress prompted emergency operation. After a difficult intubation due to severe tracheal displacement, a neck exploration disclosed a ruptured left thyroid lobe. The left lobe was encased by a large expanding hematoma; the right lobe seemed normal. No larynx, trachea, or vascular injury was noted. A left thyroid lobectomy was performed.
The second patient was operated on due to deteriorated respiratory distress, soon after she was stabilized and the hyperthyroid state was partially corrected. A neck exploration confirmed the presence of a neck hematoma due to rupture of the upper thyroid artery. The right thyroid lobe seemed to be injured as well and a subtotal thyroidectomy was performed.
After operation, both patients were in agitated state for 4 and 6 hours respectively, along with hyperpyrexia and tachycardia. Thiamazole and propranorol were administrated for 1 week postoperatively, and thyrotoxic symptoms were declined with body temperature and heart rate of 36 to 36.7[degrees] C and 80 to 90 beats/minute respectively. Follow-up thyroid hormone studies at 1- day interval were gradually improved. Hormone values were lowered and became normal within 6 days. At 2-months and 1-year follow-up the patients were doing well.
Neck trauma is common in motor vehicle accidents and may result in bony, muscular, nervous, vascular, and aerodigestive tract injuries.7, 8 Traumatic hemorrhage into a normal thyroid gland however, is rarely reported and therefore an unexpected finding. Few cases have been published, mostly in patients with pre-existing goiter or thyroid adenoma, and this may explain the isolated thyroid gland hemorrhage.1-4, 7 In our two patients there was no history of goiter, thyroid gland adenoma, or hyperthyroidism. Besides, no pathology other than hemorrhage was found in the examined gland specimens.
The diagnosis of isolated thyroid gland injury due to blunt neck trauma is difficult. An increasing paratracheal or pretracheal cervical swelling may be present in most patients after neck trauma. The onset of life-threatening symptoms and severe respiratory distress may require emergent airway management, including intubation or tracheostomy, usually before the diagnosis of thyroid gland injury is established. Most of the patients are operated urgently and neck exploration confirms the diagnosis of thyroid gland injury.4-9 Emergency investigations, such as computed tomography and/or ultrasonography of the neck, can establish the diagnosis of thyroid gland injury preoperatively.4, 7-10 In most cases however, radiological examinations are omitted due to patients’ crucial condition, and this happened in our patients as well.
Although Hsieh and Chou7 reported one case of conservative treatment of thyroid gland injury after blunt cervical trauma, almost all cases of traumatic thyroid gland hemorrhage were treated surgically by evacuation of the hematoma, debridement of the crushed thyroid tissue, and lobectomy or thyroidectomy. Most of these patients were operated on immediately after respiratory distress was encountered.1-4, 9 Few patients without respiratory symptoms required delayed operation after the diagnosis of thyroid trauma was established.8
Thyroid storm is a potentially life-threatening medical emergency caused by an exacerbation of the hyperthyroid state characterized by decompensation of one or more organ systems. It usually develops in patients with longstanding untreated hyperthyroidism. The crisis has an abrupt onset and is more often precipitated by an acute event such as surgery, trauma, or infection. Early recognition and aggressive treatment are fundamental in limiting the morbidity and mortality associated with this condition.11, 12 The clinical picture is characterized by four main features: fever, tachycardia or supraventricular arrhythmias, central nervous system symptoms, and finally gastrointestinal symptoms. The diagnosis of thyroid storm is often made on the basis of clinical findings alone, inasmuch as it is difficult in most emergency departments to obtain rapid confirmatory laboratory or nuclear medicine tests.12 Treatment of thyrotoxic crisis is multimodal. Initial medical and supportive therapies are directed at stabilizing the patient, correcting the hyperthyroid state, managing the systemic decompensation, and treating the underlying cause.5 Our two patients denied a previous history of goiter or symptoms of hyperthyroidism. Thyroid storm was due to blunt thyroid gland injury after direct neck trauma, as a consequence of rupture of acini and liberation of thyroid hormones into the bloodstream. The diagnosis of thyrotoxic crisis in both patients was based on clinical findings and established after emergency laboratory test results. Initial medical and supportive therapies were applied, followed by postoperative measures until symptoms resolved. REFERENCES
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STYLIANOS DELIKOUKOS, M.D., Ph.D., FOTIOS MANTZOS, M.D.
From the Department of Surgery, Halkis General Hospital, Halkis, Greece
Address correspondence and reprint requests to Stylianos Delikoukos, M.D., Ph.D., 9 Papakiriazi Street, Larissa 41 223, Greece. E-mail: [email protected]
Copyright Southeastern Surgical Congress Dec 2007
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