Clinical Communications: Adults
Thyroid Gland Rupture: A Rare Case of Respiratory Distress

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Abstract

Background: Rupture of a normal thyroid gland after blunt cervical trauma is a rare case of airway compression. This case report describes the case of a 79-year-old woman who developed severe respiratory distress after a bicycle crash. Case Report: Presenting about 2 h after the crash, the patient noted cervical swelling and increasing dyspnea. The diagnosis of thyroid gland rupture was made with a combination of computed tomography scan, cervical radiography, and bronchoscopy. Invasive airway management was required in the first few hours after the crash. The patient underwent a left hemithyroidectomy, and recovered without complications. Conclusion: This case report highlights the fact that thyroid gland rupture can be a threatening complication of blunt cervical trauma.

Introduction

Soft tissue injuries to the neck and superior mediastinum confront the clinician with a broad differential diagnosis, and often require a variety of imaging studies to correctly determine an accurate diagnosis. Only about 5% of all neck trauma is from blunt trauma. Direct impact to the anterior neck as a result of blunt trauma has been associated with carotid artery, laryngeal, tracheal, and esophageal injuries. Traumatic rupture of the thyroid gland is very rare, with only a few cases reported in the literature (1, 2, 3). Potential airway compression is the main clinical concern. Although surgical airway management may not be required, such injuries may necessitate prompt airway intervention due to compression of the trachea by hematoma. Treatment of thyroid rupture as a result of blunt neck trauma is also not well studied, and knowledge about this clinical entity is essentially based on case reports. We report a case of direct trauma to a normal thyroid gland that caused severe respiratory distress.

A 79-year-old woman was involved in a bicycle crash, and hit her anterior neck on the handlebars. About 2 h after the event, the patient developed swelling of the neck in combination with dyspnea and respiratory distress. She was brought to the closest hospital by the Emergency Medical Service. In the Emergency Department (ED), the patient presented with progressive swelling of the neck and severe dyspnea. Therefore, she was sedated and intubated orotracheally. This was performed without complications. Duplex sonography of the carotid arteries showed no pathological findings. Cervical spine radiography demonstrated soft tissue swelling anterior to the trachea and compression of the laryngeal region. A flexible bronchoscopy was arranged to view the larynx and the trachea. Due to submucosal bleeding in the ventral trachea, the presumptive diagnosis of a tracheal rupture was made. The patient was immediately transferred to the closest university hospital.

On arrival at the university ED, the patient showed the following clinical findings: blood pressure 140/80 mm Hg, heart rate 68 beats/min, and oxygen saturation 98%. The Glasgow Coma Scale score of the sedated patient was 3. Respiratory parameters included a tidal volume of 600 mL, respiratory rate 16 breaths/min, inspired oxygen concentration of 50%, and positive end-expiratory pressure of 5 cm H2O. An arterial line and a central venous catheter were placed in the ED. The arterial blood gas determination yielded the following findings: pH 7.58; partial CO2 pressure 28 mm Hg; partial O2 pressure 84 mm Hg; base excess 2.9; HCO3 concentration 23.4 mmol/L; oxygen saturation 98%. The computed tomography (CT) scan showed hemorrhage of the left lobe of the thyroid gland compressing the laryngeal region and a significant tracheal deviation to the right (Figure 1).

Based on the morphological findings in the imaging studies and the clinical presentation, a surgical exploration of the neck was performed immediately. The left thyroid lobe was found to be ruptured in its entirety, with a hematoma in the adjacent tissue. The right thyroid lobe was of normal size. In view of the extensive damage, a hemithyroidectomy of the left lobe was considered necessary. A lesion of the trachea was ruled out by CT scan and intraoperative inspection. After the operation, the patient was admitted to the intensive care unit for airway observation over the course of the next day. Medical treatment included prednisolone to prevent further swelling of the mucosal tissue in the airway. Sedation with fentanyl and propofol, and ventilation were continued overnight. The next morning, the patient was extubated without any complications. She was observed for the recurrence of respiratory disturbances, and then transferred to the regular ward on the following day. She recovered uneventfully and was discharged in good condition on the 7th postoperative day.

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Discussion

Injuries of the neck can be the result of penetrating or blunt trauma. Although blunt neck trauma is relatively rare, it can result in life-threatening injuries that demand immediate attention. Most case reports of thyroid rupture describe respiratory compromise, a palpable cervical mass, and pre-existing goiter disease (1, 4). At initial presentation, the main concern is the integrity of the airway. Blunt trauma of the neck can result in damage to the larynx, trachea, esophagus, or vascular

Conclusion

This case report highlights the fact that thyroid gland rupture can be a threatening complication of blunt cervical trauma. Although a rare event, physicians should consider thyroid gland rupture in any patient presenting with neck swelling or acute respiratory failure after blunt neck trauma. As with any blunt or penetrating cervical trauma, the key consideration is determining whether, and where, there will be anatomic distortion from bleeding or organ injury. It is prudent to actively manage

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