Practical management of post-thyroidectomy hematoma

Abstract

Thyroid diseases and surgery for thyroid neoplasms are both very common. Several complications of thyroidectomy are well known. Some of these are quite disturbing, such as recurrent laryngeal nerve injury and permanent hypoparathyroidism. However, postoperative hematoma often in the recovery room may be fatal. Close observation and early intervention are of utmost necessity in the post-thyroidectomy period. In a series of 600 thyroidectomies performed over a period of 11 years, eight patients developed postoperative hematoma. Seven of them underwent re-exploration, while one patient was treated conservatively. Two patients had second re-exploration for hematoma reaccumulation. All patients recovered very well after re-exploration except one elderly patient who required ventilatory support due to poor pulmonary reserve; after a week of ventilatory support and a tracheostomy, she too recovered well. One patient had the hematoma re-explored as late as 24 hours after the operation, while the remainder were re-explored within 4-6 hours after the initial procedure. Because of the extent of edema of the larynx and pharyngeal wall, it is very important that a senior, experienced person perform intubation in these patients. It is also very important to recognize that when the patients lie down flat, they may develop acute airway distress; hence, one must be prepared to intubate them emergently. We recommend close recovery room observation after thyroidectomy and early exploration and evacuation of hematoma in all patients who develop postoperative hematoma. A conservative approach may be considered in selected patients with minimal hematoma and no progression. However, it generally takes a long time for the hematoma to resorb. A better understanding of the complications of thyroidectomy will minimize morbidity and make thyroidectomy a safer procedure and a surgical triumph.

Drainage after total thyroidectomy or lobectomy for benign thyroidal disorders

“…Previous studies established that the greatest risk of respiratory failure caused by hematoma occurs during the first 6 h after thyroid surgery and this result disencourages the discharging of the patients on the day of the operation (Hurtado-López et al, 2001;Matory and Spiro, 1993;Shaha and Jaffe, 1994). In the present study, developed two hematomas were minimal and possibly developed over a long time.…”

Patterns, timing and consequences of post-thyroidectomy haemorrhage

“…[1][2][3] While a variety of factors (eg postoperative hypertension, use of anticoagulants and extent of dissection) have been implicated in increasing the risk of post-thyroidectomy haemorrhage, it is generally considered a low frequency stochastic event, which is difficult to predict. [4][5][6][7] Bleeding deep to the strap muscles is associated with a higher risk of life threatening airway swelling and obstruction, and the risk of post-thyroidectomy haemorrhage is highest in the early hours following surgery. 8 For these reasons, patients traditionally remained in hospital for 72 hours or longer after thyroidectomy.…”

Hemithyroidectomy with or without use of drain a randomized prospective clinical study

“…2,9,11,12,14 Two large nonrandomized studies of 250 and 400 patients have also documented that no benefits of using the drains in thyroid surgery. 15,17 Author found that drain was containing fluid even in the absence of collection in thyroid bed by ultrasonography. The reason for this may be an inflammatory effect of drain itself and effect of suction which prevents lymphatic channels from sealing off.…”

“…Though this complication is rare, ranging from 0.3 to 2.5%. [14][15][16] This serious complication most of the time appears between 2 to 6 hours post-operatively and many patients complain coughing just before hemorrhage. Possible causes for this are slippage of an improperly applied suture and improperly cauterized area.…”