Neck Hematoma after Thyroidectomy

摘要

The most common complications after thyroidectomy include hypocalcemia, damage to the recurrent laryngeal nerve and a neck hematoma. Postoperative neck bleeding can be life threatening due to acute airway obstruction and occur in 1.5 to 4% of all thyroidectomies. The cause of bleeding after thyroidectomy includes slippage of a ligature on major vessels, reopening of cauterized veins, retching and bucking during recovery, Valsalva maneuver, increase blood pressure or oozing from the cut surface of the thyroid gland. Total airway obstruction progress once the critical compression pressure occurs in the compartment below the strap muscles. This leads to compression of the trachea, impairment of venous and lymphatic drainage causing laryngopharyngeal edema and airway obstruction. Incomplete closure of the strap muscles or no reapproximation inferiorly during closure is recommended to allow decompression of the deep space of the neck into the superficial area. Time intervals for most hematomas to develop is less than 24 hrs, though 20% can occur three days after surgery. Patients with a postoperative neck hematoma present with respiratory distress, pain, pressure sensation in the neck, dysphagia and salivation. Signs include progressive neck swelling, suture line bleeding, dyspnea, stridor or ecchymosis in the neck skin. Early recognition with immediate surgical evacuation of the hematoma including intubation due to airway obstruction or bedside decompression of the wound is essential. Once laryngopharyngeal edema occurs there might be inability to intubate the patient with need of immediate tracheotomy. The source of hematoma is almost always found (92%) and most are caused by arterial bleeding (upper pole). The incidence of hematoma or seroma do not change with the use of a postoperative neck drain. The risk of postoperative hemorrhage is a limiting factor for outpatient thyroid surgery or early discharge from the hospital. Age (old), sex (male), race (African-American), obesity, geographic region, comorbidity, alcohol abuse, underlying diagnosis (Grave's disease), bleeding disorders, previous neck surgery, and type of surgical procedure (total thyroidectomy, substernal thyroidectomy, neck dissection) are independent risk factor for neck hematoma. Hospital bed size, location, teaching status or volume is not associated with increase risk of this complication. The incidence of hematoma after parathyroidectomy is lower than after thyroidectomy. Early severe neck hematoma with rapid mucosal edema and airway swelling needs intubation or tracheotomy. With late swelling of the neck a seroma or chyloma should be sought to be the cause.