Teaching Case

A 66-year-old female patient presented to the emergency room with spontaneous soft-tissue haematoma in the neck and chest (Figure 1), that had appeared several days before. She noticed dysphagia that was limited to solid foods. No previous trauma. She had prior history of goitre and hypertension.

Chest radiography was normal. A CT was performed revealing a multinodular goitre, with a greater volume increase of the left thyroid lobe. Bilateral heterogeneous solid nodules were seen, some with coarse calcifications and fibrosis. In the lower pole of left lower lobe, a homogeneous hypodense area was observed that did not present thyroid nodule morphology with an average density of 30 HU (Figure 2a, 2b and 2c). No signs of acute bleeding were observed. Biopsy and radiological findings suggested intraparenchymal haemorrhage. The goitre contacted with the trachea and the esophagus without conditioning stenosis. An anterior cervical subcutaneous cellular oedema can be seen and can be explained by the blood which has seeped into subcutaneous layer.

The diagnosis was a multinodular intrathoracic goitre with spontaneous haematoma in the lower pole of left thyroid lobe. The posterior nodule of left lobe was biopsied without identifying malignant cells.
Although the thyroid gland is very well vascularised, the haemorrhage of a thyroid nodule is a very rare complication. It usually tends to be secondary to blunt trauma or mechanisms that increase blood pressure (cough, Valsalva manoeuvre etc.) especially in anticoagulated patients[1]. The symptomatology is variable: dysphagia, dyspnoea, pain, aphonia.
Intracystic haemorrhage in patients with goitre is an uncommon complication. Its frequency has been estimated at 3% of simple goitre [2].
Goitre favours the appearance of structural alterations; the tissue is more fragile with predominantly venous vascularisation and the enlargement of the gland decreases the covering of the true capsule. In case of a haematoma, all above facilitate that it spreads through cervical spaces, especially through the retropharyngeal prevertebral space which is a crucial path from neck to mediastinum [1].
It can produce an abrupt increase in the size of the gland, which can lead to important symptoms such as respiratory distress, recurrent paralysis or upper airway obstruction due to the compressive effect of the gland [3]. If the patient is stable and the airway is secured, it can be monitored and conservative treatment can be applied.
Even though highly vascularised, the thyroid gland rarely has spontaneous bleeding. Although patients may be stable at initial presentation, bleeding into the thyroid gland can result in potentially lethal acute airway compromise [3].

Written informed patient consent for publication has been obtained.