Parathyroid adenoma causing spontaneous cervical hematoma: two case reports

Secondary Mediastinal Bleeding Caused by Parathyroid Adenocarcinoma: A Case Report

Introduction

The clinical picture of parathyroid tumors is mainly related to hypercalcemia such as kidney stones and bone and muscle pain. However, spontaneous cervical hemorrhage due to parathyroidoma bleeding is rare with clinical manifestations of the painful swelling and bruising of the neck accompanied by dysphagia and dyspnea.

Case presentation

We report a case of a 71-year-old female patient who presented with acute cervical swelling and extensive bleeding spreading from the neck to the abdomen and 2 flanks. Investigation of patients revealed increased parathyroid hormone levels and hypercalcemia. The neck ultrasound showed the thyroid nodules in 2 lobes, and goiter plongeant on the right. Computed tomography scan images showed a hematoma spreading from the right side of the neck to the mediastinum.

Result

The patient required emergency surgery due to dyspnea and hemodynamic instability. The preoperative diagnosis was cervical bleeding with the likely cause being thyroid nodule rupture. However, during the surgery, the bleeding source was determined to be the right parathyroid tumor located deeply below the superior mediastinum. The patient's histopathological result of the tumor is parathyroid adenocarcinoma.

Conclusion

From our experience, the hemorrhage from parathyroid tumor should be considered as a cause of acute neck bleeding when no history of trauma or surgery is identified. Post-surgery histopathological analyses of the tumor are very important to detect parathyroid adenocarcinoma.

Difficult airway due to cervical haemorrhage caused by spontaneous rupture of a parathyroid adenoma: A case report

BACKGROUND

Cervical haemorrhage due to spontaneous rupture of a parathyroid adenoma is a rare complication that may cause life-threatening acute airway compromise.

CASE SUMMARY

A 64-year-old woman was admitted to the hospital 1 day after the onset of right neck enlargement, local tenderness, head-turning difficulty, pharyngeal pain, and mild dyspnoea. Repeat routine blood testing showed a rapid decrease in the haemoglobin concentration, indicating active bleeding. Enhanced computed tomography images showed neck haemorrhage and a ruptured right parathyroid adenoma. The plan was to perform emergency neck exploration, haemorrhage removal, and right inferior parathyroidectomy under general anaesthesia. The patient was administered 50 mg of intravenous propofol, and the glottis was successfully visualised on video laryngoscopy. However, after the administration of a muscle relaxant, the glottis was no longer visible and the patient had a difficult airway that prevented mask ventilation and endotracheal intubation. Fortunately, an experienced anaesthesiologist successfully intubated the patient under video laryngoscopy after an emergency laryngeal mask placement. Postoperative pathology showed a parathyroid adenoma with marked bleeding and cystic changes. The patient recovered well without complications.

CONCLUSION

Airway management is very important in patients with cervical haemorrhage. After the administration of muscle relaxants, the loss of oropharyngeal support can cause acute airway obstruction. Therefore, muscle relaxants should be administered with caution. Anaesthesiologists should pay careful attention to airway management and have alternative airway devices and tracheotomy equipment available.

Spontaneous extracapsular parathyroid adenoma hemorrhage: when surgery is required?

PURPOSE

Spontaneous bleeding is a rare but serious complication of parathyroid adenomas and few cases were reported in the literature. Clinical manifestations and treatment may vary but sometimes an immediate surgery is required. In other cases a conservative approach can be preferred based on clinical stability and patients' conditions. The purpose of this work is to describe our case and to carry out a review of the current literature on this topic.

METHODS

We reported a case of a parathyroid adenoma hemorrhage in an elderly patient describing its management. Moreover, a literature review of 57 cases was carried out, with the aim of collecting data about the most involved parathyroid gland and identifying the most correct management based on clinical manifestations and chosen treatments.

RESULTS

The patients had an age between 29 and 81 years (mean 56.9 ± 16.4 years). Forty-four patients were females (77.2%), whereas 12 were males (21.8%). Based on clinical severity, age, comorbidities and calcemic status, three possible scenarios were identified, each with a recommended management.

CONCLUSIONS

In parathyroid adenoma hemorrhages a careful clinical assessment is crucial to identify emergency conditions requiring immediate intubation, tracheostomy or neck exploration. Elderlies and comorbid patients have a higher risk of perioperative complications and indication for surgery should be evaluated case by case: whenever feasible, a conservative approach should be preferred in these subjects, especially in those with a stable course and without hypercalcemia-related symptoms.

An unusual case of neck hematoma and hypercalcemia

One of the most frequent cause of hypercalcemia is primary hyperparathyroidism, which can lead to systemic involvement and life-threatening conditions. We described a rare case of a parathyroid adenoma rupture with consequent bleeding and respiratory airway compression. An 84-year-old man presented to the emergency department complaining neck swelling and related dysphagia. A computer tomography of the neck revealed an extensive left lateral hematoma, and a neck ultrasonography evidenced a hemorrhagic parathyroid adenoma, later confirmed by a 99 mTc-MIBI scintigraphy. To date only 40 cases of ruptured parathyroid adenomas have been described in literature, however due to the possibility of massive bleeding and compression of the airways this diagnosis should always be ruled out. The rupture of a parathyroid adenoma is a rare, but possibly life-threatening event due to airways compression and hemodynamic instability. Testing for hypercalcemia and hyperparathyroidism is mandatory to obtain a correct diagnosis.

Importance of serum calcium in spontaneous neck haematoma

We present an unusual case of spontaneous cervical haemorrhage secondary to extra-capsular bleeding from a parathyroid adenoma. Signs and symptoms on presentation included sore throat, dysphagia and anterior chest ecchymosis. While CT confirmed active cervical haemorrhage, elevated serum calcium and parathyroid hormone raised suspicion of possible parathyroid pathology. This case report and literature review highlight the diagnostic value of serum calcium in presentations of acute spontaneous neck haematoma. This should be considered especially in the acute phase, where imaging may not identify the source of haemorrhage. Initial observation and deferred surgery is the treatment of choice, with emergency operative management reserved for respiratory distress and worsening compressive symptoms.

Rare cause of acute neck hematoma

Emergencies in endocrine surgery are rare. Acute neck hematoma may result from recent surgery or spontaneous as with ruptured thyroidal cyst, thyroidal vessel, or parathyroid adenoma. We are reporting a case of acute neck hematoma caused by a ruptured of parathyroid adenoma, which required urgent surgical intervention.

Nontraumatic Parapharyngeal Haematoma: A Rare Lesion

Nontraumatic haematoma of parapharyngeal space is very rare and may cause dysphagia and dyspnea. The authors present a case report of a 74-year-old woman with sudden nontraumatic neck swelling without dyspnea and with left pharyngeal bulging and endolaryngeal displacement. Parathyroid hormone elevation and imaging exams confirmed bleeding from a parathyroid adenoma. Symptoms and signs resolved after one week of conservative treatment. There are few cases of parapharyngeal haematomas caused by parathyroid adenomas. Most patients can be managed without emergent surgery, but close airway monitoring is fundamental.