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Cervical hematoma following fine needle aspiration of cystic papillary thyroid carcinoma

Published:September 11, 2022DOI:https://doi.org/10.1016/j.amjms.2022.09.004

      Case Presentation

      A 57-year-old male with untreated hypertension presented with a 6 × 7 cm anterior neck mass for 6 months (Fig. 1a). Neck ultrasound with doppler flow identified a huge cystic mass with a hypervascularity exophytic solid nodule sized 2.7 cm at the left thyroid lobe (Fig. 1b). He had no recent history of taking anti-platelet or other medications. Ultrasound features aroused suspicion of a malignancy in the mural mass (Fig. 1c). Pre-fine needle aspiration (FNA) blood pressure was 164/94 mmHg and oral manidipine 10 mg was given shortly before the procedure. Approximately 55 mL of hemorrhagic fluid was aspirated and followed by FNA of the solid nodule under plain ultrasound-guidance with a 23-gauge needle. Six passes were made into the nodule. Direct compression of the FNA sites was done for a few minutes and he was clinically in good condition immediately after the procedure.
      Two days later, he came to an emergency room with swollen neck and bruise extending to anterior chest wall (Fig. 1d). He was anxious but not dyspneic, and the vital signs were stable except high blood pressure (170/90 mmHg). His oxygen saturation was 100%. Examination of his neck revealed a mild tender and ecchymosis of the swollen neck expanding to epigastrium without subcutaneous emphysema. Neck ultrasound showed new echogenic intra-cystic content. Intra-nodular bleeding was diagnosed and he was hospitalized for observation and blood pressure control. Complete blood count and coagulation studies were normal. Analgesics and anti-hypertensive drugs were given and the cervical hematoma resolved in one week. The cytological diagnosis was papillary carcinoma. One months later, an uneventful total thyroidectomy with central lymph node dissection was done. High-dose radioiodine ablation was given one month postoperatively. At the last follow-up one year after surgery, he was doing well with controlled hypertension.
      Fine needle aspiration (FNA) of the thyroid is regarded as a safe procedure. However, physicians should be watchful of hemorrhagic complications in high-risk patients. While small local hematomas are the most common complications, massive intra-thyroid hemorrhage causing acute airway obstruction was occasionally reported and could be lethal.
      • Polyzos SA
      • Anastasilakis AD.
      Clinical complications following thyroid fine-needle biopsy: a systematic review.
      Most post-FNA adverse events such as pain or minor bruise at the puncture sites are self-limited but life-threatening airways obstruction can occur. Based on a large series from Italy, ultrasound-guided FNA of 7,449 thyroid nodules, indicated that only 10 patients (0.15%) had self-limited complications.
      • Cappelli C
      • Pirola I
      • Agosti B
      • Tironi A
      • Gandossi E
      • Incardona P
      • et al.
      Complications after fine-needle aspiration cytology: a retrospective study of 7449 consecutive thyroid nodules.
      However, anecdotal reports documented serious massive uncontrolled bleeding causing upper airway respiratory obstruction which could be fatal if surgical drainage was not performed timely. These rare complications tended to develop in high-risk patients such as those with hypertension, end-stage renal disease or on antiplatelet or anticoagulation drugs.
      • Polyzos SA
      • Anastasilakis AD.
      Clinical complications following thyroid fine-needle biopsy: a systematic review.
      To minimize this rare complication, a thorough review of neck ultrasound features including vascularity of thyroid nodules and identification of aggravating factors should be carefully undertaken before the procedure.
      • Oertel YC.
      Fine-needle aspiration of the thyroid: technique and terminology.
      Even though FNA is a safe procedure, this communication reminds readers that potentially rare serious complications could be developed but preventable.

      Funding source

      None

      Author contributions

      All authors contributed to the study design and data interpretation. Yotsapon Thewjitcharoen and Krittadhee Karndumri collected patient history and took care of the patient. Auchai Kanchanapituk did the final treatments. Yotsapon Thewjitcharoen wrote and edited the paper. All authors contributed approved the final version.

      Conflicts of interest

      The authors declare no competing interests.

      References

        • Polyzos SA
        • Anastasilakis AD.
        Clinical complications following thyroid fine-needle biopsy: a systematic review.
        Clin Endocrinol (Oxf). 2009; 71: 157-165
        • Cappelli C
        • Pirola I
        • Agosti B
        • Tironi A
        • Gandossi E
        • Incardona P
        • et al.
        Complications after fine-needle aspiration cytology: a retrospective study of 7449 consecutive thyroid nodules.
        Br J Oral Maxillofac Surg. 2017; 55: 266-269
        • Oertel YC.
        Fine-needle aspiration of the thyroid: technique and terminology.
        Endocrinol Metab Clin N Am. 2007; 36: 737-751