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B) Contrast-enhanced axial CT scan at the level of the hyoid bone (A) showing oedema and subacute haemorrhage (asterisk) of a parathyroid adenoma from the left lower lobe of the thyroid. Note the reduced space and lateral displacement of the laryngeal inlet. (C) Intraoperative view of the parathyroid gland attached to the thyroid tissue (within the dashed line).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cervical haemorrhage is a rare but serious complication occurring in 5.3% of patients with parathyroid adenoma.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Clinical manifestations vary according to the site and volume of the haemorrhage. In severe cases, bleeding may extend into the mediastinum or pleural cavity.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Blood tests with phospho-calcium metabolism and imaging techniques are helpful in guiding the diagnosis. Emergency treatment includes ensuring airway patency and draining the cervical haematoma.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This case report was conducted according to the <span class="elsevierStyleItalic">CAse REport</span> (CARE) checklist guidelines. Informed consent was obtained from the patient.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 68-year-old man came to the ENT emergency department for a 24-h history of odynophagia and dyspnoea with an anterior cervical mass with ecchymosis and extension to the chest (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The patient's history included an episode of binocular diplopia and left eye blepharoptosis, which had resolved with oral corticosteroids five months earlier.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Upper airway examination revealed oedema and ecchymosis of the left hypopharynx and hemilarynx, with 70% reduction of the airway. Computed tomography (CT) showed a hyperdense left retrothyroid mass suggestive of parathyroid haematoma without active bleeding (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). A tracheostomy was performed to secure the airway.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Blood tests showed hypercalcaemia of 13.3<span class="elsevierStyleHsp" style=""></span>mg/dL and parathyroid hormone (PTH) of 694<span class="elsevierStyleHsp" style=""></span>pg/mL which returned to normal after intensive medical treatment.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The examination was completed by positron emission tomography (PET-CT) which showed the CT-detected mass and a hypermetabolic lymph node at the left level IV of the cervical area. Two bone lesions suggestive of brown tumours were described.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Serial flexible fibreoptic endoscopies showed resolution of oedema and ecchymosis, and the tracheostomy tube was removed on discharge.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Retrospective evaluation suggested that ophthalmological involvement may be related to phospho-calcium metabolism imbalance.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was discharged and underwent an ultrasound-guided puncture with collection of inflammatory cells and elective left hemithyroidectomy and parathyroidectomy was performed. Histopathological findings confirmed parathyroid adenoma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C) and the lymphadenopathy at left level IV showed no pathological characteristics. Adherence to the procedure and tolerability were good and there were no adverse events or unexpected outcomes.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Spontaneous cervical haemorrhage can be a life-threatening emergency requiring prompt assessment and treatment for airway preservation. Differential diagnoses include strangulation, abscesses or tumours of the upper airway, and parathyroid or thyroid haemorrhagic lesions.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The cases reported so far were middle-aged women with no previous manifestations of hyperparathyroidism. The patient's acute presentation was very similar to previous case reports.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In the ENT emergency, clinical and endoscopic examination of the upper airway is essential for the initial approach to spontaneous cervical haemorrhage. The definition of the haemorrhagic area is often difficult by CT and requires deferred examinations for specific diagnosis. Blood analysis including basic parameters of phospho-calcium metabolism may lead to diagnosis.</p><p id="par0065" class="elsevierStylePara elsevierViewall">99mTc-sestamibi scintigraphy is the best imaging tool to identify parathyroid adenoma,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> but CT or magnetic resonance imaging (MRI) is usually performed. Both techniques can identify acute or chronic bleeding.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Familiari et al. proposed a practical approach to cervical haemorrhage due to parathyroid adenoma, indicating an immediate intubation or tracheotomy with subsequent drainage of the haematoma in case of rapidly increasing haemorrhage with airway obstruction, hypotension, acute anaemia and/or hypercalcaemic crisis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Intensive medical treatment with IV hydration and bisphosphonate-based therapy is essential. Multidisciplinary teams of head and neck surgeons, endocrinologists and general practitioners should evaluate the best therapeutic option for each patient. Deferred parathyroidectomy is usually indicated in haemorrhagic parathyroid adenoma.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusions</span><p id="par0075" class="elsevierStylePara elsevierViewall">Spontaneous haemorrhage from a parathyroid adenoma is a rare presentation of the disease. It can compromise the airway, so securing the respiratory tract is a priority. A high degree of suspicion is required to establish the diagnosis. Blood tests including basic phosphor-calcium metabolism and imaging techniques are essential to avoid unnecessary procedures and to reach the diagnosis.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Ethical considerations</span><p id="par0080" class="elsevierStylePara elsevierViewall">Ethical approval was obtained. Informed consent was obtained from the patient.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Funding</span><p id="par0085" class="elsevierStylePara elsevierViewall">This work has not received any funding.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflict of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusions" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Ethical considerations" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 666 "Ancho" => 1674 "Tamanyo" => 160487 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0605" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Cervical mass with oedema and echinosis extending into the chest at the emergency department visit. B) Contrast-enhanced axial CT scan at the level of the hyoid bone (A) showing oedema and subacute haemorrhage (asterisk) of a parathyroid adenoma from the left lower lobe of the thyroid. Note the reduced space and lateral displacement of the laryngeal inlet. (C) Intraoperative view of the parathyroid gland attached to the thyroid tissue (within the dashed line).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hematoma cervical espontáneo por rotura de un adenoma de paratiroides: 3 casos y revisión de la literatura" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "I. Osorio Silla" 1 => "L. Lorente" 2 => "J.J. Sancho" 3 => "A. Sitges-Serra" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Endocrinol Nutr" "fecha" => "2014" "volumen" => "61" "paginaInicial" => "e5" "paginaFinal" => "e6" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spontaneous extracapsular parathyroid adenoma hemorrhage: when surgery is required?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Familiari" 1 => "D. Di Santo" 2 => "A. Galli" 3 => "G. Danè" 4 => "L. Giordano" 5 => "R. Mellone" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s12020-021-02876-x" "Revista" => array:6 [ "tituloSerie" => "Endocrine" "fecha" => "2022" "volumen" => "75" "paginaInicial" => "575" "paginaFinal" => "582" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34554413" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spontaneous cervical haemorrhage of a parathyroid adenoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Ulrich" 1 => "G. Knee" 2 => "C. Todd" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Endocrinol Diabetes Metab Case Rep" "fecha" => "2015" "volumen" => "2015" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic Imaging (Head and Neck)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B.L. Koch" 1 => "B.E. Hamilton" 2 => "P.A. Hudgins" 3 => "H.R. Harnsberger" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "edicion" => "3rd edition" "fecha" => "2017" "editorial" => "Elsevier" "editorialLocalizacion" => "Philadelphia PA" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000016100000006/v1_202309251317/S2387020623003509/v1_202309251317/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000016100000006/v1_202309251317/S2387020623003509/v1_202309251317/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020623003509?idApp=UINPBA00004N" ]
Journal Information
Vol. 161. Issue 6.
Pages 273-274 (September 2023)
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Vol. 161. Issue 6.
Pages 273-274 (September 2023)
Letter to the Editor
Spontaneous haemorrhage from a parathyroid adenoma with airway involvement
Hemorragia espontánea de un adenoma paratiroideo con compromiso de la vía aérea
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