Key Clinical Message
We should consider parathyroid extraglandular bleeding for patients with
acute neck pain and swelling. Evaluation of serum calcium and
parathyroid hormone (PTH) levels is crucial for a suspected neck
hematoma associated with parathyroid adenoma.
Case
A healthy 43-year-old woman presented with acute odynophagia and
dysphagia, accompanied by anterior neck swelling. She had no history of
trauma or medical procedures. She had no systemic symptoms of
inflammation or infection. Physical examination revealed diffuse
non-tender swelling of the neck without rash. An initial CT scan
revealed a low-density lesion behind the oropharynx without contrast
enhancement (Picture A ). A Follow-up CT scan after two days
demonstrated a rapid increase in the size of the lesion (Picture
B, asterisk ) with increased subcutaneous fat density (Picture
B, arrows ). In addition, ecchymosis of the anterior neck and chest
appeared (Picture C ). Laryngoscopy findings indicated a
submucosal hematoma. Laboratory findings showed normal serum calcium
levels and elevated PTH levels of 119 pg/mL. The level of soluble
interleukin-2 receptor, thyroid function, and coagulation function were
normal. All the above findings, she was diagnosed with hematoma
associated with parathyroid adenoma. Surgery was performed, and an
enlarged left parathyroid adenoma was removed (Picture D ). The
PTH level was normalized within three days after surgery.
Discussion
Spontaneous neck hemorrhage is a rare and severe surgical emergency due
to the traumatic rupture of vessels or extraglandular bleeding of the
thyroid or parathyroid. A parathyroid extracapsular hemorrhage is a
complication of parathyroid gland enlargement associated with
hyperplasia, adenoma, and cancer. The precise mechanisms of such
non-traumatic bleeding are not known. Some previous reports suggested
that blood supplies may occasionally fail to meet the increased demands
caused by the lesions (1). This case highlights the importance of a
diagnostic approach for patients who present with acute neck pain,
swelling, and ecchymosis. In addition to a CT scan, clues to the
diagnosis include a thorough endocrine history and elevated calcium and
PTH levels (2).