Post-Parathyroidectomy Hematoma: Recognition and Emergency Management

A neck hematoma after parathyroidectomy is a surgical emergency due to risk of airway compression.

Pathophysiology

• Inadvertent injury to thyroid vessels (superior/inferior thyroid arteries), anterior jugular veins, or capillary ooze.
• Blood accumulates in tight pretracheal/paratracheal spaces → tracheal deviation/compression.

Timeline & Presentation

• Immediate (OR/PACU): Swelling, tachycardia, hypertension, venous congestion.
• Delayed (6–72h): Most common. Neck fullness, dysphagia, dyspnea, stridor, hoarseness, anxiety.

Diagnosis

• Clinical: inspection, palpation, tracheal position.
• Fiberoptic laryngoscopy: vocal cord function, airway patency.
• CT neck (if stable): extent, active extravasation (contrast).
• Labs: CBC (trend), coags, type & screen.

Management Algorithm

1. Airway first: Prepare for intubation (video laryngoscopy, bougie, surgical airway kit at bedside).
2. Bedside evacuation: Remove sutures/clips, evacuate clot, identify bleeder, cauterize/ligate. Can be life-saving.
3. OR return: If bedside fails, expanding hematoma, or hemodynamic instability.
4. Supportive: Head elevation 30°, IV fluids, transfuse if Hb <7–8, calcium (hypocalcemia risk post-parathyroid).

Prevention

• Meticulous hemostasis, bipolar cautery, thrombin gel.
• Drain placement (controversial; may mask expansion).
• Post-op monitoring: q1h vitals/neck check × 4–6h.
• Anticoagulant management per protocol.

Early recognition and bedside decompression prevent tracheostomy or death.