The Joint Annual Scientific Meetings of the Endocrine Society of Australia and the Society for Reproductive Biology 2018

Management of an intrathyroidal cystic parathyroid gland with posttraumatic haemorrhagic transformation causing acute airway compromise (#236)

Johanna Kuehn 1 , Cino Bendinelli 2 3 , Christopher W Rowe 1 3 , Francesco Amico 2
  1. Department of Diabetes & Endocrinology, John Hunter Hospital, Newcastle, NSW, Australia
  2. Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia
  3. School of Medicine and Public Health, University of Newcastle, Newcastle, NSW

Case Report:

A 68-year old male presented to a peripheral hospital following a motor accident, sustaining manubrium and rib fractures. A large neck mass was identified causing tracheal compression, requiring semi-elective intubation for airway compromise. Relevant background included atrial fibrillation on rivaroxaban, obstructive sleep apnoea and renal calculi awaiting lithotripsy. Computed tomography confirmed a hypopharyngeal mass 90x52x57mm, thought to be large goitre resulting in trachea compression. Serum biochemistry revealed marked PTH-dependent hypercalcemia ((calcium 3.35mmol/L (RR 2.1-2.6), PTH 342pg/ml (15-68)) and hypophosphatemia. TSH was normal.

Persistent tracheal compression from the hypopharyngeal mass precluded extubation, necessitating transfer to a tertiary centre. In the absence of dedicated parathyroid imaging, and to minimize surgical insult in the setting of critical illness, a unilateral para/thyroid resection was proposed (proceeding contralaterally only if pathologic parathyroid was not identified). He underwent right hemithyroidectomy, isthmusectomy and right superior parathyroidectomy. Histopathology showed a 30mm (5.04g) right superior parathyroid, while the right thyroid lobe was substituted by a 62mm (124g) hyperplasic intrathyroidal parathyroid, both showed extensive central haemorrhage. Following unilateral parathyroidectomy, extubation was achieved, but hypercalcaemia persisted. An elective contralateral exploration cured multigland parathyroid hyperplasia; evaluation for familial disease was arranged.


Parathyroid tissue causing airway obstruction is rare, with few cases reported [1-5]. In this case, neck trauma and systemic anticoagulation may have precipitated intra-parathyroidal haemorrhage within already hyperplastic tissue, resulting in rapid parathyroid enlargement, airway compromise, and rise in serum PTH and calcium. This case of a hyperfunctioning haemorrhagic parathyroid masquerading as thyroid goitre highlights the paradigm of “damage control neck surgery”. We believe that in the presence of life-threatening airway obstruction, and in the absence of preoperative parathyroid localization a unilateral approach should be favoured to release tracheal compression whilst minimizing the risks associated with bilateral neck exploration such as recurrent laryngeal nerve palsy or hypoparathyroidism [6-8].

  1. Garrahy A, Hogan D, O'Neill JP, Agha A. Acute airway compromise due to parathyroid tumour apoplexy: an exceptionally rare and potentially life-threatening presentation. BMC Endocr Disord. 2017;17(1):35.
  2. Hotes LS, Barzilay J, Cloud LP, Rolla AR. Spontaneous hematoma of a parathyroid adenoma. Am J Med Sci. 1989;297(5):331-3.
  3. Woods RH, Eisele DW. Parathyroid adenoma with cervical tracheal compression. Otolaryngol Head Neck Surg. 1992;107(3):463-5.
  4. Shanley CJ, Overbeck MC, Mazzara P, McLeod MK, Thompson NW, Rodriguez JL. Traumatic rupture of a cervical parathyroid adenoma. Surgery. 1994;115(3):394-7.
  5. Cheng Zhao, Xiurong Wang, Hui Wei, Guifeng Ma Parathyroid adenoma causing a spontaneous cervicaland mediastinal massive hematoma. Int J Clin Exp Med 2015;8(11):21826-21829
  6. Testini, Mario & Logoluso, Francesco & Lissidini, Germana & Gurrado, Angela & Campobasso, Giuseppe & Cortese, Rocco & Luca, Giuseppe & Franco, Ilaria & De Luca, Alessandro & Piccinni, Giuseppe. (2012). Emergency total thyroidectomy due to non traumatic disease. Experience of a surgical unit and literature review. World journal of emergency surgery : WJES. 7. 9. 10.1186/1749-7922-7-9.
  7. “The Risks of Thyroidectomy: Words of Caution for Referring Physicians.” Journal of General Internal Medicine 13.1 (1998): 60–61. PMC.
  8. Atwan M, Chetty R. An unusual “thyroid cyst”: intrathyroidal parathyroid cyst.. Endocr Pathol. 2011;22:108–111