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.
Discussion:
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].