Learning Objectives

At the conclusion of this educational activity, participants should be able to:

• Identify patients at risk for postoperative cervical hematomas
• Describe the signs of cervical hematoma in the early postoperative period
• Understand the approaches for managing cervical hematomas

The Cases

Case #1: A 61-year-old man presented with a history of hypertension, peripheral neuropathy, osteoarthritis, and spinal stenosis, status/post two previous spine surgeries and long-term use of opioid analgesics. He reported a recent history of right arm weakness, which was attributed to severe cervical spinal canal and foraminal stenosis at the C4-C5 level. He underwent elective C3-C5 anterior discectomy and cervical disc arthroplasty. The patient recovered in the Post-Anesthesia Care Unit (PACU) overnight, was evaluated by physical therapy, and was discharged home about 24 hours after surgery with home health follow-up. The nurse’s discharge note mentioned that the patient’s nurse practitioner was notified regarding neck swelling and evaluated the patient one hour before discharge.

About three days later, the patient was transported by ambulance in cardiopulmonary arrest after complaining to his wife of shortness of breath and becoming unresponsive. The paramedic was unable to intubate the patient due to “excessive airway swelling and tracheal deviation”; they also noted “blood weeping through surgical incision.” Intubation was attempted multiple times after the patient arrived in the Emergency Department (ED). The ED provider noted bright red blood in the oropharynx, significant retropharyngeal distension, and a 2.5 cm vertical laceration of the posterior pharynx below the uvula, with bleeding. The patient could not be resuscitated and expired. Autopsy revealed a large hematoma at the operative site, causing compression of the upper airway, which was the suspected cause of respiratory and cardiac arrest.

Case #2: A 52-year-old woman with a chronic cough attributed to COVID-19 pneumonia one year earlier was admitted to a tertiary care center for elective thyroid lobectomy for papillary thyroid cancer. Her operation was uncomplicated so according to the surgeon’s protocol, she was observed in the PACU for six hours. On assessment prior to discharge, she had no significant pain or nausea, was eating, vocalized normally, and her incision had no swelling or ecchymosis. The patient was discharged to a hotel across the street from the hospital, where a one-night stay had been pre-arranged because the patient’s home was two hours away.

The following morning, the patient called the surgery clinic to report increased neck pain and swelling that developed after a coughing fit. She was instructed by a triage nurse to present to the ED, where she was fast-tracked to a resuscitation bay and met by her primary surgical team. The patient had a large hematoma but was breathing and phonating normally. She was taken emergently to the operating room for hematoma evacuation. The field was washed out and explored with no source of bleeding identified and the incision was re-closed. She was observed for 24 hours and discharged home on postoperative day 1.

The Commentary

By Claire E. Graves, MD and Maggie A. Kuhn, MD MAS

Background

These cases describe the rare but dangerous complication of hematoma following neck surgery. The estimated rate of cervical hematoma is approximately 1% to 1.5% in thyroid or parathyroid surgery^1-5 and approximately 1% in anterior cervical spine surgery (ACSS).⁶ After thyroidectomy, patients are at highest risk of hematoma within 6 hours of surgery, but delayed presentations can occur even after a week or longer.^2,7-10 Following ACSS, approximately two-thirds of hematomas occur within 24 hours, with the remainder occurring within six days.^11,12 Up to 14% of hematomas after ACSS result in airway compromise, often due to post-surgical pharyngeal edema or a parapharyngeal abscess in addition to the hematoma.¹³

Multiple risk factors associated with postoperative hematoma in thyroid and/or parathyroid surgery have been described, including (1) patient factors such as male sex, Black race, older age, hypertension, diabetes, and use of antiplatelet or anticoagulant medications; (2) disease factors including previous thyroid operation, bilateral or total thyroidectomy, concurrent neck dissection, large gland and/or dominant nodule, substernal goiter, Graves’ disease, and chronic lymphocytic thyroiditis; and (3) process-of-care factors such as procedure performance by a low-volume surgeon, low-volume hospital, and use of a surgical drain.^{1-3, 5,7,9,10,14-17}

Risk factors for hematoma following ACSS include (1) patient factors such as male sex, age over 65 years, low body mass index (e.g., ≤24), medical comorbidities or American Society of Anesthesiologists classification ≥3, and smoking;^16,17 (2) disease-related factors such as diffuse idiopathic skeletal hyperostosis (DISH) and ossification of the posterior longitudinal ligament;¹² and (3) process-of-care factors such as therapeutic anticoagulation, longer operative time, and multilevel surgery.^12,16,17 As with thyroid or parathyroid surgery, postoperative drains do not consistently prevent the development of hematoma after ACSS.¹⁸ Additionally, maneuvers that transiently raise venous pressure, such as coughing, retching, and vomiting, may predispose to postoperative cervical bleeding and may be associated with delayed presentation of hematoma, as described in Case #2.^19,20

Cervical hematomas compromise the airway directly through compression by the collection of blood, as well as indirectly by venous and lymphatic obstruction. Decreased venous return and lymphatic obstruction cause airway edema, which is often the main cause of obstruction and can lead to rapid onset of stridor, tachypnea, and airway collapse. Early recognition is crucial for patient survival after this life-threatening complication. Swelling, increased neck circumference, patient sensation of tightness, and purple discoloration of the skin are classic signs of hematoma, but early hematoma can be subtle and difficult to recognize or distinguish from routine postoperative swelling. Notably, respiratory distress, voice changes, agitation or stridor are late manifestations of airway compromise, and even patients with life-threatening airway obstruction usually have normal oxygen saturation levels.^19,21

When postoperative cervical hematoma is suspected, prompt patient evaluation is necessary. The order and timing of subsequent interventions depends on the severity of presentation and surgeon judgment. Bedside evacuation by re-opening the incision may be required if the patient has any signs or symptoms of airway compromise. In Case #1, multiple failed attempts at intubation and ventilation may have been avoided with early conversion to a surgical airway via cricothyrotomy or tracheotomy. Debkowska et al. recommend proceeding with a surgical airway after a single failed attempt at oral intubation or if two minutes have elapsed since respiratory arrest.¹³ However, with a stable patient, as was seen in Case #2, it is possible to safely transport to the operating room in order to treat in a more controlled environment. Surgical and anesthesia teams should work together to ensure a plan for airway access, as hematoma evacuation may be required prior to intubation if the airway is too constricted to accommodate an endotracheal tube.²¹ The surgeon’s goals are to release the hematoma and control any sources of active bleeding, which requires re-opening the incision and fully exploring the surgical site.

Approach to Improving Safety & Patient Safety Target

Multiple studies have demonstrated the safety of outpatient thyroidectomy in appropriately selected patients.^22,23 Benefits of outpatient thyroidectomy include improved patient comfort and reduced healthcare resource utilization,^19,24 but these benefits must be carefully considered alongside important patient safety factors. In a published consensus statement addressing outpatient thyroidectomy, the American Thyroid Association outlines eligibility criteria for same-day discharge: no major patient comorbidities, appropriate and sufficient preoperative education, a team approach to education and clinical care, a willing and available caregiver, a social setting conducive to postoperative care, and proximity to a skilled care facility.¹⁹ All patients undergoing neck surgery and their caregivers should be thoroughly counseled regarding the life-threatening risk of cervical hematoma and given detailed instructions to call the clinical team and proceed to the nearest ED for care.

Patients undergoing ACSS are commonly admitted to the hospital postoperatively for wound observation, assurance of safe ambulation, initiation of physical therapy, and resumption of an oral diet. Even patients who are monitored overnight after surgery, such as the patient in Case #1, occasionally develop a delayed hematoma or other causes of airway obstruction, such as an abscess. Up to 14% of post-ACSS complications are airway-related.¹³ Understanding these risks, many spine surgeons have advocated protocolized postoperative airway management for patients who undergo ACSS. Such protocols are based on studies demonstrating reduced postoperative airway complications when patients were extubated according to an established algorithm.²⁵ Most protocols stratify ACSS patients by surgical risk factors including exposure of >3 cervical levels, operative site C3-4 or above, operative time of >5 hours, blood loss >300ml, and significant medical comorbidity.^26,27 For patients who are selected to remain intubated postoperatively, extubation should be guided by the presence of endotracheal tube cuff leak or findings of a lateral neck radiograph, and should be performed when appropriate staff are available to manage the difficult airway should respiratory distress arise.

These two cases demonstrate disparate outcomes in cases of postoperative cervical hematoma. In Case #1, critical airway compromise developed at home resulting in cardiopulmonary arrest. In this case, delayed presentation made prompt and proactive management challenging, ultimately resulting in airway collapse and patient death. In Case #2, prompt recognition and enactment of a rapid management strategy resulted in minimal patient morbidity. This patient was given clear instructions for neck swelling, called the appropriate emergency number, was triaged correctly, and quickly arrived at the ED because of her pre-arranged proximity. On arrival, the patient was immediately evaluated, and the hematoma was recognized, with a coordinated effort to evacuate the hematoma and secure the airway in the controlled environment of the operating room.

The first case additionally highlights a possible failure to recognize signs of hematoma in the early postoperative period. Because early neck hematomas can be difficult to distinguish from benign postoperative swelling, appropriate education of all clinical staff caring for patients undergoing neck surgery is necessary. Early identification is crucial, as airway obstruction may evolve rapidly and hypoxic brain injury follows precipitously. Even when properly prepared, however, the high stress of airway emergencies can lead to cognitive overload, resulting in errors.²⁸ Often first-responders in the hospital are junior staff, and they should be instructed on pathways to summon help, as well as empowered to act quickly on their own in the case of airway compromise. Several training protocols and cognitive aids have been published to assist clinicians in early detection and management of neck swelling.^8,29 These aids include printed protocols, step-by-step guides, and, in some cases, emergency supply packs. A mnemonic device (“SCOOP”) described by Edafe and colleagues may be useful to recall the indications and steps for opening the cervical incision:⁸

Swelling of the wound
Clear steri-strips and pull suture
Open wound – cut skin and platysma stitches
Open wound – cut strap muscle stitches
Probe wound to release clots

Any physicians caring for patients undergoing neck surgery or those responding to rapid response calls should be trained to create surgical airways. Such training includes regular review of airway algorithms, methods for airway support and ventilation, as well as practicing surgical airway technique on a simulator. To successfully manage this life-threatening complication, appropriate patient, caregiver and clinical staff education, as well as systematic emergency protocols, are essential.

Take-Home Points

• Postoperative hematoma causing airway collapse is a rare but potentially lethal complication of neck surgery.
• Hypoxic brain injury occurs rapidly after airway obstruction, and prompt recognition and management of cervical hematoma is crucial.
• Most cervical hematomas occur within 6 hours of thyroid surgery and within 24 hours of anterior spine surgery, but delayed presentations can occur after patient discharge.
• All clinical staff caring for patients undergoing neck surgery should be trained to recognize and manage cervical hematoma.
• Patients undergoing neck surgery and their caregivers should be counseled on the risk of cervical hematoma and given detailed instructions on how to contact the clinical team and to proceed to the nearest emergency department for care.
• When hematoma threatens the airway, all layers of sutures should be emergently opened and hematoma evacuated – in many cases, at the bedside, before the airway is secured.
• Mucosal edema from lymphovascular congestion may render oral intubation impossible, and a surgical airway (cricothyrotomy or tracheotomy) should be performed.
• Training protocols and cognitive aids, as well as emergency supply packs, can be helpful tools for clinicians faced with management of cervical hematoma.

Claire Graves, MD
Assistant Professor, Endocrine Surgery
Department of Surgery
UC Davis Health

Maggie Kuhn, MD MAS
Associate Professor, Laryngology & Bronchoesophagology
Department of Otolaryngology – Head & Neck Surgery
UC Davis Health

References

1. Dehal A, Abbas A, Hussain F, et al. Risk factors for neck hematoma after thyroid or parathyroid surgery: ten-year analysis of the nationwide inpatient sample database. Perm J. 2015;19(1):22-28. [Free full text]
2. Liu J, Li Z, Liu S, et al. Risk factors for and occurrence of postoperative cervical hematoma after thyroid surgery: A single-institution study based on 5156 cases from the past 2 years. Head Neck. 2016;38(2):216-219. [Available at]
3. Lang BHH, Yih PCL, Lo CY. A review of risk factors and timing for postoperative hematoma after thyroidectomy: is outpatient thyroidectomy really safe? World J Surg. 2012;36(10):2497-2502. [Free full text]
4. Aspinall S, Oweis D, Chadwick D. Effect of surgeons’ annual operative volume on the risk of permanent Hypoparathyroidism, recurrent laryngeal nerve palsy and Haematoma following thyroidectomy: analysis of United Kingdom registry of endocrine and thyroid surgery (UKRETS). Langenbecks Arch Surg. 2019;404(4):421-430. [Available at]
5. Doran HE, Wiseman SM, Palazzo FF, et al. Post-thyroidectomy bleeding: analysis of risk factors from a national registry. Br J Surg. 2021;108(7):851-857. [Free full text]
6. Yee TJ, Swong K, Park P. Complications of anterior cervical spine surgery: a systematic review of the literature. J Spine Surg. 2020;6(1):302-322. [Free full text]
7. Campbell MJ, McCoy KL, Shen WT, et al. A multi-institutional international study of risk factors for hematoma after thyroidectomy. Surgery. 2013;154(6):1283-1289; discussion 1289-1291. [Available at]
8. Edafe O, Cochrane E, Balasubramanian SP. Reoperation for bleeding after thyroid and parathyroid surgery: incidence, risk factors, prevention, and management. World J Surg. 2020;44(4):1156-1162. [Available at]
9. de Carvalho AY, Gomes CC, Chulam TC, et al. Risk factors and outcomes of postoperative neck hematomas: an analysis of 5,900 thyroidectomies performed at a cancer center. Int Arch Otorhinolaryngol. 2021;25(3):e421-e427. [Free full text]
10. Salem FA, Bergenfelz A, Nordenström E, et al. Evaluating risk factors for re-exploration due to postoperative neck hematoma after thyroid surgery: a nested case-control study. Langenbecks Arch Surg. 2019;404(7):815-823. [Free full text]
11. Song KJ, Choi BW, Lee DH, et al. Acute airway obstruction due to postoperative retropharyngeal hematoma after anterior cervical fusion: a retrospective analysis. J Orthop Surg Res. 2017;12(1):19. [Free full text]
12. O’Neill KR, Neuman B, Peters C, et al. Risk factors for postoperative retropharyngeal hematoma after anterior cervical spine surgery. Spine (Phila Pa 1976). 2014;39(4):E246-252. [Available at]
13. Debkowska MP, Butterworth JF, Moore JE, et al. Acute post-operative airway complications following anterior cervical spine surgery and the role for cricothyrotomy. J Spine Surg. 2019;5(1):142-154. [Free full text]
14. Fan C, Zhou X, Su G, et al. Risk factors for neck hematoma requiring surgical re-intervention after thyroidectomy: a systematic review and meta-analysis. BMC Surg. 2019;19(1):98. [Free full text]
15. Mahoney RC, Vossler JD, Woodruff SL, et al. Predictors and consequences of hematoma after thyroidectomy: an American College of Surgeons National Surgical Quality Improvement Program Database analysis. J Surg Res. 2021;260:481-487. [Available at]
16. Epstein N. Frequency, recognition, and management of postoperative hematomas following anterior cervical spine surgery: a review. Surg Neurol Int. 2020 Oct 21;11:356. [Free full text]
17. Bovonratwet P, Fu MC, Tyagi V et al. Incidence, risk factors, and clinical implications of postoperative hematoma requiring reoperation following anterior cervical discectomy and fusion. Spine (Phila Pa 1976). 2019 Apr 15;44(8):543-549. [Available at]
18. Basques BA, Bohl DD, Golinvaux NS, et al. Factors predictive of increased surgical drain output after anterior cervical discectomy and fusion. Spine (Phila Pa 1976). 2014;39(9):728-735. [Available at]
19. Terris DJ, Snyder S, Carneiro-Pla D, et al. American Thyroid Association statement on outpatient thyroidectomy. Thyroid. 2013;23(10):1193-1202. [Free full text]
20. Bononi M, Amore Bonapasta S, Vari A, et al. Incidence and circumstances of cervical hematoma complicating thyroidectomy and its relationship to postoperative vomiting. Head Neck. 2010;32(9):1173-1177. [Available at]
21. Patel KN, Yip L, Lubitz CC, et al. The American Association of Endocrine Surgeons guidelines for the definitive surgical management of thyroid disease in adults. Ann Surg. 2020;271(3):e21-e93. [Free full text]
22. Khavanin N, Mlodinow A, Kim JYS, et al. Assessing safety and outcomes in outpatient versus inpatient thyroidectomy using the NSQIP: a propensity score matched analysis of 16,370 patients. Ann Surg Oncol. 2015;22(2):429-436. [Free full text]
23. Lee DJ, Chin CJ, Hong CJ, et al. Outpatient versus inpatient thyroidectomy: a systematic review and meta-analysis. Head Neck. 2018;40(1):192-202. [Available at]
24. Marino M, Spencer H, Hohmann S, et al. Costs of outpatient thyroid surgery from the University HealthSystem Consortium (UHC) database. Otolaryngol Head Neck Surg. 2014;150(5):762-769. [Available at]
25. Kim M, Choi I, Park JH, et al. Airway management protocol after anterior cervical spine surgery: analysis of the results of risk factors associated with airway complication. Spine (Phila Pa 1976). 2017;42(18):E1058-E1066. [Available at]
26. Palumbo MA, Aidlen JP, Daniels AH, et al. Airway compromise due to laryngopharyngeal edema after anterior cervical spine surgery. J Clin Anesth. 2013;25(1):66-72. [Available at]
27. Sagi HC, Beutler W, Carroll E, et al. Airway complications associated with surgery on the anterior cervical spine. Spine (Phila Pa 1976). 2002;27(9):949-953. [Available at]
28. Chrimes N. The Vortex: a universal “high-acuity implementation tool” for emergency airway management. Br J Anaesth. 2016;117 Suppl 1:i20-i27. [Free full text]
29. Phillips A, Graham J, Eyeington C, et al. THYRAID: a cognitive aid for the management of neck haematoma following thyroid surgery. ANZ J Surg. 2022;92(3):320-324. [Available at]