Two Cases of Cervical Hemorrhage with Upper Airway Obstruction: A Life-Threatening Condition

Several are the causes of cervical masses and among them a spontaneous hemorrhage presents a rare and life-threatening condition. Sometimes hemorrhage develops from a previous silent neck lesion as in the case of an anaplastic thyroid carcinoma associated with bleeding. We present two cases: a 70-year-old woman suffering from enlarging cervical mass causing respiratory distress because of upper airway compression due to a spontaneous rupture of the superior thyroid artery and a 74-year-old woman who drew our attention because of a progressively worsening dyspnea due to a large medial cervical mass with rapid onset. We removed it surgically, finding out an anaplastic thyroid carcinoma that is associated with internal bleeding. We discuss our management of these rare and life-threatening conditions, recalling that the patency of upper airway should always be the prerogative in every emergency. Besides, we make a review of the recent literature. 1. Introduction A spontaneous cervical hemorrhage presents a rare and life-threatening condition due to potential airway injury. The ethiologies of spontaneous cervical hemorrhage may be different; according to Gonzàlez-Cruz et al. [1], the most plausible explanation of haematoma in multinodular goitre is venous bleeding due to an increasing blood supply. In spontaneous thyroid haemorrhage, an increase in venous pressure after a Valsalva manoeuvre was postulated; another cause is hemodynamic alteration in the context of a hemodialysis session, along with the use of heparin [2]. Saylam et al. [3] claim that secondary thyroid hemorrhage of a previously normal thyroid gland as a result of trauma is a very rare condition; possible causes of bleeding could be: trauma, deceleration injury, cervical hyperflexion and Valsalva manoeuvre which increases venous pressure [4], including straining during defecation or heavy lifting. In our opinion hypertension can be the trigger in patients with known or unknown thyroid disease [5], especially if patients present coagulopathy [6]. It is also possible that a sudden neck swelling occurs due to hemorrhage of a rare thyroid cancer, such as an anaplastic thyroid carcinoma (ATC). This is the rarest, but the deadliest histologic type among thyroid malignancies, with a dismal median survival of 3–9 months [7–9]. It represents less than 2% [7, 10] of all thyroid tumors; however, this is the cause of 14%–39% of thyroid carcinoma-related deaths. The female/male ratio is 5 to 1 and the peak of incidence is in the sixth and seventh decade of life. Usually, it turns out to be a rapidly