Delayed Tracheal Perforation After Thyroidectomy: A Case Report and Literature Review

Introduction

Thyroidectomy is a safe procedure that is commonly performed for both benign and malignant thyroid diseases. ¹ Complications occur in only about 3%–5% of patients after thyroidectomy, with tracheal perforation occurring in approximately 0.06% of cases. ² Tracheal perforation related to thyroidectomy is usually detected during surgery, and recovery without major complications is possible with appropriate management. However, delayed tracheal perforation without an intraoperative tracheal injury is an extremely rare but life-threatening condition, with only about 25 cases reported worldwide. We present a case of delayed tracheal perforation in a 36-year-old male patient 2 weeks after a left thyroidectomy, accompanied by a literature review.

Case Presentation

A 36-year-old male patient underwent left thyroidectomy for a 4.0 × 3.5 cm follicular neoplasm at the Department of Surgery, Chungnam National University Hospital. The patient was discharged without any unusual issues 3 days after the surgery, and a pathological examination revealed minimally invasive follicular thyroid carcinoma. Microscopically, invasion of the lymphatic vessels was noted. Two weeks after the surgery, the patient complained of worsening dyspnea when lying down, sore throat, and coughing, and a wheezing sound was noted during inhalation. The patient visited the pulmonology department of the hospital, but no relevant findings were observed on chest radiography and pulmonary function tests.

The patient visited the otorhinolaryngology department of the hospital and underwent a computed tomography scan of the neck. A tracheal defect measuring approximately 6 × 20 mm was observed in the second and third trachea ring positions, which were expected to correspond to the site of thyroid lobectomy (Figure 1A). Flexible laryngoscopy revealed a defect in the anterior wall of the trachea, approximately 3 cm below the subglottis (Figure 1B). The patient had severe obesity (body mass index, 40.12 kg/m²), hypertension, and severe uncontrolled diabetes (hemoglobin A1c, 10.5%), but no other underlying diseases. Further tests, including blood tests and electrocardiography, showed no abnormalities. Based on the patient's clinical course, symptoms, and the results of laboratory and imaging tests, a diagnosis of dyspnea due to delayed tracheal perforation after thyroid surgery was made.

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Figure 1.

Initial neck CT and flexible laryngoscopy image. (A) Axial CT scan. 20 × 6 mm sized linear tracheal wall defect (white arrow) in the anterior tracheal wall. (B) Laryngoscopy image. A tracheal wall defect (black arrow) on the left anterior tracheal wall.

A conservative therapy plan was made, and the patient was admitted to the hospital. The patient was informed about the possibility of an emergency tracheostomy or surgery if symptoms worsened or oxygen saturation decreased. During the hospital stay, the patient received conservative therapy including fasting and bed rest, nebulizer low-oxygen therapy, prophylactic antibiotics, and low-dose steroid therapy, accompanied by close monitoring of his blood glucose levels. From the sixth day of hospitalization, no choking sounds were heard during breathing, and the patient’s breathing discomfort improved. The patient was discharged without worsening symptoms on the ninth day of hospitalization.

After 3 weeks, the patient visited the outpatient clinic and underwent flexible laryngoscopy, which showed no anterior wall defect in the trachea, although some mucosal swelling caused tracheal stenosis. A computed tomography scan taken 1 month after the discharge showed a significant decrease in the size of the previously observed tracheal defect. The patient has been symptom-free and under outpatient follow-up for 3 months.

Discussion

Thyroidectomy is commonly performed worldwide and has a low rate of complications (less than 3%–5%). ² Delayed tracheal perforation without an intraoperative tracheal injury is a rare complication, with only about 25 cases reported worldwide. The risk factors for delayed tracheal perforation related to thyroidectomy include female sex and toxic thyroid nodules, particularly if the nodules are large and compress the trachea for a long time, causing the tracheal wall to weaken. Prolonged high steroid doses before surgery,^{3 –5} previous radiation therapy, ² and other factors such as high pressure during the procedure, damage to the trachea from the suction tube, and blood flow interruption during the coagulation process with an electrocautery device can also increase the risk of tracheal perforation. ³

After surgery, repeated coughing or infections due to blood clots can become risk factors. ¹ In this particular case, the risk factors may have been the large (4.0 × 3.5 cm) thyroid nodule and the use of an electrosurgical device. The patient’s uncontrolled diabetes may also have caused delayed wound healing and inflammation, resulting in the occurrence of delayed tracheal perforation.

The 25 reported cases of delayed tracheal perforation in previous studies (Table 1) occurred between 2 and 40 days after surgery, and all but 4 cases occurred in patients who underwent total thyroidectomy. The distribution of benign and malignant thyroid diseases was relatively even, with 14 and 11 cases, respectively. The most common symptoms were neck swelling and subcutaneous emphysema, and there were also cases of fever, coughing, hemoptysis, and respiratory distress. In 14 cases, symptoms occurred after severe coughing, retching, shouting, or intense exercise. ²

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Table 1.

Previously Reported Cases of Delayed Tracheal Perforations After Thyroidectomy.

Reference	Sex/Age	Time of Presentation	Chief Complaint	Precipitating Factor	Indication of Thyroidectomy	Operation	Management	Size
Golger et al. 3	30/F	POD 8	Neck swelling, cough, and fever	Cough	Hyperthyroidism	TT	Tracheostomy, NE	-
To et al. 6	62/M	POD 10	Neck swelling, cough, and emphysema	Cough	PTCa	TT	Tracheostomy, NE	-
Jacqmin et al. 7	53/F	POD 8	Neck swelling and emphysema		Grave's disease	TT	Tracheal resection	-
Damrose et al. 8	20/F	POD 7	Neck swelling and emphysema		Grave's disease	TT	Primary closure	1 × 2 mm
Chauhan et al. 9	65/M	POD 7	Neck swelling and emphysema		MTCa	TT	Tracheostomy, NE	5 mm
Alevizos et al. 10	55/F	POD 40	Neck swelling	-	Multinodular goiter	TT	NE, primary closure	-
Rosato et al. 11	30/M	POD 10	Neck swelling, cough, and dyspnea	Cough	Grave's disease	TT	NE, primary closure	-
Bertolaccini et al. 12	45/M	POD 4	Neck swelling	-	PTCa	TT	Muscle flap	6 mm
Conzo et al. 13	65/M	POD 15	Neck swelling and emphysema	-	Thyroid nodule	TT	Conservative Tx	1.5 mm
Mazeh et al. 14	17/F	POD 9	Neck swelling and emphysema	Sneeze	Grave's disease	TT	NE, primary closure, muscle flap	25 mm
Heavrin et al. 15	55/F	POD 28	Neck swelling, cough, and dyspnea	Cough	PTCa	TT	Conservative Tx, drain catheter insertion	-
Materazzi et al. 16	39/F	POD 38	Emphysema	Sneeze	Thyroid nodule	Lobectomy	NE (endoscopic)	2 mm
Sanna et al. 17	17/F	POD 7	Emphysema, cough, and dyspnea	-	PTCa	TT	NE, muscle flap	30 mm
Choi et al. 18	72/F	POD 3	Neck swelling, emphysema, and dyspnea	-	Thyroid cancer	TT	Tracheostomy, conservative Tx	10 × 20 mm
Han et al. 19	39/F	POD 3	Neck swelling, hemoptysis, dyspnea, and fever	Cough	Thyroid nodule	Lobectomy	Tracheal stent	25 mm
Escott et al. 20	29/F	POD 14	Neck swelling, cough, emphysema, and stridor	Cough	Thyroid nodule	TT	NE, muscle flap	2.5 mm
Gonzalez et al. 21	46/F	POD 9	Neck swelling and dyspnea	Cough	Grave's disease	TT	Conservative Tx	-
Kumar et al. 22	20/M	POD 2	Neck swelling, emphysema, and dyspnea	Cough	PTCa	TT	Tracheostomy, NE	10 mm
Devaraja et al. 23	48/M	POD 5	Emphysema	-	PTCa	TT	Conservative Tx	-
Windon et al. 24	25/M	POD 27	Neck swelling	Valsalva	PTCa	Lobectomy	NE, Penrose drain insertion	1 mm
Shew et al. 25	24/M	POD 10	Neck swelling and Cough	Cough	PTCa	TT	Tracheostomy, NE, muscle flap	10 mm
Geum et al. 26	52/F	POD 28	Neck swelling	Shouting	PTCa	TT	Conservative Tx, catheter insertion	1 × 2 mm
Azar et al 4	50/M	Not noted (9 days after)	Neck swelling, emphysema, and cough	Cough	Hashimoto’s thyroiditis	Isthmusectomy	NE, primary closure, muscle flap, Penrose drain insertion	5 mm
Stevens et al 5	34/F	POD 10	Neck swelling and emphysema	-	Hashimoto’s thyroiditis	TT	NE, primary closure	5 mm
Seenarain et al 2	51/M	POD 22	Neck swelling and emphysema	-	Thyroid nodule	TT	NE, primary closure, muscle flap,	2 mm
Present case	36/M	POD 14	Dyspnea, cough, and stridor	-	FTCa	Lobectomy	Conservative Tx	20 mm

The treatment of tracheal defects depends on the severity of the patient’s symptoms and the size of the tracheal defect. ²⁶ In patients with small defects and no or improving respiratory distress, conservative treatments such as antibiotics, high-pressure oxygen supply, bed rest, and low-dose steroid therapy may be used. ²¹ However, cases of unstable or severe respiratory distress necessitate prompt surgical treatment. ²¹ It is important to be prepared to perform emergency intubation or tracheotomy. When intubating, the tracheal tube should be positioned below the defect, and high cuff pressure should be avoided to prevent further worsening of the patient's condition. ⁸ If the defect is small and the inflammation is minimal, primary suturing is sufficient. ²⁶ However, if the inflammation is severe and primary suturing is not possible, a temporary tracheotomy can be performed to induce spontaneous healing. ¹⁸ In cases of localized severe inflammation and non-circumferential defects, muscle flaps can be used to reinforce the defect; however, in cases of circumferential defects exceeding half of the trachea, tracheal resection and reconstruction or anastomosis may be necessary. ⁷ Other treatments include inserting a tracheal stent ¹⁹ or using conservative treatment by inserting a catheter or drain to remove air continuously flowing into the defect area, without cutting the skin, in cases with mild symptoms.^15,24,26

This case report differs from most previously reported cases in the literature because the patient presented with respiratory distress as the main symptom after thyroid lobectomy, instead of neck swelling and subcutaneous emphysema. A significant defect with a linear dimension of about 2 cm was found in the anterior tracheal wall by computed tomography and flexible laryngoscopy, but there was no evidence of inflammation from serum tests, stable vital signs, and normal findings of artery blood gas analysis. The patient was treated with conservative therapy, including low-dose systemic steroids, without surgical intervention, and has shown improvement without worsening of symptoms.

In conclusion, thyroidectomy is considered a safe and low-risk surgical procedure, but there is a possibility of delayed tracheal perforation and necrosis as a surgical complication. To reduce the risk of this complication, it is crucial to identify high-risk patients before surgery, minimize the use of electrocautery near the trachea during surgery, and closely inspect the trachea for injury before completing the procedure. It is also important to instruct patients to avoid activities that may place significant pressure on the trachea, such as excessive coughing or sneezing, for at least a month after surgery. Furthermore, during follow-up visits, a comprehensive medical history and physical examination, taking into account potential complications, is necessary.