Rupture without warning

In April, 2010, a 58-year-old woman with an endemic goitre presented with an acute swelling of her neck with dyspnoea, dysphagia, and headache. She was from an iodine-defi cient area of Germany, and had no history of neck trauma or infectious diseases. On examination she was in respiratory distress and had elevated blood pressure (160/90 mm/Hg). Her temperature, pulse rate, and electro cardiogram were normal. Blood tests showed normal haemoglobin concentration and thyroid function. Chest radiography showed displacement of the trachea to the left. CT was done to exclude vascular lesions and showed a large right soft-tissue mass measuring 9×10 cm that was compressing the laryngeal region (fi gure A) as well as causing the tracheal deviation. After intubation complicated by progressive swelling, the patient was taken to the operating theatre. Surgical exploration showed a haematoma in the infrahyoid muscles, which was evacuated. After exposure and clipping of the thyroid upper pool arteries, total thyroidectomy was done. The right thyroid lobe had ruptured and there was active bleeding consistent with a venous origin. She was admitted to the intensive care unit for 24 h, and after fi ve days, she had fully recovered and had normal recurrent laryngeal nerve function and calcium concentrations. She was discharged on sub stitution levothyoxine sodium 100 μg once daily. Histopathology showed a microfollicular adenoma with cystic transformations (fi gure B). Rupture of haemorrhagic cysts in the thyroid gland was fi rst described by Bradley in 1896. In 1932, McGregor and Cornett reported on a series of 18 patients (14 women) with spontaneous cyst haemorrhages in 2500 thyroid operations done under local anaesthesia by Schwoeber and colleagues between 1906 and 1923. Five of the 18 patients died. Few cases of a spontaneously ruptured thyroid gland cyst with notable haemorrhage have been reported since then. Spontaneous ruptures of thyroid glands are likely to occur only in the presence of a preexisting condition such as multinodular goitre, thyroid cysts, or, as in our patient, an undiagnosed adenoma. The walls of the adenomas are very fragile due to degeneration, and they also contain many immature blood vessels. 35% of the world’s population have iodine defi ciency (urinary iodine excretion