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\begin{document}

\title{Spontaneous neck hematoma associated with parathyroid adenoma}



\author[1]{Mitsumasa Okano}%
\author[1]{Mitsuko Yui}%
\author[1]{Masanori  Teshima}%
\author[1]{Kazuhiko Sakaguchi}%
\affil[1]{Kobe University Graduate School of Medicine}%


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  \date{May 23, 2024}


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\textbf{Case Image}

Spontaneous neck hematoma associated with parathyroid adenoma

\textsuperscript{1}Mitsumasa Okano, MD, PhD, \textsuperscript{2}Mitsuko
Yui, MD, PhD,

\textsuperscript{2}Masanori Teshima, MD, PhD,\textsuperscript{1}Kazuhiko
Sakaguchi, MD, PhD

\textsuperscript{1}Division of General Internal Medicine, Department of
Internal Medicine,

\textsuperscript{2}Department of Otolaryngology-Head and Neck Surgery,

Kobe University Graduate School of Medicine

Corresponding author: Mitsumasa Okano, Division of General Internal
Medicine,

Department of Internal Medicine, Kobe University Graduate School of
Medicine

7-5-1, Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.

Tel:+81-78-382-6596, Fax:+81-78-382-6597

E-mail: mokano@med.kobe-u.ac.jp

Key words: acute neck pain, neck hematoma, parathyroid bleeding,
parathyroid adenoma

\textbf{Consent}

Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy

\textbf{Key Clinical Message}

We should consider parathyroid extraglandular bleeding for patients with
acute neck pain and swelling. Evaluation of serum calcium and
parathyroid hormone (PTH) levels is crucial for a suspected neck
hematoma associated with parathyroid adenoma.

\textbf{Case}

A healthy 43-year-old woman presented with acute odynophagia and
dysphagia, accompanied by anterior neck swelling. She had no history of
trauma or medical procedures. She had no systemic symptoms of
inflammation or infection. Physical examination revealed diffuse
non-tender swelling of the neck without rash. An initial CT scan
revealed a low-density lesion behind the oropharynx without contrast
enhancement (\textbf{Picture A} ). A Follow-up CT scan after two days
demonstrated a rapid increase in the size of the lesion (\textbf{Picture
B, asterisk} ) with increased subcutaneous fat density (\textbf{Picture
B, arrows} ). In addition, ecchymosis of the anterior neck and chest
appeared (\textbf{Picture C} ). Laryngoscopy findings indicated a
submucosal hematoma. Laboratory findings showed normal serum calcium
levels and elevated PTH levels of 119 pg/mL. The level of soluble
interleukin-2 receptor, thyroid function, and coagulation function were
normal. All the above findings, she was diagnosed with hematoma
associated with parathyroid adenoma. Surgery was performed, and an
enlarged left parathyroid adenoma was removed (\textbf{Picture D} ). The
PTH level was normalized within three days after surgery.

\textbf{Discussion}

Spontaneous neck hemorrhage is a rare and severe surgical emergency due
to the traumatic rupture of vessels or extraglandular bleeding of the
thyroid or parathyroid. A parathyroid extracapsular hemorrhage is a
complication of parathyroid gland enlargement associated with
hyperplasia, adenoma, and cancer. The precise mechanisms of such
non-traumatic bleeding are not known. Some previous reports suggested
that blood supplies may occasionally fail to meet the increased demands
caused by the lesions (1). This case highlights the importance of a
diagnostic approach for patients who present with acute neck pain,
swelling, and ecchymosis. In addition to a CT scan, clues to the
diagnosis include a thorough endocrine history and elevated calcium and
PTH levels (2).

\textbf{Acknowledgments}

None.

\textbf{Conflict of Interest}

None declared.

\textbf{Author Contributions}

MO made a clinical diagnosis and drafted the manuscript; MY and MT
treated the patient; KS supervised the manuscript. All authors read and
approved the final manuscript.

\textbf{Data Availability Statement}

The data that support the findings of this study are available from the
corresponding author upon reasonable request.

\textbf{References}

\textbf{1.} Yoshimura N, Mukaida H, Mimura T, et al. A case of an acute
cervicomediastinal hematoma secondary to the spontaneous rupture of a
parathyroid adenoma. Ann Thorac Cardiovasc Surg \textbf{20 Suppl} :
816-820, 2014.

\textbf{2.} Shinomiya H, Otsuki N, Takahara S, et al. Parathyroid
adenoma causing spontaneous cervical hematoma: two case reports. BMC Res
Notes \textbf{8} : 726, 2015.

\textbf{Figure Legend}

Figure 1

A, Initial CT scan showed low-density lesion behind the oropharynx
without contrast enhancement.

B, Follow-up CT scan showed a rapid increase in the size of the
low-density lesion (asterisk) with increased subcutaneous fat density
(arrows).

C, Ecchymosis of the anterior neck and chest appeared.

D, Macro specimen of enlarged left parathyroid adenoma (7 x 6 x 4 mm).

\textbf{Hosted file}

\verb`Clinical_Image_M.Okano_figure-2.pptx`  available at \url{https://authorea.com/users/375479/articles/868838-spontaneous-neck-hematoma-associated-with-parathyroid-adenoma}

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