Thyroid storm induced by trauma due to spear fishing-gun trident impaction in the neck.

Abstract

A rare case of thyroid storm induced by thyroid gland injury because of penetrating neck trauma is reported. The injury was because of a spear fishing-gun trident impaction in the neck. The diagnosis of thyroid gland injury was suspected by preoperative clinical examination and established during neck exploration in the theatre. The gland injury led to thyroid storm owing to the rupture of acini and liberation of T4 into the bloodstream. Withdrawal of the impacted trident along with subtotal thyroid lobectomy and repair of soft tissue damage in addition to supported treatments, which corrected the hyperthyroid state, led to uneventful recovery.

Full text

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SHORT REPORT
Thyroid storm induced by trauma due to spear fishing-gun
trident impaction in the neck
Stylianos Delikoukos, Fotis Mantzos
............................................................... ............................................................... .....
Emerg Med J 2007;24:355–356. doi: 10.1136/emj.2006.044115
A rare case of thyroid storm induced by thyroid gland injury
because of penetrating neck trauma is reported. The injury was
because of a spear fishing-gun trident impaction in the neck.
The diagnosis of thyroid gland injury was suspected by
preoperative clinical examination and established during neck
exploration in the theatre. The gland injury led to thyroid storm
owing to the rupture of acini and liberation of T4 into the
bloodstream. Withdrawal of the impacted trident along with
subtotal thyroid lobectomy and repair of soft tissue damage in
addition to supported treatments, which corrected the
hyperthyroid state, led to uneventful recovery.
P
neck and upper mediastinum.1Although penetrating trauma to
the larynx and trachea is relatively common in neck injuries,
isolated thyroid gland trauma is extremely rare.2 3Furthermore,
trauma-induced thyroid storm is rarely reported.4 5We describe a
case of spear fishing-gun trident impaction in the neck resulting
in thyroid storm as a consequence of rupture of acini and
liberation of T4 into the bloodstream.
enetrating neck traumas after traffic or other accidents are
commonly encountered and usually fatal, because of airway
obstruction or disruption of major vascular structures in the
CASE REPORT
A 32-year-old fisherman was admitted to the emergency
department with a spear fishing-gun trident impacted in the
right part of his neck. The accident occurred during diving while
the fisherman was spearfishing. On arrival, 50 min after the
accident, the patient experienced nausea and vomiting. The
physical examination was remarkable for low-grade fever
(37.9˚C), tachycardia (125 pulses/min), high blood pressure
(165/105 mm Hg), facial abrasions and a tremor, whereas no
respiratory problems were encountered. A diagnosis of possible
thyroid storm was made, immediate blood tests were ordered and
initial medical and supported treatments were induced and
directed at stabilising the patient, correcting the hyperthyroid
state andmanaging the
Simultaneously, the neck wound was inspected by separating
the wound edges in an effort to remove the trident from the
trauma; however, this manoeuvre was unsuccessful. Plain
roentgenograms of the neck showed no larynx or trachea injury.
The patient was carried immediately to the theatre, where neck
exploration confirmed soft tissue injuries and right thyroid lobe
lacerations. No larynx, trachea or great vessels trauma was
noticed. The patient underwent a subtotal right thyroid
lobectomy. The trident was withdrawn along with the damaged
right thyroid lobe, and repair of soft tissue was made (fig 1). The
blood test results showed high thyroid hormone levels.
Postoperative recovery was uneventful, as thyroid storm symp-
toms were overcoming.
systemic decompensation.
DISCUSSION
Neck trauma owing to vehicle accident may result in bony,
muscular, nervous, vascular and aerodigestive tract injury.6
However, only sporadic case reports referring to extensive rupture
of thyroid gland after neck trauma have been encountered.7
The diagnosis of isolated thyroid gland injury owing to
penetrating neck trauma is difficult. The onset of life-
threatening symptoms (severe respiratory distress) usually
leads to urgent invasive airway management (orotracheal
intubation or tracheostomy) before definite diagnosis of thyroid
gland injury, which is established after direct exploration.6 7
Furthermore, few patients may present with thyroid storm
symptoms owing to rupture of acini in the damaged gland
tissue and liberation of T4into the bloodstream.4 5
In conclusion, we report a rare case of thyroid storm after
isolated thyroid gland injury due to spear fishing-gun trident
impaction in the neck. The diagnosis was suspected by physical
examination, and established after blood test results and neck
exploration in the theatre. Withdrawal of the impacted trident,
resection of the damaged thyroid lobe and soft tissue repair was
performed, in addition to supported treatments, which stabi-
lised the patient, correcting the hyperthyroid state and
managing the systemic decompensation.
.......................
Authors’ affiliations
Stylianos Delikoukos, Fotis Mantzos, Surgical Clinic, Halkis General
Hospital
Competing interests: None declared.
Informed consent was obtained for publication of the person’s details in this
report.
Correspondence to: Dr Stylianos Delikoukos, 9 Papakiriazi Street, Larissa
41 223, Greece; morfula@otenet.gr
Accepted 6 December 2006
Figure 1
Spear fishing-gun trident.
355
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REFERENCES
1 Lawton G. Traumatic hemorrhage into the thyroid simulating major-vessel
damage from deceleration injury. Thorax 1974;29:607–8.
2 Green G, Stark P. Trauma of the larynx and trachea. Radiol Cl North Am
1978;16:309–20.
3 Gongaware RD, Capalio DV, Logan JR. Thyrohyoid separation due to
penetrating trauma. Am Surg 1983;49:207–8.
4 Vora NM, Fedok F, Stack Jr BC. Report of a rare case of trauma-induced thyroid
storm. Ear Nose Throat J 2002;81:570–2.
5 Yoshida D. Thyroid storm precipitated by trauma. J Emerg Med
1996;14:697–701.
6 Blaivas M, Hom DB, Younger JG. Thyroid gland hematoma after blunt cervical
trauma. Am J Emerg Med 1999;17:348–50.
7 Nageris B, Rivkind A, Feinmesser R. Penetrating neck injuries. Harefuah
1991;120:379–81.
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