Spontaneous neck hematoma secondary to parathyroid adenoma: a case series

Spontaneous neck hematoma is a rare yet potentially fatal complication of primary hyperparathyroidism (PHPT). Here we aim to describe novel presentations of neck hematomas secondary to PHPT, discussing tools and signs that facilitate diagnosis.

Case series data were extracted by retrospective chart reviews of our institution's electronic medical records, including all neck hematoma cases from parathyroid origin between 2005 and 2020. Cases from PubMed and EMBASE between 1999 and 2020 were analyzed in a systematic literature review.

Four patients were identified with five acute bleeding events, including a novel report of recurrent neck hemorrhage due to parathyroid adenoma. There was postmenopausal female predominance (75%), consistent with previous reports (72.7%). Common presentations included neck pain, dysphagia and hoarseness. All bleedings spread into the retropharyngeal space. Vocal cord paralysis was found in a single case and in 8.6% of the benign lesions in the reviewed cases. A single case presented with normal calcium levels (20% of bleeding episodes), in line with the reviewed cases (17.4%). A subtle CT sign of an enhancing area within the parathyroid gland, which led to the diagnosis, was identified in a single case. Conservative treatments were employed in 80% of our cases and in 51.5% of the reviewed cases, all being successful. Neck explorations performed after a 3-month waiting period from the acute event demonstrated better results compared to immediate surgery.

A high suspicion index is needed, particularly in post-menopausal women, to reach a diagnosis and allow optimal management. Normal laboratory values do not exclude parathyroid etiology, yet assessment should include calcium and PTH levels along with targeted imaging. Since bleeding may recur, we suggest that PHPT complicated with neck hematoma should be an independent indication for definitive parathyroidectomy surgery.

3b.