What are the management options for post-thyroidectomy (surgical removal of the thyroid gland) swelling in the submental (under the chin) area?

Management of Post-Thyroidectomy Submental Swelling

Immediately assess for life-threatening hematoma using the DESATS criteria and prepare for urgent bedside evacuation if any signs of airway compromise are present. 1, 2, 3

Immediate Assessment Protocol

The priority is distinguishing between benign postoperative edema and a potentially fatal hematoma. Use the DESATS approach systematically: 1, 2, 3

• Difficulty swallowing or discomfort
• Increase in Early warning score
• Swelling of the neck/submental area
• Anxiety or agitation
• Tachypnea or difficulty breathing
• Stridor (late sign—do not wait for this)

Critical timing consideration: Hemorrhage and hematoma formation occur most frequently within the first 24 hours postoperatively, with the highest risk in the first 6 hours. 1, 2, 3

Algorithmic Management Based on Clinical Presentation

If ANY Signs of Airway Compromise Are Present:

1. Immediately administer high-flow supplemental oxygen and position patient head-up 2, 3

2. Call for senior surgical and anesthetic help simultaneously 2, 3

3. Proceed directly to bedside hematoma evacuation using the SCOOP approach without delay or transfer: 1, 2, 3

   • Skin exposure
   • Cut sutures
   • Open skin
   • Open muscles (superficial and deep layers)
   • Pack wound

4. Do not attempt intubation or transfer before evacuation—evacuation must occur at bedside first 2

5. If evacuation fails to restore adequate oxygenation, proceed to emergency intubation with videolaryngoscopy, or cricothyroidotomy if cannot intubate/cannot oxygenate 2

6. Transfer to level 2 or 3 care post-evacuation for close monitoring 2

If NO Signs of Airway Compromise:

1. Increase observation frequency to hourly monitoring for at least 6 hours 1, 3

2. Maintain head-up positioning to optimize airway patency 2, 3

3. Consider alternative diagnoses if presentation is atypical:

   • Chyle leak: Rare complication presenting days post-surgery; diagnose via needle aspiration showing chyle; manage conservatively with repeated aspirations and low-fat diet 4
   • Seroma: Managed conservatively with observation in most cases 5

4. Re-exploration is indicated if hematoma is confirmed and progressive, even without airway compromise, as conservative management leads to prolonged resorption time 5

Critical Pitfalls to Avoid

• Stridor is a LATE sign of airway compromise—intervention must occur before stridor develops 1, 2, 3

• Drains provide false reassurance—hematoma can form despite functioning drains due to clot formation preventing drainage 2, 3

• Do not delay for imaging or transfer if airway compromise is suspected—bedside evacuation takes priority 2

• Intubation in these patients is high-risk due to laryngeal and pharyngeal edema; ensure a senior, experienced person performs it, and be prepared for emergency surgical airway 5

• Patients may develop acute airway distress when lying flat—maintain head-up positioning at all times 5

Post-Evacuation Monitoring

• Transfer to higher level of care for close observation 2
• Maintain head-up positioning 2
• Avoid unnecessary positive fluid balances 2
• Monitor for signs of mediastinitis 2
• Tailor observation frequency to individual patient risk after initial 6-hour period 3