Annals of Indian Academy of Otorhinolaryngology Head and Neck Surgery

CASE REPORT
Year
: 2017  |  Volume : 1  |  Issue : 2  |  Page : 29--31

Discharging sinus of neck after thyroid surgery:A rare case report


Kamlesh Kanwar Shekhawat1, Vikram Singh Rathore2,  
1 Department of Anesthesia, Critical Care and Pain and Otorhinolaryngology, Pacific Institute of Medical Sciences, Under Sai Tirupti University, Udaipur, Rajasthan, India
2 Department of Head Neck Surgery, Pacific Institute of Medical Sciences, Under Sai Tirupti University, Udaipur, Rajasthan, India

Correspondence Address:
Dr. Kamlesh Kanwar Shekhawat
Department of Anaesthesiology, Critical Care and Pain, 2nd Floor, Main Building, Pacific Institute of Medical Sciences, Ambua Road, Village Umrada, Udaipur - 313 015, Rajasthan
India

Abstract

There are a number of complications after thyroid surgery such as compressing hematoma, tracheomalacia, wound infection, damage to the recurrent laryngeal nerve or superior laryngeal nerve, hypothyroidism, hypocalcemia, scar formation, and thyroid storm, but discharging skin sinus of the neck is a rare complication. We report a case of discharging pus sinus of the neck after hemithyroidectomy for 1 year; pus culture was positive for Pseudomonas aeruginosa. Thyroid function test was normal. Ultrasonography disclosed branching sinus tracts and right lobe thyroid nodule and the left lobe not visualized. Sinus tracts' excision surgery was done. Histopathology report revealed fibrocollagenous stroma with clusters of epithelioid cells, histiocytes, Langhans giant cells, and chronic inflammatory cells with foci of caseous necrosis. The diagnosis of thyroid tuberculosis (TB) was therefore made. Patient was put on isoniazid, rifampicin, ethambutol, and pyrazinamide. She responds well. Although seldom observed, TB should be kept in mind in the differential diagnosis of discharging sinus of neck.



How to cite this article:
Shekhawat KK, Rathore VS. Discharging sinus of neck after thyroid surgery:A rare case report.Ann Indian Acad Otorhinolaryngol Head Neck Surg 2017;1:29-31


How to cite this URL:
Shekhawat KK, Rathore VS. Discharging sinus of neck after thyroid surgery:A rare case report. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2017 [cited 2019 Sep 18 ];1:29-31
Available from: http://www.aiaohns.in/text.asp?2017/1/2/29/242234


Full Text



 Introduction



Thyroid gland is about 2 inches long and lies in front of throat below the prominence of thyroid cartilage. It has two lobes, connected by isthmus. The normal size of the thyroid gland cannot be felt. It is palpable in thyroid cancer, goiter, and hyperthyroidism, and patients may require surgery. Major postoperative complications include wound infection, bleeding, airway obstruction because of compressing hematoma, tracheomalacia, hypocalcemia, hypothyroidism and thyroid storm, and recurrent laryngeal nerve injury. However, sinus tract in neck skin is a rare complication of thyroid surgery.

 Case Report



A 40-year-old woman, weight 58 kg, came in ENT outpatient department (OPD) with complaint of discharging sinus of neck after 2 months of hemithyroidectomy done 1 year back in other institutes. Previous documents of surgery and other treatments were not available. On local examination of neck, two pus discharging sinuses on suture line and one sinus had a suture material [Figure 1]. No palpable thyroid gland and neck lymph nodes were found. Pus swab was sent for culture and sensitivity along with routine blood investigation and admitted to the female ward for further management. Ultrasound (USG) of neck was done. Her investigations were Hb12, WBC 5400, platelets count 2 lakhs, blood urea 30.4, serum creatinine 0.8, uric acid 5.5, clotting time 4, bleeding time 2, INR 1.18, TSH 2.70, T4 8.4, and T3 1.20. USG neck showed branching sinus tracts and nodules in right thyroid gland lobe and left lobe was not seen [Figure 2]. Pus swab culture was positive for Pseudomonas aeruginosa and sensitive to many antibiotics. Amikacin was started preoperatively. The patient was shifted to the operation theater for excision of sinus tracts after preanesthetic fitness and signed the informed consent form. All monitors were attached including electrocardiography, SpO2, noninvasive blood pressure cuff, and EtCO2. Injection midazolam 1 ml, metochlopromide10 mg, and ranitidine 150 mg intravenous (IV) were given as premedication. Injection nalbuphine 10 mg was given as analgesic and preoxygenated for 3 min. General anesthesia was induced with IV and inhalational anesthetic agent. Injection atracurium was used as relaxants and intubated with cuffed endotracheal tube number 7.5. Surgery was started after painting and draping, and with all aseptic precaution, a horizontal neck skin crease was increased, methylene blue dye was injected in sinus tract, and blunt dissection was done around the tract and removed. Wound closure was done in layers. The procedure was uneventful and after extubation was shifted to recovery room. The specimen was sent for histopathology examination. She was discharged on the 3rd postoperative day and turned off in OPD after 7 days with the histopathology report which was in favor of tubercular lesion [Figure 3]. Opinion was taken from tuberculosis (TB) and chest physician and antitubercular drug was started.{Figure 1}{Figure 2}{Figure 3}

 Discussion



Sinus is a blind-ending tract leads from an epithelial surface into the surrounding tissue. Most common cause of discharging neck sinus is developmental defects at birth (thyroglossal cyst, branchial cyst, dermoid cyst, epidermal cyst), and others are post trauma and radiation, or a complication of neck surgery. Infective causes are actinomycosis, chronic osteomyelitis, TB, etc. Thyroidectomy is one of the most frequently performed surgical procedures worldwide. Despite technical advances and high experience of thyroidectomy, postoperative complications cannot be avoided. Skin sinus formation is an extremely rare postthyroidectomy. In 1949, Donato first reported one case of skin sinus formation after thyroidectomy.[1] In 1986, Vesely et al. reported that sinus tract formation in the neck after a subtotal thyroidectomy was a less common complication.[2] Infection, foreign body, surgery procedure, combined disease, and iatrogenic factors may be related with skin sinus formation after thyroidectomy.[3] The incidence of surgical site infection after thyroidectomy ranges from 0.3% to 3.2% per the available literature.[4],[5],[6] The factors which resist infection are well-developed capsule, high iodine content, prosperous lymphatic, and vascular supply of thyroid.[7],[8] Residual thyroid lesion and circumferential interspace infection are possible causes of skin sinus formation after thyroidectomy. Jin et al. reported that foreign body–suture reaction was the cause of sinus formation.[3] Total thyroidectomy may reduce the formation of skin sinus effectively. Thyroid swelling because of TB infection is very rare, and difficult to diagnosed because it resembles swelling of carcinoma, cold abscess, multi nodular goiter, rarely like acute abscess, thyroid nodule or lump. TB is an extremely rare cause of sinus formation. Certain tissues that are relatively resistant to TB such as heart, striated muscles, thyroid, and pancreas are rarely encountered.[9] Colloid material of thyroid gland having bactericidal and anti tubercular action is due to increase activity of phagocytes which is seen in hyperthyroid state.[10] We do not find any case report or literature about postoperative skin sinus because of TB infection. According to the literature, frequency of thyroid TB is 0.1%–0.4% in histologically diagnosed specimens.[11] Das et al. reported that the incidence of tuberculous thyroiditis was 0.6% among 1283 thyroid lesions subjected to aspiration cytology.[12] Thyroid function test may be within normal limits in few cases of thyroid swelling, but TB should be kept in mind in the differential diagnosis of nodular lesions of the thyroid.[13] TB of thyroid gland is difficult to distinguish from other inflammations of the thyroid as well as from carcinoma. On histology, many diseases may cause granulomatous inflammation such as granulomatous thyroiditis, fungal infection, TB, sarcoidosis, granulomatous vasculitis, and foreign body reaction. However, caseating necrosis is seen only in tuberculous inflammation.[14] In our case, the patient had two discharging pus sinuses in neck just above the suture line operated for hemithyroidectomy. One sinus contains a suture. We supposed that she was diagnosed with colloid goiter for which left hemithyroidectomy was done. She was taking antibiotic on and off and got temporary relief but not cure completely. We diagnosed that sinuses were complications of surgery because of foreign body reaction of suture. Pus culture showed pseudomonas infection, but histopathology report was in favor of TB. It is a rare case report of discharging neck sinus because of TB infection. Previous literature have emphasized that tuberculosis is a rare cause of thyroid swelling and its resembles swelling of carcinoma thyroid, cold abscess, multinodular goitor, and in rare cases like acute abscess, and cystic nodules so it is very difficult to diagnosed.[15]

 Conclusion



Skin sinus formation is a rare complication of thyroid surgery. Although rare, TB of thyroid gland should be included in differential diagnosis of thyroid swellings and postoperative sinus formation, especially in countries like India, where there is high prevalence of TB.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Donato F. Post-thyroidectomy fistula of the neck caused by a foreign body. Prensa Med Argent 1949;36:2477.
2Vesely DL, Angtuaco EJ, Boyd CM. Sinus tract in the neck: A rare complication of subtotal thyroidectomy for Graves' disease. J Med 1986;17:253-61.
3Jin S, Bao W, Borkhuu O, Yang YT. Clinical study on the etiology of postthyroidectomy skin sinus formation. Surg Res Pract 2017;2017:5283792.
4Chukudebelu O, Dias A, Timon C. Changing trends in thyroidectomy. Ir Med J 2012;105:167-9.
5Dionigi G, Rovera F, Boni L, Castano P, Dionigi R. Surgical site infections after thyroidectomy. Surg Infect (Larchmt) 2006;7 Suppl 2:S117-20.
6Dionigi G, Rovera F, Boni L, Dionigi R. Surveillance of surgical site infections after thyroidectomy in a one-day surgery setting. Int J Surg 2008;6 Suppl 1:S13-5.
7Thada ND, Prasad SC, Alva B, Pokharel M, Prasad KC. A rare case of suppurative aspergillosis of the thyroid. Case Rep Otolaryngol 2013;2013:956236.
8Schweitzer VG, Olson NR. Thyroid abscess. Otolaryngol Head Neck Surg 1981;89:226-9.
9Pandit AA, Joshi AS, Ogale SB, Sheode JH. Tuberculosis of thyroid gland. Indian J Tub 1997;44:205-7.
10Gupta KB, Gupta R, Varma M. Tuberculosis of the thyroid gland. Pulmonary 2008;9:65-8.
11Kukreja HK, Sharma ML. Primary tuberculosis of the thyroid gland. Ind J Surg 1982;44:190.
12Das DK, Pant CS, Chachra KL, Gupta AK. Fine needle aspiration cytology diagnosis of tuberculous thyroiditis. A report of eight cases. Acta Cytol 1992;36:517-22.
13Zendah I, Daghfous H, Ben Mrad S, Tritar F. Primary tuberculosis of the thyroid gland: A case report. Hormones 2008;7:330-3.
14Maitra A. The endocrine system. In: Kumar V, Abbas AK, Fausto N, Aster JC. Robbins and Cotran Pathological Basis of Disease. Vol. 8. Elsevier Publication; 2010. p. 1097-164.
15Modayil PC, Leslie A, Jacob A. Tubercular infection of thyroid gland: A case report. Case Rep Med 2009;2009:416231.