A tense, expanding neck swelling after thyroid or neck surgery is a haematoma compressing the airway, and it is the one ward emergency where the surgical SHO may have to open a wound before the registrar arrives. The Difficult Airway Society, BAETS and ENT UK consensus guideline puts the incidence at 0.45% to 4.2% of thyroid operations, most within the first 24 hours and about half within 6 hours. The answer is recognition by DESATS, an immediate call for senior surgical and anaesthetic help, and SCOOP at the bedside if the airway is compromised.

Key takeaways

  • Post-thyroidectomy haematoma affects 0.45% to 4.2% of patients, mostly within 24 hours and about half within 6 hours, per the DAS, BAETS and ENT UK guideline
  • Observations should be at least hourly for the first 6 hours after thyroid surgery
  • DESATS lists the triggers: difficulty swallowing, early warning score, swelling, anxiety, tachypnoea, stridor
  • Any concern means immediate senior surgical review; any sign of airway compromise means a senior anaesthetist is informed immediately
  • If the airway is compromised, open the wound at the bedside with SCOOP: skin exposure, cut sutures, open skin, open muscles, pack wound
  • A post-thyroid surgery emergency box should be at the bedside, including during transfers, and front-of-neck airway equipment on the ward

How does a neck haematoma after thyroid surgery present?

A neck haematoma after thyroid surgery presents with the DESATS signs: difficulty swallowing or discomfort, a rising early warning score, visible swelling, anxiety or agitation, tachypnoea or difficulty breathing, and stridor. The guideline is clear that any one of these can herald the complication and that the order is not fixed.

In practice the subtle signs come first. A patient who becomes restless, keeps sitting forward, or says the dressing feels tight is telling you about venous and lymphatic obstruction before the airway narrows. Drains do not exclude a haematoma, and the guideline notes that a haematoma can form with drains in place.

What is the immediate management, A to E?

Immediate management of a suspected neck haematoma is to call for help and assess the airway at the same time, because the guideline treats these as concurrent rather than sequential steps.

Airway

Sit the patient up, give high-flow oxygen, and look and listen for stridor, voice change, drooling and desaturation. The guideline states that signs of airway compromise, or concern about a rapidly enlarging swelling, warrant immediate management and an immediate call to a senior anaesthetist.

Breathing and circulation

Respiratory rate, saturations and work of breathing. Intravenous access, bloods including a group and save and clotting, and note the anticoagulant and antiplatelet history. Do not let the bloods delay the next step.

Disability and exposure

Level of consciousness, then take the dressing down and look at the wound. Skin exposure is the first letter of SCOOP for a reason: you cannot judge a swelling through a pressure dressing.

What investigations does a neck haematoma need?

A neck haematoma with airway compromise needs no investigation before treatment; the diagnosis is clinical and the guideline warns that delay is what kills. Bloods, a clotting screen and a group and save are sent, and the venous gas can wait for the anaesthetist.

However, in a patient with a small, soft, non-progressive swelling and no DESATS signs, the plan is senior surgical review and increased frequency of observations rather than imaging. Ultrasound or CT of the neck has no place while the airway is at risk, and the guideline does not recommend imaging in the emergency algorithm.

What is the definitive management of a neck haematoma after thyroid surgery?

Definitive management of a neck haematoma is evacuation and haemostasis in theatre, but when the airway is compromised the guideline recommends decompression at the bedside first using the SCOOP approach.

SCOOP

  • Skin exposure: remove the dressing and expose the whole wound
  • Cut sutures: remove the skin closure, clips or sutures, along the full length
  • Open skin: separate the skin edges
  • Open muscles: open the strap muscles, superficial and deep layers, to release the deep haematoma
  • Pack wound: pack with gauze to control bleeding and go to theatre

The guideline states that if evacuation fails to stabilise the patient or there is further deterioration, tracheal intubation is indicated, and that theatre staff should be told to arrange a timely return to theatre. Intubation should be by a trained and experienced anaesthetist following DAS guidance, with videolaryngoscopy considered for the first attempt and the number of attempts limited; awake tracheal intubation is an option if the presentation allows. In a cannot intubate, cannot oxygenate situation, the guideline prefers scalpel cricothyroidotomy to a cannula technique.

After emergency evacuation, the surgical team, usually the consultant, should talk to the patient about what happened, including after discharge, and offer referral for clinical psychology support.

When do I escalate a neck haematoma, and to whom?

Escalate a suspected neck haematoma immediately and by two routes at once: the senior surgeon, registrar or consultant, must review at once, and if senior surgical review is not immediately available or there is any sign of airway compromise, a senior anaesthetist is informed immediately. The guideline also says to call for help through the local emergency system, which on most wards means the 2222 call.

Say this at the interview as a sequence of names: the nurse pulls the emergency buzzer and puts out the call, you start SCOOP if the airway is compromised, the registrar and anaesthetist are on their way, and theatre is told. A surgical SHO who waits for the registrar before opening a compromised airway has misunderstood the guideline.

What is the interviewer listening for in a neck haematoma scenario?

  • The words airway emergency said in the first sentence, with the time course: most within 24 hours, half within 6
  • DESATS as the recognition list and SCOOP as the action list, both named in full
  • Simultaneous escalation: senior surgeon and senior anaesthetist, plus the emergency call
  • Willingness to open the wound yourself at the bedside if the airway is compromised, and knowledge of the emergency box
  • The follow-through: theatre, then honest communication and psychological support for the patient

What are the common mistakes with a neck haematoma?

The commonest mistake in a neck haematoma scenario is to describe an examination and a set of bloods while the airway closes. The second is to say you would take the patient to theatre without saying what you would do in the ten minutes before theatre is ready.

  • Trusting the drain, when the guideline states drains do not prevent a haematoma
  • Sending the patient for a CT of the neck
  • Opening the skin only and leaving the strap muscles closed, so the deep haematoma is not released
  • Multiple intubation attempts by whoever is nearest, when the guideline asks for an experienced anaesthetist and a limit on attempts
  • Forgetting that the emergency box must travel with the patient during transfers

How this comes up at the CST interview

The CST management and clinical station sets the neck haematoma as a night-time call from the ward about a post-thyroidectomy patient who is anxious with a swollen neck, and the panel wants the SCOOP sequence, the parallel calls and the reasoning behind opening the wound yourself. The DAS, BAETS and ENT UK guideline is the citation. coresurgeryinterview includes this scenario among its 299 questions with AI-marked spoken practice, at /Question-Bank/Sample-Questions.