A warning of a rare complication—delayed tracheal rupture after thyroidectomy: a report of three cases

Introduction

Thyroidectomy is a primary surgical intervention for both benign and malignant thyroid diseases. Although surgery-related mortality is exceedingly rare, tracheal rupture is an exceptionally rare complication of thyroidectomy (0.06%) (1), typically identified and addressed during the operation. However, delayed tracheal rupture is a life-threatening complication that can lead to extensive subcutaneous and mediastinal emphysema, severe respiratory distress, neck infections, mediastinitis, mediastinal abscesses, and potentially fatal outcomes (2). With growing awareness of thyroid health in recent years, the annual number of thyroid operations performed worldwide has continued to rise. Therefore, it is increasingly important to remind surgeons to remain vigilant against this rare but potentially fatal postoperative complication. This article presents three cases of delayed tracheal rupture following thyroidectomy, aiming to share the experiences of various surgeons in managing this complication and to provide insights for its timely recognition, treatment, and prevention. We present this article in accordance with the CARE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-304/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

The first case was a 47-year-old Chinese male diagnosed preoperatively with papillary carcinoma of the right thyroid lobe, who underwent total thyroidectomy with bilateral central lymph node dissection. During the procedure, an ultrasonic scalpel, electrocautery, and bipolar coagulation were employed. On the postoperative day (POD) 5, the patient was readmitted with dyspnea, frequent coughing, and expectoration of copious grayish-brown sputum. Physical examination revealed mildly erythematous and darkened skin around the neck incision, with the skin flap moving synchronously with respiration. Extensive subcutaneous emphysema was noted on the face and neck, accompanied by palpable crepitus. Emergency computed tomography (CT) imaging revealed a disruption in the continuity of the right tracheal wall at the thoracic inlet, accompanied by extensive gas accumulation in the maxillofacial region, neck, mediastinum, and multiple intermuscular planes of the chest wall. Additionally, a significant volume of gas was observed surrounding the esophagus, trachea, and pericardial margins. On the same day, the patient underwent muscle flap wound packing (Figure 1). Postoperatively, intravenous broad-spectrum antibiotics were administered for two weeks, supplemented by symptomatic treatments including antitussives and expectorants. The patient gradually recovered from the neck exploration. However, this patient, in recovery from two operations and complicated by a bilateral pulmonary infection and a tracheal rupture, was assessed by respiratory therapy to have difficulty weaning from the ventilator. Consequently, the management involved performing a tracheostomy, and the patient was discharged with a tracheostomy tube. About five months after discharge, the tracheostomy tube was removed, and the patient resumed a normal life.

Figure 1 Opening the surgical incision reveals a rupture (white arrow) in the anterior wall of the trachea.

The second case concerned a 53-year-old female presenting with a right thyroid lobe nodule. The patient underwent right thyroid lobectomy with isthmusectomy, partial left lobectomy, and bilateral central lymph node dissection. Intraoperative visualization revealed no tracheal injury, with estimated blood loss <50 mL. Total postoperative neck drainage measured 30 mL during the first 48 hours. The drainage tube was removed on POD 3, and the patient was discharged without complications. On POD 9, the patient was readmitted to the hospital with an irritating cough and copious amounts of sputum. Neck CT revealed soft tissue defect between tracheal cartilage rings. The patient was immediately taken to the emergency operating room for tracheal intubation, where the tracheal defect was repaired using a rotational flap of strap and sternocleidomastoid muscles, along with drainage tube placement (Figure 2). The procedure was successful, and prophylactic antibiotics were administered postoperatively. Bacterial cultures of tracheal drainage remained negative for three consecutive days. The patient recovered from delayed tracheal rupture and was discharged approximately one month after the second surgery. Six months after the operation, the patient returned to our center for a follow-up bronchoscopy, which showed that the bronchial mucosal epithelium had covered the cartilaginous rings of the trachea.

Figure 2 Trachea injury (white arrow) identified during the surgery.

The third case was a 54-year-old female patient with a past medical history of no underlying disease other than hypertension. Preoperatively, the patient presented with low-grade fever. Total thyroidectomy and bilateral central lymph node dissection were still performed as planned. On POD 2, the patient developed chest and back pain with progressively worsening stridor and dyspnea. Physical examination revealed that the patient had markedly diminished breath sounds in the right lung, large turbid sounds on percussion, and diminished heart sounds. Her blood pressure fluctuated around 80/60 mmHg and oxygen saturation fluctuated between 80–90%. Emergency CT of the thorax and abdomen revealed significant right pleural effusion (Figure 3). Immediate closed thoracostomy drained approximately 650 mL of xanthochromic fluid, with partial relief of respiratory distress. Persistent hypotension (80/60 mmHg) and refractory hypoxemia (SpO₂ 70–80%) necessitated intensive care unit (ICU) transfer for septic shock management. In the ICU, the patient received endotracheal intubation, anti-infective treatment and close monitoring, supplemented by symptomatic supportive therapy such as nebulization and expectorant cough. During bronchoscopic evaluation, a high-positioned tracheal wall defect was incidentally identified but deemed clinically insignificant given its minimal dimensions. On POD 4, the patient suffered a sudden drop in heart rate, and the voluntary heart rate was restored after immediate bedside cardiopulmonary resuscitation. Blood culture results showed Streptococcus pyogenes infection, and anti-infective treatment with meropenem combined with vancomycin was administered. On POD 7, a small amount of yellowish turbid fluid drained from the patient’s neck incision, and bedside opening of the incision revealed a large amount of yellowish turbid secretion in the wound cavity and covering the entire cavity. Subsequently, repeated saline flushing was performed at the bedside, and a drain was placed. Notably, no air bubbles were seen during the flushing immersion. On POD 11, two hours after removal of the endotracheal tube, the patient again suffered a sudden cardiac arrest and recovered after immediate cardiopulmonary resuscitation, endotracheal intubation, and ventilator-assisted ventilation.

Figure 3 On the postoperative day 2, the patient’s CT showed a large amount of fluid in the right pleural cavity. CT, computed tomography.

Subsequent extubation on day 19 precipitated acute respiratory distress coinciding with new-onset air leakage from the neck wound synchronous with respiration. CT imaging demonstrated progressive pneumomediastinum and cervical subcutaneous emphysema, highly suggestive of tracheal disruption (Figure 4). Surgical re-exploration confirmed two tracheal fistulae: a 1.8 cm × 1.5 cm mid-tracheal defect and a 0.5 cm × 0.6 cm inferior defect at the thyroidectomy site (Figure 5). We placed a tracheal cannula at the bedside from the mid-section leak and with the head end of the cannula over the smaller fistula in the lower section and drained the trauma cavity with highly concentrated saline gauze. On POD 42, the patient’s dyspnea was significantly relieved, all tests returned to normal, and cultures of the neck incision showed no microbial growth. The patient eventually recovered successfully from delayed post-thyroid surgery tracheal rupture and was discharged with a tube.

Figure 4 CT scan on postoperative day 19 revealed tracheal rupture and cervical subcutaneous emphysema. CT, computed tomography.

Figure 5 A large anterior tracheal wall defect seen after bedside opening of the neck incision.

One month after discharge, the patient returned to the hospital for metal cannula extubation, followed by a failed attempt to seal the tracheotomy, and was lost to follow-up.

Discussion

Medically induced tracheal rupture is rare and occurs most of the time during invasive trachea-related procedures such as bronchoscopy or tracheal intubation. As a standard surgical procedure for various thyroid disorders, thyroidectomy has been widely performed. While the overall complication rate is relatively low, delayed tracheal perforation represents an exceptionally rare complication. As of last year, only 25 cases have been reported globally (3). This study presents three cases, demonstrating varied clinical manifestations, severity, and management of this complication. It aims to raise awareness among surgeons and offer insights for anesthesiologists regarding postoperative resuscitation and airway management.

Current research has identified some risks associated with delayed tracheal perforation after thyroidectomy, including in women and toxic goiter. This is due to the recurrent process of hyperplasia, degeneration, and fibrosis that is usually present in multinodular goiters, which are therefore more prone to the presence of dense fibrotic thyroid tissue and its connection to surrounding fibrous tissue, such as the trachea (4). The long-term compression of a toxic goiter causes the tracheal wall to become more fragile when the goiter is large. In addition to this, intraoperative thermal injury, prolonged postoperative positive pressure ventilation with tracheal intubation, and persistent coughing or sneezing may cause delayed tracheal perforation. Azar et al. found that the use of corticosteroids is also a risk factor, as it decreases the body’s immune response to injury and delays wound healing (5).

The blood in the cervical trachea is supplied by the tracheoesophageal branch emanating from the inferior thyroid artery. Suturing and ligating the blood vessels around Berry’s ligament in the vicinity of the trachea during surgical operations or the use of instruments such as an electrosurgical knife can lead to rupture, ischemia, and necrosis of the peritracheal vessels. In particular, stripping of the area during lymph node dissection in the VI region is unavoidable, leading to delayed tracheal necrosis. The risk of injury to this collateral vessel is higher in total thyroidectomy and less likely to occur in partial thyroidectomy (5). Our three cases experienced delayed tracheal rupture 5 to 19 days post-operation. All patients had undergone thyroidectomy to varying extents for papillary thyroid carcinoma, and the underlying factors contributing to this complication varied (Table 1). The first two cases are highly likely to be the result of the use of a diathermy device. It also reminds us that when performing peritracheal dissection during thyroid surgery, care should be taken to preserve the lateral tip to maintain the blood supply to the upper segment and that the thyroid branches should be ligated close to the thyroid capsule (6). We assume that the causes of delayed tracheal necrosis in the third case were diverse and complex. The first is that the patient may have had a history of upper respiratory tract infection that was not adequately treated, which coupled with the fact that the surgical procedure was a major blow to the patient, led to immunocompromised status and the seeding and multiplication of opportunistic pathogenic bacteria that promoted infection of the patient’s incision. At the same time, the pulmonary infection may cause persistent coughing or sneezing, which in turn becomes a predisposing factor. In addition, the patient had a long history of continuous tracheal intubation with positive pressure ventilation after being transferred to the ICU, which exposed the patient’s tracheal wall to the pressure of the tracheal intubation sleeve, which could have led to severe injury to the tracheal mucosa. Beyond this, whether the patient was subjected to thermal injury from instruments such as an electrosurgical knife during the surgery is also a potential factor.

Delayed tracheal rupture occurs 4–27 days postoperatively. Typical presentations include subcutaneous emphysema of the cervico-thoracic region and localized or diffuse neck swelling, and patients may also present with signs or symptoms associated with mediastinal emphysema, dyspnea, stridor, cyanosis, and pneumothorax (7-9) Surgeons must be highly vigilant and promptly observe the morphology and structure of the trachea and the surrounding tissues with the help of ultrasound and CT of the neck and other auxiliary examinations to assess the presence of abnormal manifestations such as thinning and defects of the tracheal wall or inflammatory exudation of the surrounding tissues for early diagnosis and differential diagnosis.

Once delayed tracheal rupture is recognized, the patient should be treated immediately. Current interventions fall into two main categories: surgical exploration and conservative treatment. Surgical intervention is indicated in life-threatening conditions such as subcutaneous emphysema, massive pneumothorax, or cardiopulmonary failure (7). Surgical approaches include debridement with primary closure, vacuum-assisted closure (VAC) therapy, tracheal resection with end-to-end anastomosis, and rotational flap repair using muscle flaps such as the sternocleidomastoid, strap muscles, or pectoralis major (10-13), Hemead et al. also reported a patient with extensive invasion and circumferential tracheal necrosis who achieved recovery after anterior mediastinal tracheostomy (AMT) (14). For selected patients with tears located 3 cm above the carina who are hemodynamically stable without infectious complications or ventilatory compromise, Mullan et al. suggest that conservative management may be a viable option (15). Similarly, Windon et al. reported successful recovery in patients treated with bedside incision opening, Penrose drain placement for gas drainage, and pressure dressing application (7). Yang et al. also suggested that conservative therapy could be attempted for selected patients without respiratory distress or progressive respiratory deterioration (16).

There are several important clinical implications and recommendations for surgeons. Firstly, when using energy-based devices (such as the harmonic scalpel) near the thoracic inlet during operation, extreme caution must be exercised to avoid thermal injury to the trachea. Postoperatively, patients should be closely monitored and explicitly instructed to return immediately for evaluation if symptoms such as cough, subcutaneous emphysema, or dyspnea occur. If delayed tracheal rupture is suspected, prompt imaging examinations (e.g., CT scan) should be arranged, and early multidisciplinary consultation involving thoracic surgery, anesthesiology, and ICU is strongly recommended.

Conclusions

Delayed tracheal necrosis after thyroidectomy is a rare but severe complication. Surgeons should evaluate the patient’s physical condition before surgery and carefully dissect and separate the trachea during surgery to avoid damaging the tracheal blood vessels and thermal damage to the tracheal tissues by the electric knife. Postoperatively, the patient should be carefully monitored for signs and symptoms of delayed tracheal necrosis to avoid delays. Once the diagnosis is confirmed, surgical or conservative treatment options can be chosen depending on the patient’s condition.

Acknowledgments

We would like to thank Sichuan Second Hospital of Traditional Chinese Medicine and Leshan People’s Hospital for the support for our study.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-304/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-304/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-304/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Ryo M, Goto S, Hamada K, et al. Airway Management for Tracheal Perforation After Left Hemi-Thyroid Lobectomy: A Case Report. Am J Case Rep 2025;26:e946437. [Crossref] [PubMed]
2. Han X, Mu Q, Liu C, et al. Covered Stent Implantation in the Treatment of Tracheal Rupture after Thyroidectomy. J Vasc Interv Radiol 2016;27:1758-61. [Crossref] [PubMed]
3. Heo DB, Son HO, John Sung HW, et al. Delayed Tracheal Perforation After Thyroidectomy: A Case Report and Literature Review. Ear Nose Throat J 2025;104:68S-73S. [Crossref] [PubMed]
4. Gosnell JE, Campbell P, Sidhu S, et al. Inadvertent tracheal perforation during thyroidectomy. Br J Surg 2006;93:55-6. [Crossref] [PubMed]
5. Azar SS, Patel E, Evans LK, et al. Delayed Tracheal Perforation After Partial Thyroidectomy: A Case Report and Review of the Literature. Ear Nose Throat J 2023;102:NP410-2. [Crossref] [PubMed]
6. Tartaglia N, Iadarola R, Di Lascia A, et al. What is the treatment of tracheal lesions associated with traditional thyroidectomy? Case report and systematic review. World J Emerg Surg 2018;13:15. [Crossref] [PubMed]
7. Windon MJ, Dhillon V, Tufano RP. Case report: presentation of delayed tracheal perforation after hemithyroidectomy. AME Case Rep 2018;2:24. [Crossref] [PubMed]
8. Keditsu K, Dandekar M, Yhome K, et al. Delayed tracheal necrosis presenting with stridor: A rare complication of surgery for differentiated thyroid cancer. Clin Case Rep 2022;10:e6489. [Crossref] [PubMed]
9. Conzo G, Stanzione F, Della Pietra C, et al. Tracheal necrosis, oesophageal fistula: unusual complications of thyroidectomy. Report of two case and literature review. Ann Ital Chir 2012;83:259-64.
10. To EW, Tsang WM, Williams MD, et al. Tracheal necrosis and surgical emphysema: a rare complication of thyroidectomy. Ear Nose Throat J 2002;81:738-41.
11. Philippe G, Pichon N, Lerat J, et al. Successful treatment of anterior tracheal necrosis after total thyroidectomy using vacuum-assisted closure therapy. Crit Care Res Pract 2012;2012:252719. [Crossref] [PubMed]
12. Jacqmin S, Lentschener C, Demirev M, et al. Postoperative necrosis of the anterior part of the cervical trachea following thyroidectomy. J Anesth 2005;19:347-8. [Crossref] [PubMed]
13. Mazeh H, Suwanabol PA, Schneider DF, et al. Late manifestation of tracheal rupture after thyroidectomy: case report and literature review. Endocr Pract 2012;18:e73-6. [Crossref] [PubMed]
14. Hemead H, Patel AJ, Jesani H, et al. Anterior mediastinal tracheostomy - a salvage procedure for tracheal necrosis after thyroidectomy for medullary thyroid cancer: a case-report. World J Surg Oncol 2025;23:14. [Crossref] [PubMed]
15. Mullan GP, Georgalas C, Arora A, et al. Conservative management of a major post-intubation tracheal injury and review of current management. Eur Arch Otorhinolaryngol 2007;264:685-8. [Crossref] [PubMed]
16. Yang X, Wang J, Tang Q, et al. Delayed Tracheal Perforation After Microwave Ablation of Papillary Thyroid Microcarcinoma: A Case Report and Literature Review. Ear Nose Throat J 2025; Epub ahead of print. [Crossref]