Airway obstruction after the development of Hashimoto’s thyroiditisBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1643 (Published 24 February 2014) Cite this as: BMJ 2014;348:g1643
- Muhajir Mohamed, consultant haematologist; senior lecturer in medicine12,
- Ruchira Fernando, anatomical pathologist3,
- Anurag Arora, trainee registrar1
- 1Department of Medicine, Launceston General Hospital, Launceston, TAS 7250, Australia
- 2University of Tasmania, Launceston Clinical School, Launceston, Australia
- 3Department of Pathology, Launceston General Hospital, Australia
- Correspondence to: M Mohamed
A 67 year old white woman presented to her family doctor in January 2013 with a small asymptomatic thyroid swelling. Her serum thyroid stimulating hormone (TSH) concentration was high (37 mIU/L; reference range 0.5-4.5) and serum free thyroxine was low (5.4 pmol/L; 10-21), consistent with a hypothyroid state. However, she had no clinical features of hypothyroidism. Ultrasonography of the neck showed diffuse hypoechoic enlargement of the thyroid gland, with no retrosternal extension. Her serum anti-thyroid peroxidase (anti-TPO) value was also high (>600 kU/L; <35 kU/L). These features were suggestive of autoimmune (Hashimoto’s) thyroiditis. She was advised to take thyroxine tablets (100 µg) daily, and after two months her neck swelling reduced in size and her serum TSH concentration normalised (1.2 mU/L).
However, four months later she noticed a rapid increase in neck swelling associated with dysphagia for solid foods, hoarseness of voice, and difficulty with breathing, for which she attended the emergency department of our hospital. She was a non-smoker and her medical history included hypertension, for which she was prescribed amlodipine. At that time she was still taking thyroxine and her TSH concentration was normal (2.6 mIU/L).
On examination she had inspiratory stridor, with a respiratory rate of 25 breaths/min and an oxygen saturation of 94% in room air. A large neck mass (10 cm) was visible, predominantly on the right side (fig 1⇓). Her systems examinations were normal and she had no palpable lymphadenopathy. Computed tomography of the neck showed enlargement of the right lobe of the thyroid gland, with narrowing of the larynx at the level of the piriform sinuses (fig 2⇓).