Background:
Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a novel technique that has gained popularity for its potential to avoid visible scarring. However, it introduces new complications, such as skin and mental nerve injuries. Cervical pneumatocele, an abnormal air collection in the neck, is a rare complication from trachea injury, typically presenting as swelling that increases with speaking and resolves with rest. While this condition is commonly observed intraoperatively or immediately postoperatively, delayed presentation can occasionally occur. Missing the diagnosis can lead to respiratory compromise and potentially be fatal. Here, we present a case of cervical pneumatocele following TOETVA.

Clinical Case:
A 49-year-old Thai woman was diagnosed with a multinodular goiter that had gradually increased in size over the past year with no compressive symptoms. A fine needle aspiration (FNA) performed showed Bethesda II results. Her thyroid function tests were normal. After discussing the risks and benefits, the patient opted to undergo TOETVA due to concerns about scarring. The surgery went well, but the pathology revealed papillary thyroid cancer with capsular invasion, necessitating radioactive iodine ablation. Ten days post-operation, she developed neck swelling and tenderness, which improved with antibiotics. A week later, she noticed a soft, balloon-like sagging under her chin that enlarged with speaking or Valsalva maneuver, suggesting a cervical pneumatocele (Figure 1). Although a CT scan was recommended, the patient declined. Daily telemedicine follow-ups showed that the condition resolved spontaneously within three days. After a year of follow-up, no further complications were found, and the patient achieved an excellent response to differentiated thyroid carcinoma treatment.

Conclusions:
Cervical pneumatocele can occur as a delayed complication following TOETVA and may resolve spontaneously. Tracheal injury is rare but can be exacerbated by prolonged intubation, excessive cautery, infection, and postoperative coughing. Early recognition and CT imaging are key to diagnosis and management.