Thoracic outlet syndrome presenting as an isolated external jugular vein engorgement.

To cite: Kaczynski J, Atherton S, Fligelstone L. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2012-008530 DESCRIPTION A 43-year-old man presented to the vascular surgery department with a 3-month history of right external jugular vein engorgement on upper limb elevation. The only medical history included previously sustained (10 years earlier) whip-plash injury following a road traffic accident. Physical examination confirmed external jugular vein engorgement along with reduced shoulder movements due to pain. Both Roos’ and Adson’s tests were positive. The clinical diagnosis of the venous thoracic outlet syndrome (vTOS) was made and subsequently confirmed by various investigations. The thoracic inlet radiograph revealed no abnormalities (figure 1). Ultrasound Duplex scan (UDS) demonstrated compression of the subclavian vein (SCV) under the clavicle on upper limb abduction. MRI showed mild narrowing with degenerative changes at the exit foramina of C6 and C7. Nerve conduction studies were unremarkable. The patient underwent a supraclavicular decompression of thoracic outlet by the first rib excision and scalenectomy (figures 2 and 3). The operative findings confirmed the presence of an abnormal anatomy such as hypertrophied scalene muscles (anterior and middle) and tissue band compressing the SCV and subclavian artery (SCA) (figures 4 and 5). The postoperative chest x-ray excluded a pneumothorax (figure 6). Overall, the patient made an uneventful recovery. This case shows that signs of thoracic outlet syndrome (TOS) can be subtle. Furthermore, various investigations help to confirm the diagnosis of TOS, as well as guide clinicians regarding the treatment options. TOS affects <1% of population and results from compression of the neurovascular structures in the region of the thoracic outlet. The compression can be caused by the cervical ribs, fibromuscular tissue bands, bulky scalene muscles or previous neck trauma. The most important anatomical space in the thoracic outlet is the interscalene triangle, which is bounded by the scalene muscles (anterior and middle), which comprise the sides of the scalene triangle and the first rib forming the base of the triangle. Through this relatively small space, the SCA, SCV and nerves of brachial plexus pass.