Thoracic Inlet Obstruction Research Articles

Venous Collateral Pathways in Superior Thoracic Inlet Obstruction: A Systematic Analysis of Anatomy, Embryology, and Resulting Patterns.

OBJECTIVE. For this study, we reviewed 56 standard-of-care CT examinations over a timespan of 2 years from patients with superior thoracic inlet venous obstruction and identified eight thoracic collateral pathways for venous blood return to the right heart. We evaluated each pathway individually from an anatomic and a pathophysiologic perspective for a better understanding of how such pathways form and what patterns can be expected. MATERIALS AND METHODS. All 56 patients were scanned according to our standard CT protocol. Images of the thoracic region were acquired in the craniocaudal direction during breath-holding using a second-generation dual-source CT scanner. Contrast medium was administered via a cubital or antecubital vein; the amount of contrast material ranged from 49 to 81 mL depending on patient body weight. RESULTS. Of the 56 patients, CT showed superior vena cava syndrome exclusively in 22 (39%) patients and showed superior vena cava syndrome and involvement of the left or right brachiocephalic vein or even the subclavian vein in the remaining 34 (61%) patients. We could not find any remarkable feature leading to the formation of only one collateral pathway or to a specific pattern depending on underlying cause or the level or the extent of obstruction. Thus, we believe that there are no specific patterns for how these venous detours form and that they are most probably driven by pressure gradients. CONCLUSION. Recognizing imaging findings associated with venous collateral pathways may prevent misdiagnosis or unnecessary follow-up examinations. Furthermore, knowledge of these collateral pathways and an understanding of the underlying cause can support interventional radiologists and vascular surgeons in planning interventional procedures and revascularization procedures.

The management of thoracic inlet syndrome associated with Hurler's syndrome: a novel surgical technique☆

A 21-year-old male developed significant swelling of his tongue after a respiratory arrest. The patient had a history of Hurler's syndrome. Magnetic resonance imaging (MRI) angiogram delineated that the swelling was due to compression of his internal jugular veins at the level of the first rib, resulting in thoracic inlet obstruction. The standard surgical treatment of thoracic inlet obstruction was not suitable in this patient's case due to his short thick neck and his characteristic Hurler's syndrome body habitus. Therefore, a novel surgical strategy was used to decompress his head and neck vessels. The manubrium was widened using an iliac crest bone graft, stabilised using internal fixation plates and reconstructed with a pectoral muscle flap.

A review of open biopsy for mediastinal masses.

To review the recent experience with biopsied mediastinal lesions in children and to assess the impact of recent advances in imaging and surgical techniques on diagnosis. The clinical and radiological features of 55 patients who had mediastinal biopsies at The Royal Alexandra Hospital For Children (RAHC) over 15 years were reviewed. Fifty-five patients presented to RAHC between 1978 and 1993 with lesions of the mediastinum requiring biopsy of that site. Thirty-one of the 55 (56%) lesions were malignant. Neurogenic tumours were the most common (40%). In order of frequency the following lesions were found: neuroblastoma (15), teratoma (eight), non-Hodgkin's lymphoma (NHL; eight), enteric cyst/duplication (five), ganglioneuroma (five), bronchogenic cyst (three), ganglioneuroblastoma (two), lymphangioma (two), abscess (two), Hodgkin's lymphoma (HL; two), oesophageal granuloma (one), Langerhan's cell histiocytosis (one), congenital fibromatosis (one). Eighty-two per cent of neurogenic tumours were located in the posterior mediastinum, while 75% of teratomas and 100% lymphoid tumours were located anteriorly. Symptoms were generally unhelpful in establishing a specific diagnosis and in 27% of cases the lesions were discovered incidentally. Physical signs, such as thoracic inlet obstruction and neurological findings, were helpful clinically in localizing lesions within the mediastinum. Chest radiography enabled lesions to be subdivided within the mediastinum. This localization, in combination with the age at presentation, predicted the tissue diagnosis. Computerized tomography (CT) and magnetic resonance imaging (MRI) further defined the lesion and demonstrated involvement of adjacent structures. Histology, however, was essential to distinguish benign from malignant lesions. The clinical presentation of mediastinal masses is often non-specific or incidental. Despite recent advances in imaging technology and biopsy techniques, full histological examination is required to exclude malignancy.

Beidseitige Riesenblähzysten bei Lymphangioleiomyomatose der Lunge als seltene Ursache einer Einflußstauung

We report on a 27-year-old female developing acute thoracic inlet obstruction by bilateral pulmonary cysts which arose from pulmonary lymphangioleiomyomatosis and increased with respiratory treatment. Bilateral synchronous bullectomy via median sternotomy was necessary to resolve the life-threatening condition. The most frequent differential diagnoses are tension pneumothorax and pericardial tamponade. Although this case of thoracic inlet obstruction was caused by a rare disease it may serve to recall the therapeutic problems encountered in bullous pulmonary lesions under tension, especially regarding acute volume expansion due to one-way valve mechanism during respiratory treatment or general anaesthesia.

The various presentations of thyroiditis. Diagnostic considerations.

The syndromes of thyroiditis include five disorders. Hashimoto's thyroiditis, the commonest, is an autoimmune disease whose principal manifestations are goiter and hypothyroidism. Subacute granulomatous thyroiditis is probably viral in origin and usually presents with a tender goiter. Subacute lymphocytic thyroiditis is of unknown pathogenesis, but the postpartum form may be autoimmune. Its principal manifestations are goiter and spontaneously reversible hyperthyroidism. Acute suppurative thyroiditis results from bacterial or fungal infection causing abscess. Riedel's struma, a disease of unknown cause, presents with a goiter and thoracic inlet obstruction. Thyroiditis may require differentiation from other diseases. The goiter may resemble that of Graves' disease or thyroid lymphoma. Thyroid nodules may resemble neoplasms. Hyperthyroidism may suggest Graves' disease or other hyperthyroid syndromes with low radioactive iodine uptake. Neck pain can also occur with some thyroid malignancies. Local abscess is usually infectious but may be undifferentiated thyroid carcinoma. Finally, hypothyroidism may be transient or permanent.

Acute Thoracic Inlet Obstruction in Achalasia with Adenoid Cystic and Squamous Cell Carcinoma

Respiratory symptoms due to compression of the trachea by the dilated esophagus in achalasia are extremely rare. A patient is presented whose respiratory manifestations included engorged neck veins and a neck swelling that fluctuated with respiration. He also had two malignant tumors in his dilated esophagus, a squamous cell carcinoma and an adenoid cystic carcinoma.

Thoracic inlet compression due to amiodarone induced goitre

We report a case of amiodarone induced toxic goitre, presenting with thoracic inlet obstruction which required surgical intervention. Though thyrotoxicosis caused by amiodarone is recognised, to our knowledge thoracic inlet compression has not been previously described.

Allescheria boydii infections in the immunosuppressed host

Allescheria boydii, a true fungus frequently isolated from soil, is best known as a causative agent of maduromycosis of the foot. In our report we describe two patients under treatment for acute leukemia who died from rapidly progressive A. boydii infections. One patient had signs of central nervous system infection and was found at autopsy to have had a large brain abscess. The second patient had a cavitary necrotizing pneumonia with thoracic inlet obstruction (Pancoast's syndrome) and failed to show improvement despite treatment with amphotericin B. The clinical spectrum of allescheriasis is reviewed with particular emphasis on its role as a pathogen in the compromised host. Since A. boydii may resemble other fungi morphologically in tissue sections and may produce infections clinically similar to other mycoses, culture of the organism is required for definitive diagnosis. Based on recently reported in vitro susceptibility studies, miconazole may have a future role in the therapy of A. boydii infections which are resistant to presently available antifungal agents.