Cervical lymphocoele: a simple solution for a complicated problem

Abstract

Spontaneous cervical lymphocoeles are extremely rare. Their surgical management can pose many challenges with the lack of clear surgical planes potentiating risks. We present the case of a patient with an extensive right-sided cervical lymphocoele. Surgical excision would have involved extensive surgery with risk to the great vessels and lungs. We describe the successful use of talc sclerotherapy in the management of this patient, who made a rapid post-operative recovery with no evidence of recurrence on follow-up. Talc sclerotherapy may be used successfully in the management of patients with cervical lymphocoeles, obviating the need for high risk surgical procedures.Lymphocoeles are subcutaneous lymphatic accumulations lined by an endothelial sac. Primary spontaneous cervical lymphocoeles are extremely rare, the acquired variety occurring more frequently, usually in the context of a traumatic or iatrogenic aetiology.1 They are also predominantly left sided. The exact pathophysiology is elusive. However, there are suggestions that the spontaneous types are a result of congenital weakness.2 The clinical presentation is usually of a fluctuant, asymptomatic cystic swelling of the neck in otherwise healthy individuals. 2 We present the case of a patient with a large complicated spontaneous cervical lymphocoele treated with talc sclerotherapy. Case historyA 35-year-old man was referred to the ear, nose and throat (ENT) clinic with a 12-month history of a right-sided neck lump. There were no other upper aerodigestive tract symptoms. The patient was otherwise fit and well with no other co-morbidities.Examination revealed a large non-tender fluctuant right-sided neck mass in the right supraclavicular region extending below the clavicle (Fig 1). It was not possible to determine the lower extent of the mass. The rest of the ENT examination including the upper aerodigestive tract was normal.Fine needle aspiration revealed a straw coloured aspirate mainly consisting of mature lymphocytes, raising the suspicion of a lymphocoele. Gadolinium enhanced magnetic resonance imaging showed a large unilocular mass lesion, deep to the sternocleidomastoid and extending below the clavicle, inserted between the subclavian vessels without distorting them. The working diagnosis was that of a spontaneous cervical lymphocoele. Surgical excision would involve a combined ENT/cardiothoracic approach, with access to the lower end facilitated by disarticulating the clavicle from the sternum to aid safe dissection from the great vessels. This would carry the risk of significant morbidity. The alternative option would be sclerotherapy. Following a consensus discussion, the plan was to manage this case with sclerotherapy.

Ultrasound-guided sclerotherapy for benign non-thyroid cystic mass in the neck

“…Although resection of a lymphocele accompanied by ligation of the involved lymphatic duct is the standard surgical method, there have been a few reports of sclerotherapy using OK-432 or talc as a treatment of these cysts [33-35]. …”

“…A lymphocele is a benign cyst, usually unilocular, that may occur spontaneously or after trauma or surgery [ 33 ]. Although resection of a lymphocele accompanied by ligation of the involved lymphatic duct is the standard surgical method, there have been a few reports of sclerotherapy using OK-432 or talc as a treatment of these cysts [ 33 - 35 ].…”

Girl With a Sudden Lump in the Neck

“…Although traumatic lymphocele could be due to a sudden weakening of the lymphatic duct wall, consequent expansion, and cyst formation, 1 atraumatic lymphoceles can be due to mild unrecognized trauma or spontaneous appearance, potentially because of a congenital weakness in the duct wall. 2,3 Most patients are asymptomatic, but compression may lead to dysphagia or dyspnea. The differential diagnosis for such neck masses includes congenital cysts and tumors.…”

The Use of Ethanol Sclerotherapy To Treat a Large Cervical Lymphocele

“…Several case reports have described the use of sclerotherapy as an alternative to surgical excision for cervical lymphoceles. Bleomycin, picibanil (OK-432), and talc have all been described as potential sclerosing agents in the head and neck [ 3 , 4 ]. However, research is limited on the use of ethanol as a sclerosing agent for cervical lymphoceles.…”