Distended External Jugular/Choking

[craigeburns]

Neck Mass

Question

Approximately two years ago I was lifting wts pretty heavily (incline bench) I pushed hard that day, and when I was done I felt, a sharp pain deep in my chest that got my attention, and then shortly thereafter another. For weeks I wasn't really myself, I was tired all the time and it took me a long time to get back to "normal". About a month after the incident I noticed a lump in my neck, about an inch below my adams apple. It was soft, about an inch in diameter and it would stick out about ½ inch with any type of ValSalva maneuver. I'm sure that I've never seen it before. Not quite feeling well, I first went to the Dr. in late May and they put me on antibiotics as they thought that I had "bronchitis" (No CXR, slight fever, normal HR). By the end of July I went back and they worked me up for thyroid with Thyroid Ultrasound (normal)  and bloodwork (normal). All came back normal. I was beginning to notice a substantial cough, from irritation of my trachea. Finally, I requested a CXR (I was afraid I had an aortic aneurysm or something, with the mechanism of injury, wheezing etc. I was a wreck), and they also ordered a CT with contrast. It showed that I had the following:

Chest X-Ray: (2 Views, frontal and lateral) Cardiac silhouette, mediastinum, pulmonary vasculature and lung parenchyma are within normal limits without evidence of focal infiltrate, CHF or effusions. No significant hyperinflation or interstitial changes are appreciated. Impression: No acutedisease.

CT w/contrast This patient does have a very prominent branch of the external jugular which crosses the midline at the level of the thyroid gland and is responsible for this patient's mass. It is a benign venous branch arising from what appears to be a large external jugular. It is simply, however a tortuous collateral. No worrisome mass lesion is seen. I do not see any adenopathy on this examination. Submandibular and parotid glands are normal. Thyroid gland is normal. There does not appear to be significant plaque in the carotids. Superior mediastinum clear. Lung apices clear as well. Impression: This patient does have a venous tortuous collateral arising from the external jugular on the left which crosses the midline and would account for the midline mass. This is not a worrisome mass lesion and would probably have no clinical significance, but may vary in size relative to venous pressure.

So that was it. I had this lump, a vascular anomaly, that still markedly irritates my trachea to severe coughing spells a couple of times per day. Particularly with any type of excessive post nasal drip. Also, when I markedly extend my neck, I feel a "choking…very definite irritation" over my trachea. About 2 inches below my adams apple.  So,….my questions are these:

1.What causes exist for obstruction of EJV? (ie, tumor, aneurysm, mechanical trauma etc)

2.Does compression or obstruction of the EJV lead to collateral formation?

3.What other causes are there for formation of EJV Collateral?)

4.What structures can be irritated by engorged EJV Collateral (i.e., trachea, larynx etc)

5. Are there surgical treatments available?

I had a conversation with one interventional radiologist, who believes that this could have transpired from an "effort induced thrombus". So to my understanding, this would be a clot/blockage which would have caused the need for collateral circulation. Does this increase my risk of a recurrence?...or worse a P.E. of some type? Any help is appreciated.

Thanks;

Craig Burns [phone]

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[kenkeith]

An acute event can open collateral vessels.  You may want to search the archives for more information on collateral.

Your research appears adequate. But  contact your doctor to relate with specificity to your medical conditon.  The doctor will have your medical history, tests, symptoms, etc.

[craigeburns]

Thank you so very much for your input. Even though it's not necessarily info that I embrace,..it makes a little more sense to me than some other feedback that I've recieved. Do you think that if this was any type to clotting issue that it would have been revealed in a CT of the superior mediastinum? (Particularly the theory of some type of effort induced thrombus). Would an infarction of the R ventricle lead to such a sudden collateral formation, and venous distension? (unless it was present before and I just never noticed it). It was a very disconcerting period for me. After this happened I definitely had a period of markedly reduced endurance, for probably 6 to 8 weeks. I also had, what I percieved to be a very sharp pain, in the area of the Jugular that could be reproduced with any significant Val Salva type maneuver (eg. I was inflating a cushion, and the act of simply pushing down on the valve to hold it in place would reproduce this sharp pain the the area,....which would cease as soon as I let up). Anyway,...at this point I am symptom free. I walk 6 miles a day, and jog a couple of miles each night. (no more weight lifting). I still occasionally get the odd feeling of discomfort in the deep jugular area, although there is no corrolation with activity or movement anymore.

[kenkeith]

Your questions are specialized and may be better answered with a doctor on the expert forum (to your right and scroll down).

I can provide some general insight, and it appears you have some knowledge of medical terms so I won't explain the meaning:

The most common cause of elevated jugular venous pressure is an increase right ventricular pressure such as occurs in patients with pulmonary stenosis , pulmonary hypertension, or right ventricular failure secondary to right ventricular infarction. The venous pressure also is elevated when obstruction to right ventricular inflow occurs,such as with tricuspid stenosis or right atrial myxoma, or when constructive pericardial disease impedes right ventricular inflow. It may also result from vena caval obstruction and, at times an increase blood volume. Patients with obstructive pulmonary disease may have an elevated venous pressure only during expiration.

Increased use of internal jugular and subclacian vein as a venous access route has recently caused an increase in prevalence of thrombotic complications of these veins. Cancers, hypercoagulable conditions, infection, peripheral venous lines, intravenous drug abuse and trauma are other well known risk factors for thrombosis of upper extremity and neck veins. Here, we describe a patient who had chronic obstructive pulmonary disease and developed combined thrombosis of left internal jugular and subclavian veins just following prolonged and vigorous coughing bouts. The patient was treated initially with intravenous continuos
heparin infusion and subsequently with oral coumadin with no early complications or late sequels.