Multiple venous aneurysms of neck.

Venous aneurysm of neck is a rare anomaly, usually presenting as a painless mass which increases in size on valsalva maneuver. A child with multiple aneurysms of the right common facial and external jugular veins diagnosed on Doppler ultrasonography and magnetic resonance venography is reported.

INTRODUCTION

Venous aneurysm is an abnormal saccular or fusiform dilatation of vein. It can be primary (congenital) or acquired due to trauma, surgery, infection and tumors. The cause of primary venous aneurysm is uncertain.[1-5] Venous aneurysm of neck in children is a rare entity and usually involves the internal jugular vein. Multiple unilateral cervical venous aneurysms in a child, involving external jugular and common facial vein, have not been previously reported in English literature.

CASE REPORT

An 8-years-old male child presented with two painless cervical swellings in the right side slowly increasing in size over the last few months as he started to learn singing. There was no prior history of trauma or surgery. They were soft, compressible and non pulsatile. The larger swelling was in the upper part of anterior triangle of right side of neck and smaller one in the lateral aspect of right supraclavicular region measuring approximately 3 × 2 cm and 2 × 1 cm respectively. The swellings enlarged on valsalva maneuver [Figure 1]. A provisional diagnosis of laryngocele was made for the larger swelling considering the history with the differential diagnosis of venous aneurysm and superior mediastinal mass considering their number, locations and response to valsalva. The chest radiograph was normal. Doppler ultrasound showed three well defined, compressible cystic lesions with venous flow, the largest one communicating with the internal jugular vein [Figure 2] and the smaller ones with the upper part (not clinically evident) and lower part of external jugular vein. The left neck veins were normal. These findings suggested venous aneurysms of right internal and external jugular veins. Magnetic resonance venography (MRV) done with 10 ml of intravenous gadolinium-based contrast agent revealed aneurysm of common facial vein, which drained into internal jugular vein and two aneurysms of external jugular vein [Figure 3].

Figure 1

An 8 year old child with two swellings in the right side of neck enlarging on valsalva maneuver

Figure 2

Doppler ultrasound showing venous aneurysm communicating with the internal jugular vein

Figure 3

Coronal 3D TRICKS MR Venography image showing aneuryms of common facial vein [arrow] and external jugular vein [orange and blue asterisks]

DISCUSSION

Neck swellings are a common complaint in children. Among the various differential diagnosis, laryngocele, superior mediastinal mass and venous aneurysm enlarge on valsalva maneuver.

Venous aneurysm is a rare cause of neck mass in children. Histopathologically, there is thinning of the elastic and muscular layers causing congenital fragility.[45] It can involve any vein in the neck, most commonly the internal jugular vein.[3-5] It generally presents as a soft, painless neck swelling which increases on straining, coughing or valsalva maneuver.

Ultrasound with Doppler, multidetector computed tomography (MDCT) angiography, magnetic resonance venography (MRV) are the non-invasive imaging techniques utilised for diagnosis.[4-7] It was interesting to find aneurysms of both common facial and external jugular veins in the same side in our patient which, to the best of our knowledge, has not been reported.

Venous aneurysm of neck is a benign, self-limiting condition and complications like thrombosis, embolism, rupture, thrombophlebitis are rarely reported.[1-5] Careful follow up is most important, so we have advised the patient voice rest and kept the patient on follow up. Surgery may be required for cosmetic ground, discomfort, pressure symptoms or thrombosis. Karapolat et al.[4] suggested that surgery should be considered owing to the risk of thrombosis leading to pulmonary embolism and rupture. Tangential or total excision of the aneurysm may have to be done. In total excision, ligation of the involved vein or its by-pass with a graft is done depending on the feasibility to sacrifice the involved vein. For thrombosis, angioplasty or percutaneous thrombectomy may be done.

The importance of the case lies in the fact that one needs to remember this entity while discussing the differential diagnosis of other neck swellings which occur far more frequently particularly the conditions with similar clinical features like laryngocele, mediastinal mass with neck vein engorgement etc. Also of importance is the fact that one needs to adopt a conservative approach in managing such lesions and this is possible only when there is awareness.