Endgames Picture Quiz

A man with dilated veins on his upper chest

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d4674 (Published 05 August 2011) Cite this as: BMJ 2011;343:d4674
  1. Sebastian P Wallis, core trainee 21,
  2. Dipan Mistry, specialist registrar1,
  3. Andrew P Coatesworth, ear, nose, and throat consultant2,
  4. Michael Porte, consultant radiologist2
  1. 1Ear, Nose, and Throat Department, York Hospital, York YO31 8HE, UK
  2. 2Radiology Department, York Hospital
  1. Correspondence to: S P Wallis sebwallis{at}hotmail.com

A 77 year old man was referred by his general practitioner because of skin changes over his anterior chest wall (fig 1). These skin changes had been present for several years and were not worsening. He had no history of dysphagia, voice change, shortness of breath, neck pain, neck swelling, or weight loss. His medical history included a goitre treated by radioiodine eight years earlier. He had no other medical history of note, he was not taking any drugs, and he did not smoke.

On examination he appeared well with no stridor. He was haemodynamically normal. Fullness was seen in the lower neck but no discrete lump was palpated. Numerous dilated veins were seen over the upper anterior chest wall on both sides, although they were more pronounced on the right side. He had no cervical lymphadenopathy or cachexia.

Blood tests showed normal thyroid function and thyroid antibodies were not raised. Computed tomography was performed (fig 2). Fine needle aspiration was not performed.

Questions

  • 1 What changes are seen in the photograph?

  • 2 What does the computed tomogram show?

  • 3 What else should you evaluate on the computed tomogram?

  • 4 What are the other potential causes of this condition?

  • 5 What are the management options for this man?

Answers

1 What changes are seen in the photograph?

Short answer

Chronic venous obstruction by a large goitre has led to numerous chest wall collaterals. The right external jugular vein is also dilated.

Long answer

A large …

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