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Endgames Case Review

New onset facial swelling

BMJ 2017; 356 doi: (Published 12 January 2017) Cite this as: BMJ 2017;356:i6474

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Re: New onset facial swelling and a second look at the neck veins

In principle, by the time a mediastinal mass has "compresse[d] the superior vena cava to a slit"(1) the neck veins should be engorged. That should be the case notwithstanding the observation that, overall, distension of the neck veins is documented in only 63% of patients with the superior vena cava syndrome(2). The reality behind this statistic is that elevation of the jugular venous pressure is notoriously difficult to evaluate(3)(4), partly because "measurement of jugular venous pressure(JVP) [is] discredited"(4). Testifying to the devaluation of the JVP is the not infrequent documentation of the physiologically meaningless entity of "JVP raised 2cm". When marked elevation of JVP is overlooked, one of the consequences is delay in the diagnosis of constrictive pericarditis(CP), sometimes to the extent that patients with CP-related ascites are misdiagnosed as having cirrhosis of the liver and, consequently, subjected to inappropriate liver biopsy(5). Although neck veins are non-pulsatile in superior vena cava syndrome engorgement of the neck veins in such patients might be just as easy to overlook as engorgement of the neck veins in CP. Accordingly, I would urge the authors of the clinical vignette(1) to take a second look at the neck veins in the reported case
(1) Cuddihy C and O'Rourke N
New onset facial swelling
BMJ 2017;356:i16474
(2)Wilson LD., Detterbeck FC., Yahalom J
Superior vena cava syndrome with malignant causes
N Engl J Med 2007;356:1862-1869
(3) Sinisalo J., Rapola J., Rossinen J., Kupari M
Simplifying the estimation of jugular venous pressure
Am J Cardiol 2007;100:1779-1781
(4) van't Laar A
Why is the measurement of jugular venous pressure discredited?
Netherlands Journal of Medicine 2003;61:268-272
(5)Reed MC., Dhaliwal G., Saint S., Nallamothu K
The right angle
N Engl J Med 2011;364:1350-1356

Competing interests: No competing interests

14 January 2017
oscar,m jolobe
retired geriatrician
manchester medical society
simin building, brunswick street, manchester M13 9PL