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 history

A 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.

Figure 1.

Photograph and gadolinium enhanced coronal and transverse magnetic resonance imaging of right-sided supraclavicular swelling (CL = cervical lymphocoele; T = trachea; C = level of clavicle)

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.

Under general anaesthesia the lymphocoele was decompressed percutaneously and talc (hydrated magnesium silicate) was infiltrated to sclerose the lining of the cavity. A drain was placed in situ. This was spigotted for two hours to assess for reaccumulation, which did not occur. Post-operatively, the patient was well and discharged the following day with the drain in situ and advised to have a fat free diet. At the follow-up visit two weeks later there was no reaccumulation. There was no further drainage output and the drain was removed without complication. The patient resumed a normal diet. A subsequent follow-up appointment four months later revealed no further recurrence (Fig 2).

Figure 2.

Post-operative photograph demonstrating successful outcome without recurrence at four months

Discussion

A lymphocoele is a benign tumour consisting of a lymphatic collection lined by endothelium. As there is no true epithelial lining or discrete margin, surgical excision can be fraught with difficulties due to the lack of surgical planes.¹ Spontaneous cervical lymphocoeles are extremely rare, particularly on the right side. This can be explained anatomically as the majority of lymph is drained from the lower body by the left-sided thoracic duct while the right is drained by a lymphatic channel 2–5mm in length formed by convergence of the jugular, subclavian and transverse cervical lymph trunks. The right drains the head, neck and upper limb so lymphatic flow is significantly lower.³

Historically and in recent case series, complete surgical excision has been considered the treatment of choice for cervical lymphocoeles. However, for large extensive lymphocoeles there can be significant risk to vascular, neurological and pulmonary structures. The use of sclerotherapy is limited with differing practices and outcomes.¹ As there are currently no randomised controlled trials comparing sclerotherapy with surgical excision for cervical lymphocoeles, the options for treatment remain open.

Sclerotherapy itself is effective in the treatment of congenital cystic neck malformations and has significantly fewer risks.⁴ Bleomycin and OK-432 have both been used as potential sclerosing agents in the head and neck but talc is less well studied. Talc is known to be effective in treating pelvic lymphocoeles⁵ and is a well known and safe sclerosing agent that has been used since 1935. A brief review of the published literature failed to identify any cases demonstrating the use of talc in cervical lymphocoeles.

This case highlights the benefits of using talc sclerotherapy in large cervical lymphocoeles, where the morbidity of surgical excision may be significant. There are significant benefits in terms of reduced hospital stay, post-operative morbidity and a quicker return to normal function.⁴ In this case both options were considered and the patient was made aware of the risks and benefits. Talc sclerotherapy was a successful treatment in the short and long term.

Conclusions

The reported case provides evidence that talc sclerotherapy can be used successfully for cervical lymphocoeles. The technique used was economical, low risk, time saving and avoided the significant morbidity associated with open surgery. Clearly, it would be useful to study the use of talc sclerotherapy in a further cohort of cases to understand the long-term sequelae. It is our opinion that in carefully selected cases of cervical lymphocoeles talc sclerotherapy should be considered in lieu of open surgery.