Rare left-sided presentation of internal jugular vein ectasia in an adult

A 27- year-old male with no known medical issues was referred to the otorhinolaryngology clinic for anterior neck swelling. He had complained of a solitary swelling over the anterior neck region since the age of 15 years. The swelling was painless and did not increase in size. He denied any history of dysphagia, dyspnea and hoarseness. There was no chronic cough, constitutional symptoms, and he had had normal thyroid function since noticing the swelling. He did not complain of regurgitation after meals and did not have halitosis. No similar presentation was noted among the family members. On examination, there was swelling over the left anterior neck region measuring 5×3 cm with normal skin color. Swelling occurred only during deglutition and the Valsalva maneuver. The swelling was soft, nontender and non-pulsatile. There was no other swelling over the head and neck region (Figure 1). No abnormality was seen on oral examination. Systemic examination, indirect laryngoscopy and thyroid function tests were normal.

Figure 1.

A) Normal neck at rest; B) prominent left neck swelling during Valsalva maneuver (arrow).

CT of the neck found no structural abnormality or outpouching. An ultrasound of the neck was performed at rest and during deglutition. The swelling was prominent only when the patient swallowed. The ultrasound revealed that the left internal jugular vein increased in size during swallowing as well as during the Valsalva maneuver (Figure 2). As the patient was asymptomatic, we decided on conservative management with follow-up visits to monitor his condition, which was diagnosed as internal jugular ectasia. Internal jugular ectasia is frequently missed in the differential diagnosis. It is benign and not commonly seen in adults. The Valsalva maneuver can increase the size of the swelling and it usually involves the right side when intrathoracic pressure increases.^1–4 The exact cause of this condition remains unknown; it is thought that inflammation, injury and straining could be contributing factors,¹ but none were present in the history of our patient. The condition is reported more commonly in males than females. We were conflicted by the presence of the internal jugular vein ectasia on the left instead of the right side. The condition is less common on the left side because of the anatomy of the left internal jugular vein, which is more medially situated and subjected to less stress from an increase in intrathoracic pressure.^1–4

Figure 2.

Ultrasonography of the internal jugular vein (arrow) A) at rest and B) distended during Valsalva maneuver with diameters 0.843 cm and 1.55 cm, respectively.

An appropriate radiological investigation is important for diagnosis and planning for further intervention. Ultrasonography is recommended as the initial screening method especially for younger patients because it is quick, inexpensive, non-invasive and involves no radiation. ^2–5 However, we chose a CT scan instead because our provisional diagnosis was laryngocele and we wanted to identify any structural abnormalities. We found no abnormalities and the diameter of the bilateral internal jugular veins showed no significant difference from one another by intravenous contrast agent. We scanned the patient only once at rest (no increase in intrathoracic pressure) because of the additional radiation exposure of another scan during the Valsalva maneuver. We prefer ultrasonography since dilatation of the internal jugular vein during the Valsalva maneuver can only be appreciated when compared with the resting state. Treatment is indicated if any complications arise; otherwise conservative management is recommended.^1–3