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Year : 2003  |  Volume : 13  |  Issue : 1  |  Page : 27-29
Right sided supraclavicular chyloma : Radiographic findings and role of imaging in diagnosis


Department of Radiology and Imaging, University College of Medical Sciences, E-3, GTB Hospital Campus, Dilshad Garden, Delhi-110095, India

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Keywords: Chyloma, Chyle, Lymphangiography, Scintigraphy

How to cite this article:
Bhargava N, Bhatt S, Bhargava S K, Jain S, Gupta P. Right sided supraclavicular chyloma : Radiographic findings and role of imaging in diagnosis. Indian J Radiol Imaging 2003;13:27-9

How to cite this URL:
Bhargava N, Bhatt S, Bhargava S K, Jain S, Gupta P. Right sided supraclavicular chyloma : Radiographic findings and role of imaging in diagnosis. Indian J Radiol Imaging [serial online] 2003 [cited 2020 Feb 24];13:27-9. Available from: http://www.ijri.org/text.asp?2003/13/1/27/28620
The formation of a chyloma is an extremely rare event occurring secondary to either a penetrating trauma to the back or as a complication following blunt tauma [1]

The incidence of injury to the thoracic duct or any of the lymphovenous portals following penetrating trauma is 0.9%. [2]

The thoracic duct lies extra pleurally along the right anterior surface of the vertebral bodies up to the level of the 5th to 7th thoracic vertebrae, then it crosses over to the left side of the mediastinum and lies posterolateral to the oesophagus. A damage below this causes a right sided chylothorax while injury above this level leads to a left sided chyloma or a chylous fistula. The thoracic duct terminates by opening into either the left subclavian or the internal jugular vein near their junction. In some cases it bifurcates, one of them terminating in its usual position, while the other terminates across the midline into the junction of the right subclavian and the jugular vein. In the literature, multiple lymphovenous portals have been described. On the right three main trunks (the jugular, subclavian and the bronchomediastinal trunks) converge towards their venous junctions, while on the left four main trunks (three corresponding to the right sided trunks, but additionally the largest trunk, the thoracic duct). The morphology of these is subject to much variation. In one fifth of the subjects all three fuse to form a short (1cm) single right lymphatic duct [3].

In our case, this chyloma developed in the right supra clavicular region, crossing across the midline posterior to the oesophagus, an unusual location. The injury to any of the main lymphatic channels or the anomalous insertion of the thoracic duct could be the cause for this chyloma.

A middle aged male, victim of a road traffic accident, was admitted to the hospital. On examination, he was drowsy with a 2x2cm laceration and tenderness at the root of the neck with a few bruises on the forehead. Heart rate and BP was 100/min and 110/70 mm Hg respectively. Chest radiograph showed a scapular fracture. Cervical spine radiographs did not reveal any abnormality.

On the second day, the patient complained of swelling in the right supraclavicular region, which on ultrasound examination appeared to be a cystic collection. Adjacent neck vessels appeared normal. A repeat chest x-ray did not show any haemothorax but a soft tissue density was seen at the root of the neck on the right side. This finding led to a CT examination which revealed a negative density collection extending from the retro-esophageal space to the right supraclavicular region. Right IJV showed thrombosis. Rest of the vessels appeared well opacified and normal. Also noted was the aberrant right subclavian artery and the right scapular fracture. The entry track of the penetrating trauma was also identified.

Hence the diagnosis of a right sided chyloma with an aberrant right subclavian artery, fracture scapula and right IJV thrombosis was made. Clinically the diagnosis of chyloma was confirmed on the macroscopic appearance of the haemorrhagic fluid and its physico-chemical analysis. Lymphoscintigraphy revealed accumulation of the radiopharmaceutical agent in the right supraclavicular region.

Lymphangiography, was postponed till the decision for intervention. The patient was conservatively managed with total parenteral nutrition (TPN), allowing no oral intake. Although the chyle has bacteriostatic properties, antibiotic prophylaxis was given. The patient once required transfusion of plasma and blood, as his circulating lymphocytes showed gradual reduction. The neck collection was repeatedly aspirated. The volume of chyle drainage showed gradual reduction. Repeat ultrasound follow ups were done, the volume showed reduction, and the patient was discharged ten days later. No surgical intervention was required.

He had no more related problems and is fit and well at a follow up six months later.

Disruption of the thoracic duct results in the production of chylothorax and or extra pleural chyle collection - called a chyloma.[4]

Congenital malformations of the lymphatic channels may cause chyloma as may a multitude of acquired lesions, including injury to the thoracic duct in the radical neck dissection, blunt and penetrating trauma and as a complication of various diagnostic procedures such as subclavian line insertion, translumbar aortography. Spontaneous chylothorax has been described, as well as non traumatic chylo thorax neoplasms. [4] but development of a chyloma is a rare event [1]. The volume of chyle leak is related to the level of disruption - disruption closest to its entry into the subclavian vein produces the largest chylous loss [5] and hence the maximum lymphopenia and immuno-supression. The diagnosis may be difficult. Plain radiographs may show soft tissue swelling in the neck or mediastinal widening. CT scan on the other hand shows the fluid collection and approximate region of injury, but the thoracic duct is not visualized. Hence the exact site cannot be predicted. CT also enables visualization of the subclavian vein and ijv, which lie in close proximity and are prone to collateral damage.

Lymphangiogram is the best technique available to outline the thoracic duct and delineate the exact level of injury [4]. On the basis of review of literature [5], it is stated that adequate conservative management should initially be the treatment of choice [4]. It includes drainage of the collection and reduction of the chyle production by TPN or by a low fat diet with medium chain triglyceride supplementation. The commonly encountered problem is of immunosuppression following the loss of t lymphocytes, which represents 90% of the circulating lymphocytes, present in the thoracic duct [5].

Empirically, it is generally agreed that surgical correction of a chyloma should be considered before the patient becomes severely malnourished or immunocompromised. [5] Hence it is the role of lymphangiography to exactly delineate the site of injury. Lymphoscintigraphy on the other hand may not identify the exact site due to increased activity in the adjacent collection. In our case we did not do lymphangiography as the patient improved on conservative management and no further investigation was required. But in patients requiring surgery the following options are available:

Supradiaphragmatic thoracic duct ligation or a direct ligation at the level of the fistula but this is usually complicated by difficulty in identifying the leaking site, in which case the identification is facilitated by the use of lymphatic injection of methylene blue [2],[5]. Alternatively pleuroperitoneal shunting or thoracoscopic fibrin glue injection have been tried with success [4]. Postoperatively patients show a good recovery [2].

This report is presented because injury to thoracic duct or any of the lymphovenous portals is extremely rare. It may have varied presentations. However, for a fat density collection in a known case of trauma - the possibility of chyloma /chylo thorax /chylous fistula should be kept in mind. This may become a life saving diagnosis as most patients die within the first few days due to immunosuppression which results as a consequence of chyle leak.

 
   References Top

1.Fitz-hugh, g.s. Cowgill, R; chylous fistula: a complication of neck dissection. Arch otolaryngol., 91: 543-547, 1970.  Back to cited text no. 1    
2.Mark HW, fizan a, vernick jj, rabinovici r: thoracic duct injury in penetrating neck trauma: the American surgeon dec. 1995 vol 61, no. 12 1072-1075.  Back to cited text no. 2    
3.Thoracic duct: gray's anatomy, thirty seventh edition 1989, 841-43.  Back to cited text no. 3    
4.Sunclair D, Woods E, Saibil EA, Taylor ga. 'chyloma' : a persistent post traumatic collection in the left supraclavicular region. The journal of trauma Vol 27 no. 5 may 1987 567-569.  Back to cited text no. 4    
5.Fogli l, Gorini p, belcastro s. conservative management of traumatic chylothorax: a case report. Intensive care medicine 1993 176-177.  Back to cited text no. 5    

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Correspondence Address:
S K Bhargava
Department of Radiology and Imaging, University College of Medical Sciences, E-3, GTB Hospital Campus, Dilshad Garden, Delhi-110095
India
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Source of Support: None, Conflict of Interest: None


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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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