Postgrad Med J: first published as 10.1136/pgmj.33.378.180 on 1 April 1957. Downloaded from I 8o BENIGN OBSTRUCTION OF THE SUPERIOR VENA CAVA By A. W. FAWCETT, M.B., F.R.C.S. and B. S. DHILLON, M.B., F.R.C.S.(ENG.), F.R.C.S.(ED.) Royal Infirmary, Sheffield Hunter' was the first to report a case of superior vena cava obstruction. Ehlrich2 et al. and McIntire and Sykes3 have extensively reviewed the world literature. Obstruction of the superior vena cava due to primary endothoracic malignant tumours or aneurysm is not uncommon, accounting for 94 per cent. of our cases, but benign lesions causing obstruction of this vessel are rare Oschner and Dixon4 collected I20 cases of thrombosis of the by copyright. superior vena cava from the world literature. From the available data they concluded that 44 were due to phlebitis, 35 from external com- pression, 28 resulted from mediastinitis and in I3 cases the cause was either unstated or unknown. Of the 44 cases of phlebitis and associated throm- bosis, only io could be termed as idiopathic. In the remaining the underlying aetiological agent named in order of frequency was syphilis, cardiac http://pmj.bmj.com/ disease, pyogenic infections, tuberculosis and trauma. Thrombo-phlebitis arising in the main veins of the upper extremities may spread to involve the superior vena cava. Obstruction of the superior vena cava due to chronic mediastinitis was described by Hallet5 and of the 28 cases in the ... .. ......i.. i i Oschner and Dixon4 series were due to syphilis, on September 28, 2021 by guest. Protected io to tuberculosis, one to pyaeogenic infection, one to trauma and five to unknown aetiology. Erganin and Wade6 reported three cases due to non-specific chronic fibrosing mediastinitis and Tubbs7 reported three cases due to chronic medi- astinitis; in two of his cases the underlying cause could not be discovered. Benign tumours seldom cause superior vena cava obstruction. McArt et al.8 have reported a case of superior vena cava syn- drome produced by retrosternal goitre, while FIG. I. McIntire and Sykes3 could find only two cases of benign tumours in the world literature. Pericardial of the superior vena cava associated with con- bands and adhesions have also been mentioned as stricting bands. sole cause of superior vena cava obstruction. Gray We are presenting three patients with benign and Skinner' have reported two cases ofthrombosis obstruction of the superior vena cava1 Postgrad Med J: first published as 10.1136/pgmj.33.378.180 on 1 April 1957. Downloaded from April 1957 FAWCETT and DHILLON: Benign Obstruction of the Superior Vena Cava i8i B - st; N - : :S: B Wa.:..i.>.eS.. : W eRe. !- 4' ... .. .: ::}. : : .. xU :..:: ..,,: W:::. l..?g-::: E:- EE*:.. ,:S, :4. - :: .. - \\e *:X *br E - -s - .......' w |- :. by copyright. FIG. 2. Physical examination showed that the upper FIG. iB. extremities shared the cyanotic hue of the head Case I and neck, and in contrast the lower extremities A male patient aged 49 years was admitted to were of normal colour. There was swelling of the hospital on March i, I956, with progressive dys- face and neck, and to some extent of both upper pnoea on exertion and pain in the left chest for limbs. The eyes were prominent and the eyelids four months prior to admission. were puffy (Fig. i). The superficial veins in the neck, forehead, both arms and antecubital fossae http://pmj.bmj.com/ Past History were distended and prominent. There were tre- In 1936 he noticed sudden onset of swelling of mendously enlarged, tortuous and prominent veins both upper limbs, face and neck. He was dis- on the anterior aspect of his chest and abdomen tressed by intense headaches, dizziness, tinnitus and the flow in these was from above downwards. and shortness of breath on slight exertion. He A continuous venous ' hum' was audible over the was admitted to a hospital as an emergency with distended veins on ausculation. Heart N.A.D. B.P. I2o/8o. the presumptive diagnosis of Hodgkins' disease on September 28, 2021 by guest. Protected involving the mediastinal glands. He was given a Lungs: There was dullness on percussion over short course of D.X.R. therapy to the superior the apical segment of the left lower lobe with mediastinum, without immediate relief. His absent breath sounds. general condition improved gradually, but the X-ray chest showed a mass occupying the swelling of his upper limbs, head and neck per- apical segment of the left lower lobe (Fig. 2). sisted. Over a period of the next few years The mediastinum was not widened. tremendously dilated tortuous veins appeared over Both diaphragms were mobile. the front of his chest and abdomen. His headaches, Angiocardiogram showed complete obliteration of tinnitus and dizziness became less troublesome, the subclavian and innominate veins and the but he developed slight deafness. He obtained a superior vena cava (Fig. 3). job as a surface worker in a coalmine, doing light work, as heavy physical exertion made him unduly Laboratory Findings short of breath with increased swelling of the face i. Hb. 8o per cent. and neck. 2. W.R. and Kahn negative. Postgrad Med J: first published as 10.1136/pgmj.33.378.180 on 1 April 1957. Downloaded from i82 POSTGRADUATE MEDICAL JOURNAL April I957 Aff::: s FIG. 3. by copyright. FIG. 4. 3. Vital capacity 2.2 litres. 4. Circulation time (Decholin), arm to tongue, thrombus. No lymph glands were seen or palpated 6o seconds. in the superior mediastinum. Venous Pressures Case 2 Upper limb, antecubital fossa. A female patient aged: 34 was admitted to 400 mm. of H20 above the sternal angle. hospital complaining of swelling of the face and The pressure increased to 435 mm. of H20 neck, -breathlessness on exertion, tinnitus, severe http://pmj.bmj.com/ after exercise of the hand and forearm and to ' bursting' headaches and' spots ' before the eyes. 470 mm. of H20 after tying a tourniquet around She was perfectly well until 1948, when she noticed the chest. On deep inspiration the pressure rose progressive breathlessness and swelling of the face to 4I2 mm. of H20- and neck, worse after exertion. She was unable to The venous pressure in the lower extremities do her housework, as the slightest exertion and was I55 mm. of H20 and it fell to I53 mm. of stooping produced violent bursting headaches. H20 after exercise of the leg. On deep inspiration She also noticed prominent veins on the front of the pressure rose to i65 mm. of H20. her chest and around the shoulders. on September 28, 2021 by guest. Protected Bronchoscopy showed the mouth of the apical She was admitted to a hospital in I950, when segment of the left lower lobe to be distorted and superior vena cava obstruction was diagnosed, and narrowed, presumably by a growth. From his moderate dosage of D.X.R. therapy to the superior history and investigations it was concluded that the mediastinum was given, but the treatment-pro- patient had superior vena cava obstruction for the duced no improvement and was discontinued. She past 20 years and his recent illness was due to became pregnant in 195I and went through the carcinoma of the left lower lobe. pregnancy, although at one stage termination of Left pneumonectomy (B.S.D.) was performed pregnancy was considered because of marked on March 29, 1956. At operation it was noticed deterioration in her condition. Her dyspnoea and that he had enlarged intercostal veins. The incapacitating headaches persisted and she was internal mammary vein was not enlarged. The referred to us in November 1954. mediastinum was soft and mobile. The left innominate vein was thickened and its lumen was Physical Examination completely obliterated, presumably by organized An obese woman -who had swelling of the neck, Postgrad Med J: first published as 10.1136/pgmj.33.378.180 on 1 April 1957. Downloaded from April 1957 'AWCE'r'14 and DHILLON: Benign Obstructiontr-BXSc } ;-l is ... ej,of e ............;-'.,:the .......... 0>S,'tSuperior:::: .; }>S a.: ^}.i !:} ........::::...... ......Vena:.}.:: :. ':Pi 0 Cava - ...X t.e::!;v;, e.::::: a- -g..:.e,..R.... .';....' Me. e r eww 5ffi *; ly ; , oSs;X.n. |.. .i. FIG. 5. a.:'. i r: .ila ...... ;.,. ii.'Pe ... '.'.''.;....: r .:::.. :.. , ..r .r.:: .°>.8 .,, .....i iimX... i,,,:. o.S§>N ;-...... .. w.s.;,..tMi ;t<,.8a. !; <,., -i:.. !:;<f. .;.:.i.i.{f...... e::.9l- . by copyright. *1. http://pmj.bmj.com/ FIG. 7. lids were puffy and the retinal veins were prominent and tortuous. Lungs N.A.D. Heart N.A.D. B.P. I45/80. on September 28, 2021 by guest. Protected X-ray chest showed slight broadening of the superior mediastinum to the right and a group of calcified glands in the right paratracheal area. There was a healed tuberculous focus in the apex of the right upper lobe. Fluoroscopy: Right diaphragm was paralysed. Tomograms showed a calcified mass in the right paratracheal area (Fig. 5). FIG. 6. Angiocardiogram showed complete obliteration of the superior vena cava immediately after its face and upper limbs, with cyanotic lips. The commencement (Fig. 6). superficial veins in the neck, on the anterior aspect Infra-red photograph (Fig. 7) showed wide- of the chest and abdomen were distended and meshed, abundant subcutaneous veins. blood flow was from above downwards. The eye- Bronchoscopy revealed no abnormality. Postgrad Med J: first published as 10.1136/pgmj.33.378.180 on 1 April 1957. Downloaded from 184 POSTGRADUATE MEDICAL JOURNAL Aprili 957 Laboratory Findings -+ ~~~~.- i. Hb. 14-5 g./IOO ml. 2. R.B.C. 4I9 m./cu. mm. 3. W.B.C. 9,ooo/cu.