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A sudden pain in the neck: an atypical presentation of cystic lymphangioma
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  1. Melanie Dowling1,
  2. Tracey Ellis2
  1. 1Tameside General Hospital, Manchester, UK
  2. 2Department of ENT, Tameside General Hospital, Manchester, UK
  1. Correspondence to Melanie Dowling, melanie.dowling{at}doctors.org.uk

https://doi.org/10.1136/bcr-2015-209505

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    Description

    A 12-year-old girl presented with a 4 h history of pain and sudden onset neck swelling. There were preceding symptoms of a mild upper respiratory tract infection. On examination there was a fluctuant tender swelling extending into the anterior and posterior triangles (levels III, IV and V; figures 1). Skin erythaema occurred 24 h following onset of swelling. Laboratory results reported a white cell count of 13.8 and C reactive protein of 15. During admission she spiked a temperature of 38.5°C. An ultrasound was performed followed by an MRI that reported a multiloculated cystic mass measuring 7.8×2.2×3.2 cm anterior to sternocleidomastoid and abutting the brachiocephlic vein and carotid artery (figures 2 and 3). There was also postcontrast enhancement of surrounding tissue. She received 24 h of intravenous antibiotics then was discharged on oral continuation. At 1-month follow-up the swelling had completely resolved. Should swelling of the lymphangioma recur surgical excision or use of a sclerosing agent would be considered.

    Figure 1
    Figure 1

    (A, B) Clinical photographs showing right anteroposterior triangle swelling.

    Figure 2
    Figure 2

    Coronal view of T2-weighted short-τ inversion recovery MRI with contrast showing a large hyperintense mass, right side of the neck.

    Figure 3
    Figure 3

    Axial view of T2-weighted short-τ inversion recovery MRI with contrast showing a large hyperintense mass, right side of the neck.

    A cystic lymphangioma is a congenital lymphatic malformation that typically presents as a non-tender, slowly expanding, fluctuant mass. Our case unusually describes pain as a presenting symptom likely due to infection and the rapid expansion of the cystic lymphangioma. These swellings are rare in adolescents or adults and are most commonly diagnosed at birth. By the age of 2 90% of cystic lymphangiomas will have become clinically evident.1 Differential diagnoses includes branchial cleft cyst, lipoma, thyroid mass, lymphadenopathy, hamartoma, haemangioma and thyroglossal duct cyst.2

    Learning points

    • Neck swelling due to cystic lymphangioma is rare after the age of 2.

    • Typically they present as gradually expanding non-tender, fluctuant masses.

    • They may atypically present with rapid onset of swelling and pain.

    References

    1. ↵
      1. Mirza B,
      2. Ijaz L,
      3. Saleem M, et al
      . Cystic hygroma: an overview. J Cutan Aesthet Surg 2010;3:139–44. doi:10.4103/0974-2077.74488
      OpenUrlCrossRefPubMed
    2. ↵
      1. Sherman BE,
      2. Kendall K
      . A unique case of the rapid onset of a large cystic hygroma in the adult. Am J Otolaryngol 2001;22:206–10. doi:10.1053/ajot.2001.23430
      OpenUrlCrossRefPubMedWeb of Science
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    Footnotes

    • Contributors MD wrote the article, and TE edited and supervised it.

    • Competing interests None.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.