BMJ Case Reports 2013; doi:10.1136/bcr-2012-008530

Thoracic outlet syndrome presenting as an isolated external jugular vein engorgement

  1. Louis Fligelstone
  1. Department of Vascular Surgery, ABM University Health Board, Swansea, UK
  1. Correspondence to Jakub Kaczynski, jakub.kaczynski{at}


A 43-year-old man presented to the vascular surgery department with a 3-month history of right external jugular vein engorgement on upper limb elevation. The only medical history included previously sustained (10 years earlier) whip-plash injury following a road traffic accident. Physical examination confirmed external jugular vein engorgement along with reduced shoulder movements due to pain. Both Roos’ and Adson's tests were positive. The clinical diagnosis of the venous thoracic outlet syndrome (vTOS) was made and subsequently confirmed by various investigations. The thoracic inlet radiograph revealed no abnormalities (figure 1). Ultrasound Duplex scan (UDS) demonstrated compression of the subclavian vein (SCV) under the clavicle on upper limb abduction. MRI showed mild narrowing with degenerative changes at the exit foramina of C6 and C7. Nerve conduction studies were unremarkable.

Figure 1

Preoperative thoracic inlet radiograph.

The patient underwent a supraclavicular decompression of thoracic outlet by the first rib excision and scalenectomy (figures 2 and 3). The operative findings confirmed the presence of an abnormal anatomy such as hypertrophied scalene muscles (anterior and middle) and tissue band compressing the SCV and subclavian artery (SCA) (figures 4 and 5). The …

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