Biphasic stridor and plethora

A 73 y/o female presented with dyspnea and malaise. Underlying disease of cervical cancer and metastasis to lung/mediastinum/head were found last month. She was scheduled to receive palliative radiotheray next weeek. On inspection, there were facial and bilateral upper limbs flushing, dilated and engorged anterior chest vein. Biphasic stridor was also noted. Here was her chest radiography

 

 

1. What is the possible differential diagnosis ?
        a. Superior vena cava syndrome
        b. Superior mediastinal syndrome
        c. Vocal cord palsy
        d. Trachea stenosis
        e. Portal-A related DVT
        f. Cardiac tamponade

 

2. What is the common etiologies of SVC syndrome ?
       a. •lung cancer, especially small cell, and lymphoma in approximately 90% of cases.
       b. –fibrosing mediastinitis
       c. thrombosis of indwelling central venous devices. 
       d. •Syphilitic aortic aneurysm and tuberculosis use to be common causes in developed countries.


3. What is the common symptoms of SVC ?
       facial or neck swelling(plethora) (82%),
       arm swelling (68%),
       dyspnea (66%),
       cough (50%),
       dilated chest veins (38%),
       orthopnea is commonly noted.
       Facial swelling and plethora, exacerbated when supine and cyanosis can be dramatic.

 

 

4. What is  Pemberton's sign ?
    Pemberton's sign is the development of facial flushing,[1] distended neck and head superficial veins, inspiratory stridor and elevation of the jugular venous pressure (JVP) upon raising both of the patient's arms above his/her head simultaneously, as high as possible (Pemberton's maneuver).

It is named for Dr. Hugh Pemberton, who characterized it in 1946.

5. How to treat ?

    a. corticosteroids and diuretics provide temporay relief

    b. avoid IV catheters placed at upper limbs

    c. radiation therapy is the treatment of choice

Nodules over scalp and forehead were caused by skull metastasis