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Chylous Fistula of the Neck Workup

  • Author: Philip E Zapanta, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Jan 06, 2015
 

Laboratory Studies

Chyle has unique chemical characteristics that enable easy and accurate diagnosis. It has a high concentration of chylomicrons with high triglyceride (>5 g/L) and low cholesterol concentrations. Furthermore, chyle stains with lipophilic dyes, such as Sudan III, and when mixed with 1-2 mL of ethyl ether, chyle turns from milky to clear fluid.

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Imaging Studies

Radiograph

Chest radiographs in patients with chylous fistula can demonstrate a soft-density opacity at the root of the neck. Chylothorax is an uncommon complication of chylous fistula and may be seen on chest radiographs as a pleural effusion.

CT scanning

CT scanning is used to confirm the presence, site, and extent of a neck collection. However, it is not useful for accurate localization of the thoracic duct injury.

Lymphangiography

Lymphangiography is an invasive procedure used to visualize the lymphatic vessels and thoracic duct as well as to identify the site of a chyle leakage. It requires catheterization of afferent lymph vessels in the foot and is associated with adverse effects such as local tissue necrosis, fat embolism, lymphoedema, and hypersensitivity reaction.

Lymphoscintigraphy

The use of nuclear medicine to identify the site of chyle leakage following thoracic duct injury has become increasingly popular. Lymphoscintigraphy is a quick, noninvasive technique that involves the administration of oral and intravenous water-based radionuclide, the flow of which is traced with a gamma camera or proton-emission scanner. Computer analysis of the data creates images of the lymph flow and determines the speed of uptake, allowing localization of the site of chyle leakage.[14, 15]

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Direct Visualization

Leaks are typically low volume thus making identification difficult. If an intraoperative leak is suspected, the anesthesiologist may apply positive pressure, similar to the Valsalva maneuver, thus increasing intra-abdominal pressure and the flow of the leak. Alternately, manual abdominal compression may be applied.[16]

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Contributor Information and Disclosures
Author

Philip E Zapanta, MD, FACS Associate Professor of Surgery, Otolaryngology Residency Program Director and Medical Education Fellowship Co-Director, George Washington University School of Medicine and Health Sciences; Staff Surgeon, Division of Otolaryngology-Head and Neck Surgery, Medical Faculty Associates

Philip E Zapanta, MD, FACS is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Christian Medical and Dental Associations, Medical Society of the District of Columbia

Disclosure: Nothing to disclose.

Coauthor(s)

Sean B Bury, MD Research Assistant, Division of Otolaryngology–Head and Neck Surgery, Medical Faculty Associates

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Karen H Calhoun, MD, FACS, FAAOA Professor, Department of Otolaryngology-Head and Neck Surgery, Ohio State University College of Medicine

Karen H Calhoun, MD, FACS, FAAOA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, Association for Research in Otolaryngology, Southern Medical Association, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, Society of University Otolaryngologists-Head and Neck Surgeons, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Benoit J Gosselin, MD, FRCSC Associate Professor of Surgery, Dartmouth Medical School; Director, Comprehensive Head and Neck Oncology Program, Norris Cotton Cancer Center; Staff Otolaryngologist, Division of Otolaryngology-Head and Neck Surgery, Dartmouth-Hitchcock Medical Center

Benoit J Gosselin, MD, FRCSC is a member of the following medical societies: American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, North American Skull Base Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario, New Hampshire Medical Society, Ontario Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Gordana Ninkovic, MBBS Specialist Training in Otolaryngology, St George's Hospital

Gordana Ninkovic, MBBS is a member of the following medical societies: British Medical Association, Royal College of Surgeons of Edinburgh, and Royal Society of Medicine

Disclosure: Nothing to disclose.

F Carl van Wyk, MB, ChB, MRCS, FRCS(Edin) ENT Surgeon in Private Practice, George, South Africa

F Carl van Wyk, MB, ChB, MRCS, FRCS(Edin) is a member of the following medical societies: British Association of Otorhinolaryngologists, Head and Neck Surgeons, British Association of Paediatric Otorhinolaryngologists, British Rhinological Society, European Academy of Facial Plastic Surgery, Otorhinolaryngological Research Society, and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Acknowledgments

The authors would like to thank Dr Jeroen DF Kerrebijn from the Eramus Medical Centre in Rotterdam for his permission to use the intraoperative photo, as well as Mr Philip Adds from the anatomy department at St George's Medical School, London, for kindly dissecting a thoracic duct in a cadaveric neck, which enabled us to demonstrate the site of insertion of the duct into venous circulation.

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Intraoperative photo of the thoracic duct low in the neck on the left.
Thoracic duct inserting at the junction of internal jugular and subclavian vein in a cadaveric specimen.
 
 
 
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