(P113) Rare Presentation of a Cystic Hygroma in an Adolescent Female

Chief Complaint : Increasing neck pain and mass

History of Present Illness : A 15 -year-old Hispanic female, with a past medical history of asthma, presented to our emergency department with a chief complaint of neck pain and a right-sided neck mass, increasing in size for one month. The patient reported increasing pain with neck movement and carrying her backpack over the past month. Denied fever, chills, dysphagia, dyspnea, loss of appetite or weight loss.

Pertinent Physical Exam: Her vital signs were stable and as follows: temperature of 36.4 °C (97.5 °F), heart rate of 97, blood pressure 103/64, respiration rate of 20 and oxygen saturation of 99%. Remarkable exam findings were as follows: comfortable- appearing, obese, adolescent female with a soft, non-pulsatile, nontender, approximately 5x5 cm right-sided neck mass located at the right supraclavicular notch with pain on active ROM. Remainder of the physical exam was unremarkable.

Pertinent Laboratory Data: Further investigations with blood tests revealed no abnormalities and CT chest with contrast revealed a 6.5 x 5.5 x 5.5cm right neck cystic hygroma. Patient was ultimately scheduled to surgically excise the mass one month after initial presentation.

Case Discussion: The etiology of cystic hygroma is not entirely understood. It is thought to arise from a defect in the development of the lymphatic system during fetal development, which results in the formation of abnormal lymphatic tissue. In some cases, genetic factors may also play a role in the development of the condition.

Cystic hygroma is more common in females than males and usually presents in the head and neck region, most commonly in the posterior triangle of the neck. with a strong right-sided predominance. Other locations outside of the head and neck region, including chest wall, and even mesenteric lesions are exceedingly rare. Cystic hygromas in adolescents and adults are rare due to the congenital nature of this pathology. Though cases in these ages are rare, with less than 150 reported cases upon literature review, most are associated with some sort of trauma and located in the head and neck area. Theoretically, given our patient is of school age, repeated microtrauma from backpack usage may have been a proponent to her spontaneous cystic hygroma.

The curative treatment of choice for cystic hygroma is surgical excision. Complete excision is important to prevent recurrence, and is usually more successful in older children and adults. In some cases, cystic hygroma may be unresectable due to the involvement of vital structures, and in such cases, other treatment options such as sclerotherapy or radiation therapy may be considered. Something else to consider is an observation period in select cases if possible, as there is a high complication and recurrence rate associated with intervention. The main complication noted in literature is neurological damage. Various treatment options have their advantages and disadvantages, the selected treatment modality should depend on the patient's individual status and available technology and expertise.

References and Acknowledgements (Optional): Acknowledgements to patient and family for allowing us to learn from this case