Authors: Dr. Amit Aggarwal, (Senior Lecturer), Dr. Sudhanshu Mehta, Dr. Ravinder Singh Sohi, Dr. Isha Singla (P.G Student)Department of oral medicine and radiology, M.M. College of Dental Sciences and Research

Introduction
Venous aneurysms or phlebectasias are rare vascular entities in adults and children.^[1] Jugular phlebectasia is a rare anomaly of the neck veins and is of interest and importance in the differential diagnosis of swellings in the neck. Very few cases are reported in the literature.^[2] It is a benign condition which refers to an isolated abnormal fusiform or saccular dilatation of the jugular vein of unknown etiology.^[3] Dilatation of the internal jugular vein with a Valsava maneuver suggests a mechanical obstruction in the neck or mediastinum.^[4] Phlebectasia of a jugular vein is an unusual neck swelling.^[4] It usually present with a swelling in the posterior triangle of the neck.^[3] Phlebectasia may affect any vein in the neck in the sequence of internal jugular, external jugular, anterior jugular and the superficial communicantes.^[3] Jugular phlebectasia is usually a childhood disease. It is very rare in older patients.^[3] Diagnosis is confirmed on the basis of ultrasonography combined with Doppler flow imaging or computerized tomography scanning with contrast.^[5]

Case Report
A 41-year old lady reported to department of Oral Medicine and Radiology with history of swelling since three years and pain since the past 6 months on the right side anteromedial to the right sternomastoid muscle. There was no history of trauma. The patient had a history of occasional ‘chulha’ blowing. The swelling was initially noticed only on blowing, then there after it appeared on singing, shouting, sitting on knees & any work requiring physical stress. The swelling also appeared on forward bending. Initially pain was of mild degree, but after that there was constant localized dull pain on right side of neck at site of the swelling. The physical examination revealed a soft tissue swelling of size 3 to 3.5 cm on right side of neck anteromedial to the right sternomastoid muscle just above the suprasternal notch. Marked enlargement of the mass occurred on blowing or during the Valsalva maneuver & disappeared on relaxation. No pulsations or bruits were detectable. There was no palpable lymphadenopathy. The physical examination revealed no abnormality except for the findings in the right side of the neck. The clinical impression was that of a laryngocele. On palpation the swelling subsided & could not be palpated in standing position, but it was palpable on forward bending. Patient was sent for the ultrasonography of the swelling. Ultrasonography with color doppler was performed on Logiq 500 pro (GE, USA) with the help of real time linear broadband transducer at 11 Mega Hertz frequency. Images were obtained in the longitudinal and transverse planes. On Ultrasonography, the swelling showed right sided saccular dilatation of external jugular vein with anteroposterior diameter measuring 1.1cm at rest and on Valsalva maneuver diameter increased to 1.8cm. There was no evidence of thrombus in whole of the visualized external jugular vein. Slow flow with valsalva seen as internal echoes in the dilated vein on grey scale and as turbulence on color Doppler examination. Internal jugular vein and carotid vessels were normal. Left sided vessels were normal. The Electrocardiogram, X- ray chest and the routine blood investigations were normal.

Discussion
Gerwig introduced the term phlebectasia to describe an abnormal fusiform or saccular dilatation of a vein to differentiate it from the term "varicose" which implies tortuosity plus dilatation.^[4] Jugular vein phlebectasia is a rare venous anomaly.^[1] It consists of an abnormal dilatation of the jugular vein that is visually presented as a soft and compressible cervical mass that increases the intra-thoracic pressure.^[1] The etiology of jugular phlebectasia is unknown but is presumed to be due to an inherent weakness in the vessel wall.^[6] Incidence is higher on the right side.^[3] Three types of swelling distend on Valsalva and disappear completely at rest: (a) tumors or cyst of the superior mediastinum, (b) external laryngeal diverticulum and laryngocele, and (c) venous enlargement of the superior vena caval system.^[6] Colour-doppler ultrasonography is a noninvasive accurate and readily reproducible imaging technique to distinguish the jugular venous enlargement.^[6] A number of diagnostic techniques have been recommended in the literature including direct needle aspiration, venography, arteriography, computed tomography, ultrasonography, and color Doppler flow imaging. Venography is a choice for diagnosis. This invasive technique is potentially dangerous with complications such as hematoma, perforation of the lesion, thoracic duct injury and pseudoaneursyms. Ultrasonography with Doppler before, during and after Valsalva maneuvre is the preferred method for diagnosis.^[3] No treatment is needed for this benign condition in most of the assymptomatic patients, except for the few patients who complains of symptoms like feeling of constriction, choking, discoloration, thrombosis, discomfort and tongue pain which can be excised without any significant complication.^[7]
Conclusion

Jugular vein phlebectasia is a rare cause of neck swelling.^[8] However, it is under diagnosed, and must be considered in neck swelling cases associated to straining.^[1] Colour-doppler ultrasonography is particularly enough for the diagnosis of jugular phlebectasia.^[6]

References
1. Souza AMv, Guerra AFM., Lima TMA, Duprat AC. Jugular phlebectasia: A cause of neck Swelling - Case report. International Journal of Pediatric Otorhinolaryngology Extra 2008; 3: 158- 60
2. John EL. Jugular Phlebectasia. Postgraduate Medical Journal 1962; 38: 470-3
3. Pandey M, Kumar P, Khanna AK. Phlebectasia of the External Jugular Vein. The Internet Journal of Surgery 2009;19
4. Nwako FA, Agugua NE, Udeh CA, and Osuorji RI. Jugular Phlebectasia. Journal of Pediatric Surgery 1989;24:303-5
5. Jeon CW, Choo MJ, Bae IH, Shin SO, Choi YS, Lee DW, Sim KH. Diagnostic criteria of internal jugular phlebectasia in Korean children. Yonsei Med J. 2002; 43: 329-34
6. Demircan M, Gursoy MH, Uguralp S, Aydinc M, Muezzinoglu B. Jugular Phlebectasia in Children : A Case Report. Turgut Ozal Tip Merkezi Dergisi 1997; 4:107-8
7. Bhalodiya N, Supriya M, Singhania A. Anterior Jugular Phlebectasia. Indian Journal of Otolaryngology and Head and Neck Surgery 2004; 56: 123-4
8. Hughes PL, Qureshi SA, Galloway RW. Jugular venous aneurysm in children. The British Journal of Radiology 1988; 61:1082-4
Figures with legends

Fig I. Extra-oral photograph of the patient	Fig II. Swelling of neck during the Valsalva maneuver	Fig III. Grey scale sonography is showing dilated external jugular vein.

Fig IV. Color doppler sonography is showing flow in the dilated external jugular vein.	Fig V. Grey scale sonography with Valsalva maneuver is showing more dilatation of the external jugular vein with internal echoes suggestive of slow flow.