Letter to the Editor Diagnostic Criteria of Pediatric Internal Jugular Phlebectasia
read the study of Eksioglu et al1 with great interest. The most common cause of a neck swelling increasing in size during straining would be a laryngocele, although internal jugular phlebectasia (IJP) must be kept in mind as the differential diagnosis. Diagnosis of IJP is confirmed on the basis of ultrasonography combined with Doppler flow imaging or CT scanning with contrast.2 Eksioglu et al1 examined 88 normal children and 21 pediatric IJP patients: 11 with right IJP, 8 with left IJP, and 2 with IJP on both sides. They found 220 mm2 to be the cutoff value for the cross-sectional area (CSA) of the right internal jugular vein (IJV) during the Valsalva maneuver (VM) for diagnosis of IJP by sonographic measurement; this cutoff value had a sensitivity of 92.3% and specificity of 92%. Two previous articles have mentioned the CSAs of pediatric IJP patients determined during the VM.2,3 Jeon et al2 reported that the CSAs of the IJV in three pediatric IJP patients averaged about 300 mm2, and a second study reported that, in a 4-year-old girl with IJP, the IJV was 20 mm in the transverse direction and 30 mm along the longitudinal axis during the VM; thus, the CSA was about 470 mm2.3 Because of the limited number of references allowed in letters to the editor, I cannot present more IJP patients; however, from these previously reported results, it appears that a CSA cutoff value of 220 mm2 or higher is appropriate for diagnosis of IJP. In the study by Eksioglu et al,1 the CSA during the VM was 328.77 6 142.25 (possible range, 45–612) mm2 in the 11 right IJP patients and 393.57 6 272.93 (possible range, 0–849) mm2 in the 8 left IJP patients. These ranges seem quite wide. I would like to know what percentage of CSAs during the VM in
I
these IJP patients exceeded 220 mm2. From the reported sensitivity of 92.3% and specificity of 92%, I think this would be 9 or 10 of the 11 CSAs in the case of right IJP and 7 of 8 CSAs in the case of left IJP. In another article, Eksioglu et al presented the CSA values of the IJV during the VM among 236 normal pediatric subjects.4 They stated that the normal value is important for diagnosing pediatric IJP. The CSAs of the right IJV during the VM exceeded 220 mm2 in about 26 of the 236 normal subjects.4 These 26 children are highly likely to have IJP on the basis of this criterion. Therefore, I wish to know why these 26 children were diagnosed as normal. In conclusion, we may need to examine more patients or conduct larger studies to determine the CSA cutoff value for the diagnosis of pediatric IJP. Kenji Kayashima, MD Department of Anesthesia Japan Community Health Care Organization Kyushu Hospital, Kitakyushu 806-8501 Fukuoka, Japan
REFERENCES 1. Eksioglu AS, Senel S, Cinar G, et al. Sonographic measurement criteria for the diagnosis of internal jugular phlebectasia in children. J Clin Ultrasound 2013;41:486. 2. Jeon CW, Choo MJ, Bae IH, et al. Diagnostic criteria of internal jugular phlebectasia in Korean children. Yonsei Med J 2002;43:329. 3. Hung T, Campbell AI. Surgical repair of left internal jugular phlebectasia. J Vasc Surg 2008;47: 1337. 4. Eksioglu AS, Tasci Yildiz Y, Senel S. Normal sizes of internal jugular veins in children/adolescents aged birth to 18 years at rest and during the Valsalva maneuver. Eur J Radiol 2014;83:673.
J Clin Ultrasound 43:47, 2015; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu. 22237 C 2014 Wiley Periodicals, Inc. V
VOL. 43, NO.1, JANUARY 2015
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read the study of Eksioglu et al1 with great interest. The most common cause of a neck swelling increasing in size during straining would be a laryngocele, although internal jugular phlebectasia (IJP) must be kept in mind as the differential diagnosis. Diagnosis of IJP is confirmed on the basis of ultrasonography combined with Doppler flow imaging or CT scanning with contrast.2 Eksioglu et al1 examined 88 normal children and 21 pediatric IJP patients: 11 with right IJP, 8 with left IJP, and 2 with IJP on both sides. They found 220 mm2 to be the cutoff value for the cross-sectional area (CSA) of the right internal jugular vein (IJV) during the Valsalva maneuver (VM) for diagnosis of IJP by sonographic measurement; this cutoff value had a sensitivity of 92.3% and specificity of 92%. Two previous articles have mentioned the CSAs of pediatric IJP patients determined during the VM.2,3 Jeon et al2 reported that the CSAs of the IJV in three pediatric IJP patients averaged about 300 mm2, and a second study reported that, in a 4-year-old girl with IJP, the IJV was 20 mm in the transverse direction and 30 mm along the longitudinal axis during the VM; thus, the CSA was about 470 mm2.3 Because of the limited number of references allowed in letters to the editor, I cannot present more IJP patients; however, from these previously reported results, it appears that a CSA cutoff value of 220 mm2 or higher is appropriate for diagnosis of IJP. In the study by Eksioglu et al,1 the CSA during the VM was 328.77 6 142.25 (possible range, 45–612) mm2 in the 11 right IJP patients and 393.57 6 272.93 (possible range, 0–849) mm2 in the 8 left IJP patients. These ranges seem quite wide. I would like to know what percentage of CSAs during the VM in
I
these IJP patients exceeded 220 mm2. From the reported sensitivity of 92.3% and specificity of 92%, I think this would be 9 or 10 of the 11 CSAs in the case of right IJP and 7 of 8 CSAs in the case of left IJP. In another article, Eksioglu et al presented the CSA values of the IJV during the VM among 236 normal pediatric subjects.4 They stated that the normal value is important for diagnosing pediatric IJP. The CSAs of the right IJV during the VM exceeded 220 mm2 in about 26 of the 236 normal subjects.4 These 26 children are highly likely to have IJP on the basis of this criterion. Therefore, I wish to know why these 26 children were diagnosed as normal. In conclusion, we may need to examine more patients or conduct larger studies to determine the CSA cutoff value for the diagnosis of pediatric IJP. Kenji Kayashima, MD Department of Anesthesia Japan Community Health Care Organization Kyushu Hospital, Kitakyushu 806-8501 Fukuoka, Japan
REFERENCES 1. Eksioglu AS, Senel S, Cinar G, et al. Sonographic measurement criteria for the diagnosis of internal jugular phlebectasia in children. J Clin Ultrasound 2013;41:486. 2. Jeon CW, Choo MJ, Bae IH, et al. Diagnostic criteria of internal jugular phlebectasia in Korean children. Yonsei Med J 2002;43:329. 3. Hung T, Campbell AI. Surgical repair of left internal jugular phlebectasia. J Vasc Surg 2008;47: 1337. 4. Eksioglu AS, Tasci Yildiz Y, Senel S. Normal sizes of internal jugular veins in children/adolescents aged birth to 18 years at rest and during the Valsalva maneuver. Eur J Radiol 2014;83:673.
J Clin Ultrasound 43:47, 2015; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu. 22237 C 2014 Wiley Periodicals, Inc. V
VOL. 43, NO.1, JANUARY 2015
47
