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AN35.1-10 | Deep structures in the neck — Part 3
Cervical Rib and Thoracic Outlet Syndrome (AN35.9)
Thoracic Outlet Syndrome — Neurogenic vs Vascular
| Feature | Neurogenic TOS | Vascular TOS |
|---|---|---|
| Structure compressed | Lower trunk of brachial plexus (C8-T1) | Subclavian artery |
| Symptoms | Ulnar border pain, intrinsic muscle wasting, weak grip | Upper limb ischaemia, Raynaud's, cold fingers |
| Signs | Thenar and hypothenar wasting, sensory loss C8-T1 | Absent radial pulse, positive Adson's test, aneurysm |
| Frequency | More common (95%) | Rare (5%) |
| Treatment | Physiotherapy first; surgical rib resection if refractory | Surgical rib resection + vascular repair |
Cervical rib:
- Anomalous rib arising from C7 vertebra (0.5–1% population; bilateral in 50%; more symptomatic in women)
- Articulates with the 1st rib anteriorly (complete) or terminates in fibrous band (incomplete)
- Compresses the lower trunk of the brachial plexus (C8, T1) and/or the subclavian artery (Part 3)
Figure: Cervical Rib and Thoracic Outlet Syndrome (AN35.9)
Thoracic Outlet Syndrome — Neurogenic vs Vascular
| Feature | Neurogenic TOS | Vascular TOS |
|---|---|---|
| Structure compressed | Lower trunk of brachial plexus (C8, T1) | Subclavian artery or vein |
| Prevalence | ~95% of cases | ~5% of cases |
| Presentation | Wasting of small muscles of hand (thenar > hypothenar), pain along medial forearm | Pallor, coolness, claudication (arterial); arm swelling, cyanosis (venous) |
| Key test | Adson test (turn head to affected side, deep breath) | Elevated arm stress test, arteriography |
| Treatment | Physiotherapy first; surgical excision of cervical rib if refractory | Surgical decompression, vascular repair |
Thoracic Outlet Syndrome (TOS) — two types:
| Type | Structure compressed | Presentation |
|---|---|---|
| Neurological (more common) | Lower trunk (C8, T1) | Wasting + weakness of medial forearm/hand muscles; Hypothenar and thenar wasting (T1 > C8); numbness on medial side of forearm/hand (C8, T1 dermatome) |
| Vascular | Subclavian artery/vein | Ischaemia of arm; Raynaud's in young women; subclavian artery post-stenotic dilation; venous TOS → axillary vein thrombosis (effort thrombosis) |
Adson's test: extend the arm, rotate head toward the affected side, deep inspiration → obliterates radial pulse (positive in vascular TOS)
Figure: Thoracic Outlet Syndrome (TOS) — two types:
Treatment: physiotherapy first; surgical resection of cervical rib + fibrous band if refractory.
SELF-CHECK
A. Upper trunk of brachial plexus (C5, C6)
B. Middle trunk of brachial plexus (C7)
C. Lower trunk of brachial plexus (C8, T1)
D. Right phrenic nerve
Reveal Answer
Answer: .
The lower trunk (C8, T1) is the most commonly compressed by a cervical rib. C8, T1 supply the intrinsic hand muscles and the medial cutaneous nerve of forearm. Upper trunk compression (C5, C6) causes Erb's palsy pattern (deltoid, biceps weakness) — not seen here.
SELF-CHECK
A. Right CN III palsy from uncal herniation
B. Interruption of the right cervical sympathetic chain by the Pancoast tumour
C. Right facial nerve palsy
D. Disruption of the hypothalamic sympathetic output
Reveal Answer
Answer: .
Pancoast (superior sulcus) tumour at the lung apex compresses the cervical sympathetic chain → Horner syndrome (ptosis, miosis, anhidrosis). It also often compresses the lower trunk (C8–T1) → wasting of small hand muscles. CN III palsy causes complete ptosis + mydriasis (not miosis) — the opposite pattern.
CLINICAL PEARL
Retropharyngeal abscess — don't miss it: In Indian ENT practice, retropharyngeal abscess (often secondary to TB cervical lymphadenitis or upper respiratory infection in children) presents with fever, neck stiffness, dysphagia, and stridor. The retropharyngeal space lies between the posterior pharyngeal wall and the alar fascia. The danger: infection can spread through the 'danger space' (between alar and prevertebral fasciae) directly into the posterior mediastinum → descending necrotising mediastinitis (mortality >40% without surgery). Diagnosis: lateral soft-tissue X-ray of neck shows widening of the prevertebral soft tissue (>7 mm at C2, or >14 mm at C6 in adults). CT neck with contrast is definitive. Treatment: urgent surgical drainage + IV antibiotics + airway management.