Spontaneous cervical chyle fistula: A case report.

BACKGROUND: Cervical chylous fistulae are rare complications usually occurring from iatrogenic injury to the thoracic duct. There have been no reported cases of spontaneous chyle leaks in surgical naïve necks.

METHODS: Case report.

RESULTS: A 50 year-old female presented with progressive left neck swelling without fever, dyspnea, or dysphagia. Imaging demonstrated extensive infiltrative changes of the left neck with retropharyngeal fluid extending into strap musculature and the mediastinum. Flexible laryngoscopy revealed posterior pharyngeal wall edema. Differential diagnosis included abscess versus necrotizing fasciitis. Broad-spectrum antibiotics were initiated and she was taken to the OR for neck exploration. Intra-operatively, milky fluid was present around the carotid sheath and in the retropharyngeal space. Fluid analysis demonstrated chylomicrons and triglycerides >2400 mg/dL. Repeat imaging of the neck, chest, and abdomen did not reveal malignancy or obstructive masses. A lymphangiogram showed dilated lymphatic vessels near the cervical thoracic duct. On post-operative day four, the patient was taken back to the OR for thoracic duct ligation and biopsy of nearby tissue. Pathology demonstrated benign lymph nodes with dilated sinusoids. A low-fat diet was started and she was discharged home on hospital day nine. She has followed up regularly with no signs of recurrence.

CONCLUSION: A cervical chylous fistula usually results from iatrogenic injury to the thoracic duct. To our knowledge, this is the first reported case of a spontaneous cervical chyle leak.