Question of the Week # 339

339)  A 55 year old man presents to the Emergency Room with complaints of  swelling of his face and worsening cough for the past two days. Swelling increases on lying down. He complaints of shortness of breath for past 2 hours. He has no significant past medical problems.  He smoked about 1 pack per day for the past 25 years and consumes alcohol socially. On examination, he is in moderate respiratory distress with audible, loud Stridor. His face is grossly swollen and the veins over the neck, anterior chest  and the face are engorged. On auscultation, there are no crepitations, s1 and s2 are regular and normal and there is no s3 gallop . A chest X-ray is shown below:

Archer USMLE Step 3


Which of the following is the most appropriate next step in management?

A) Radiation Therapy

B) Chemotherapy

C) CT guided Per-cutaneous Needle Biopsy

D) Video-Assisted Thoracoscopic Surgery (VATS)

E) Epinephrine

9 Responses

  1. E) Epinephrine

    • I’m guessing its

      A) Radiation Therapy

      we need to address the respiratory distress first here…not sure if epinephrine will help much with the respiratory compromise caused by a tumour (Pancoast) so directly give radiation therapy to relieve obstruction??

      Radiation therapy might itself cause swelling resulting further obstruction…so give epinephrine/steroid after radiation??

  2. c

  3. E: patient has difficulty breathing and face swelling, he may have some sort of allergic reaction which progressed to breathing compromise.

  4. radiation therapy

  5. D-its superior venacava obstruction due to pancost tumor

  6. ~E.

  7. Finally I got the answer>…
    SVC syndrome alone is not considered as an emergency unless life threatening condition.
    If the patient condition is stable -> get the diagnosis first, biopsy for further management. If tumor is response to chemo –> chemo, if tumor type is response to radio –> radio Rx. According to histology.
    If the patient condition is unstable and life threatening –> Emergency radiotherapy.
    This patient has loud stridor – that is severe laryngeal odema and it is life threatening — so Emergency Radio therapy should be done.

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