Thyroid nodules

Thyroid nodules

Definition  :
Thyroid nodules are solid or fluid-filled lumps that form within your thyroid, a small gland located at the base of your neck, just above your breastbone.

The great majority of thyroid nodules aren't serious and don't cause symptoms. Thyroid cancer accounts for a small percentage of thyroid nodules.

You often won't know you have a thyroid nodule until your doctor discovers it during a routine medical exam. Some thyroid nodules, however, may become large enough to press on your windpipe, making it uncomfortable or difficult to swallow.

Treatment options depend on the type of thyroid nodule that you have.

Symptoms:
Most thyroid nodules don't cause signs or symptoms. Occasionally, however, some nodules become so large that they can:

• Be felt
• Be seen, often as a swelling at the base of your neck
• Press on your windpipe or esophagus, causing shortness of breath or difficulty swallowing

In some cases, thyroid nodules produce additional thyroxine, a hormone secreted by your thyroid gland. The extra thyroxine can cause problems such as:

• Sudden, unexplained weight loss
• Nervousness
• Rapid or irregular heartbeat

A few thyroid nodules are cancerous (malignant) but it's difficult to tell which nodules are malignant by symptoms alone. Although size isn't a predictor of whether a nodule is malignant or not, cancerous thyroid tumors are more likely to be large fixed masses that grow quickly.

When to see a doctor
Although most thyroid nodules are noncancerous (benign) and don't cause problems, ask your doctor to evaluate any unusual swelling in your neck, especially if you have trouble breathing or swallowing. It's important to eliminate the possibility of cancer.
Also seek medical care if you develop signs and symptoms of hyperthyroidism, such as:

• Sudden weight loss even though your appetite is normal or has increased
• A pounding heart
• Trouble sleeping
• Muscle weakness
• Nervousness or irritability

Causes:
Several conditions can cause one or more nodules to develop in your thyroid gland:

• Iodine deficiency. Lack of iodine in your diet can sometimes cause your thyroid gland to produce thyroid nodules. But iodine deficiency is uncommon in the United States, where iodine is routinely added to table salt and other foods.
• Overgrowth of normal thyroid tissue. Why this occurs isn't clear but such growth — which is sometimes referred to as a thyroid adenoma — is generally noncancerous (benign) and isn't considered serious unless it's bothersome or causes complications. Some thyroid adenomas (autonomous or hyperfunctioning thyroid nodules) produce thyroid hormones outside of your pituitary gland's normal regulatory influence, leading to an overproduction of thyroid hormones (hyperthyroidism).
• Thyroid cyst. Fluid-filled cavities (cysts) in the thyroid most commonly result from degenerating thyroid adenomas. Often, solid components are mixed with fluid in thyroid cysts. Cysts are usually benign, but they occasionally contain malignant solid components.
• Chronic inflammation of the thyroid (thyroiditis). Hashimoto's disease, a thyroid disorder, can cause thyroid inflammation and enlargement, and reduce thyroid gland activity (hypothyroidism).
• Multinodular goiter. "Goiter" is a term used to describe any enlargement of the thyroid gland, which can be caused by iodine deficiency or a thyroid disorder. A multinodular goiter contains multiple distinct nodules within the goiter but its cause is less clear.
• Thyroid cancer. Although the chances that a nodule is malignant are small, you're at higher risk if you have a family history of thyroid or other endocrine cancers, are younger than 30 or older than 60, are a man, or have a history of radiation exposure, particularly to the head and neck. A nodule that is large and hard or causes pain or discomfort is more worrisome in terms of malignancy.

Complications:
Complications associated with thyroid nodules include:

• Problems swallowing or breathing. Large nodules or a multinodular goiter — an enlargement of the thyroid gland containing several distinct nodules — can interfere with swallowing or breathing.
• Hyperthryoidism. Problems can occur when a nodule or goiter produces thyroid hormone, leading to hyperthyroidism. Hyperthyroidism in turn can result in unintended weight loss, muscle weakness, heat intolerance, and anxiousness or irritability. Potential complications of hyperthyroidism include heart-related complications; weak bones (osteoporosis); and thyrotoxic crisis, a sudden and potentially life-threatening intensification of your signs and symptoms that requires immediate medical care.
• Problems associated with thyroid cancer. If a thyroid nodule is cancerous, surgery is usually required. Generally, most or all of your thyroid gland is removed, after which you'll need to take thyroid hormone replacement therapy for the rest of your life. Most thyroid cancers are found early, though, and have a good prognosis.

Treatments and drugs:
Treatment depends on the type of thyroid nodule you have.
Treating benign nodules
If a thyroid nodule isn't cancerous, there are several treatment options:

• Watchful waiting. If a biopsy shows that you have a benign thyroid nodule, your doctor may suggest simply watching your condition, which usually means having a physical exam and thyroid function tests at regular intervals. You're also likely to have another biopsy if the nodule grows larger. If a benign thyroid nodule remains unchanged, you may never need treatment beyond careful monitoring.
• Thyroid hormone suppression therapy. This involves treating a benign nodule with levothyroxine (Levoxyl, Synthroid, others), a synthetic form of thyroxine that you take in pill form. The idea is that supplying additional thyroid hormone will signal the pituitary to produce less TSH, the hormone that stimulates the growth of thyroid tissue. Although this sounds good in theory, levothyroxine therapy is a matter of some debate. There's no clear evidence that the treatment consistently shrinks nodules or even that shrinking small, benign nodules is necessary.
• Surgery. Occasionally, a nodule that's clearly benign may require surgery, especially if it's so large that it makes it hard to breathe or swallow. Surgery is also considered the best option for people with large multinodular goiters, particularly when the goiters constrict airways, the esophagus or blood vessels. Nodules diagnosed as indeterminate or suspicious by a biopsy also need surgical removal, so they can be examined more thoroughly for signs of cancer.

Treating nodules that cause hyperthyroidism
If a thyroid nodule is producing thyroid hormones, overloading your thyroid gland's normal hormone production levels, your doctor may recommend treating you for hyperthyroidism. This may include:

• Radioactive iodine. Doctors often use radioactive iodine to treat hyperfunctioning adenomas or multinodular goiters. Taken as a capsule or in liquid form, radioactive iodine is absorbed by your thyroid gland, causing the nodules to shrink and signs and symptoms of hyperthyroidism to subside, usually within two to three months.
• Anti-thyroid medications. In some cases, your doctor may recommend an anti-thyroid medication such as methimazole (Tapazole) to reduce symptoms of hyperthyroidism. Treatment is generally long-term and can have serious side effects on your liver, so it's important to discuss the treatment's risks and benefits with your doctor.
• Surgery. If treatment with radioactive iodine or anti-thyroid medications isn't an option, you may be a candidate for surgery to remove your thyroid gland. Surgery also carries certain risks that should be thoroughly discussed beforehand.

Treating cancerous nodules
Treatment for a nodule that's cancerous usually involves surgery.

• Surgery. The usual treatment for malignant nodules is surgical removal, often along with the majority of thyroid tissue — a procedure called near-total thyroidectomy. Risks of thyroid surgery include damage to the nerve that controls your vocal cords and damage to your parathyroid glands — four tiny glands located on the back of your thyroid gland that help control the level of calcium in your blood. After thyroidectomy, you'll need lifelong treatment with levothyroxine to supply your body with normal amounts of thyroid hormone.

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Thyroid cancer

Thyroid cancer

Definition  :
Thyroid cancer occurs in the cells of the thyroid — a butterfly-shaped gland located at the base of your neck, just below your Adam's apple. Your thyroid produces hormones that regulate your heart rate, blood pressure, body temperature and weight.

Although thyroid cancer isn't common in the United States, rates seem to be increasing. Doctors think this is because new technology is allowing them to find small thyroid cancers that may not have been found in the past.

Most cases of thyroid cancer can be cured with treatment.


Symptoms:
Thyroid cancer typically doesn't cause any signs or symptoms early in the disease. As thyroid cancer grows, it may cause:

• A lump that can be felt through the skin on your neck
• Changes to your voice, including increasing hoarseness
• Difficulty swallowing
• Pain in your neck and throat
• Swollen lymph nodes in your neck

When to see a doctor
If you experience any these signs or symptoms, make an appointment with your doctor. Thyroid cancer isn't common, so your doctor may investigate other causes of your signs and symptoms first.

Causes:
It's not clear what causes thyroid cancer. Thyroid cancer occurs when cells in your thyroid undergo genetic changes (mutations). The mutations allow the cells to grow and multiply rapidly. The cells also lose the ability to die, as normal cells would. The accumulating abnormal thyroid cells form a tumor. The abnormal cells can invade nearby tissue and can spread throughout the body.
Types of thyroid cancer
The type of thyroid cancer determines treatment and prognosis. Types of thyroid cancer include:

• Papillary thyroid cancer. The papillary type of thyroid cancer is the most common, making up about 80 percent of all thyroid cancer diagnoses.
• Follicular thyroid cancer. Follicular thyroid cancer also includes Hurthle cell cancer.
• Medullary thyroid cancer. Medullary thyroid cancer may be associated with inherited genetic syndromes that include tumors in other glands. However, most medullary thyroid cancers are sporadic, meaning they aren't associated with inherited genetic syndromes.
• Anaplastic thyroid cancer. The anaplastic type of thyroid cancer is very rare, aggressive and very difficult to treat.
• Thyroid lymphoma. Thyroid lymphoma begins in the immune system cells in the thyroid. Thyroid lymphoma is very rare.

Complications:
Thyroid cancer that comes back
Despite treatment, thyroid cancer can return, even if you've had your thyroid removed. This could happen if microscopic cancer cells spread beyond the thyroid before it's removed. Thyroid cancer recurrence can occur decades after thyroid cancer treatment.
Thyroid cancer may recur in:

• Lymph nodes in the neck
• Small pieces of thyroid tissue left behind during surgery
• Other areas of the body — most often the lungs or the bones

Thyroid cancer that recurs can be treated. Your doctor may recommend periodic blood tests or thyroid scans to check for signs of a thyroid cancer recurrence.

Treatments and drugs:
Your thyroid cancer treatment options depend on the type and stage of your thyroid cancer, your overall health and your preferences.
Most cases of thyroid cancer can be cured with treatment.

Surgery
Most people with thyroid cancer undergo surgery to remove all or most of the thyroid. Operations used to treat thyroid cancer include:

• Removing all or most of the thyroid (thyroidectomy). Surgery to remove the entire thyroid is the most common treatment for thyroid cancer. In most cases, the surgeon leaves small rims of thyroid tissue around the parathyroid glands to reduce the risk of parathyroid damage. Sometimes surgeons refer to this as a near-total thyroidectomy.
• Removing lymph nodes in the neck. When removing your thyroid, the surgeon may also remove enlarged lymph nodes from your neck and test them for cancer cells.

Thyroid surgery is performed by making an incision in the skin at the base of your neck. Thyroid surgery carries a risk of bleeding and infection. Damage can also occur to your parathyroid glands during surgery, later leading to low calcium levels in your body. There's also a risk of accidental damage to the nerves connected to your vocal cords, which can cause vocal cord paralysis, hoarseness, soft voice or difficulty breathing.

Thyroid hormone therapy
After thyroid cancer surgery, you'll take the thyroid hormone medication levothyroxine (Levothroid, Synthroid, others) for life. This pill has two benefits: It supplies the missing hormone your thyroid would normally produce, and it suppresses the production of thyroid-stimulating hormone (TSH) from your pituitary gland. High TSH levels could conceivably stimulate any remaining cancer cells to grow.
You'll likely have blood tests to check your thyroid hormone levels every few months until your doctor finds the proper dosage for you.

Radioactive iodine
Radioactive iodine treatment uses large doses of a form of iodine that's radioactive. Radioactive iodine treatment is often used after thyroidectomy to destroy any remaining healthy thyroid tissue, as well as microscopic areas of thyroid cancer that weren't removed during surgery. Radioactive iodine treatment may also be used to treat thyroid cancer that recurs after treatment or that spreads to other areas of the body.

Radioactive iodine treatment comes as a capsule or liquid that you swallow. The radioactive iodine is taken up primarily by thyroid cells and thyroid cancer cells, so there's a low risk of harming other cells in your body.
Side effects may include:

• Nausea
• Dry mouth
• Dry eyes
• Altered sense of taste or smell
• Pain where thyroid cancer cells have spread, such as the neck or chest

Most of the radioactive iodine leaves your body in your urine in the first few days after treatment. During that time you'll be given instructions for precautions you need to take to protect other people from the radiation. For instance, you may be asked to temporarily avoid close contact with other people, especially children and pregnant women.

External radiation therapy
Radiation therapy can also be given externally using a machine that aims high-energy beams at precise points on your body. Called external beam radiation therapy, this treatment is typically administered a few minutes at a time, five days a week, for about six weeks. During treatment, you lie still on a table while a machine moves around you. External radiation therapy is generally used to treat thyroid cancer that has spread to the bones.

Chemotherapy
Chemotherapy is a drug treatment that uses chemicals to kill cancer cells. Chemotherapy is typically given as an infusion through a vein. The chemicals travel throughout your body, killing quickly growing cells, including cancer cells.
Chemotherapy is not commonly used in the treatment of thyroid cancer, but it may benefit some people who don't respond to other, more standard therapies.

Clinical trials
Clinical trials are studies of new cancer treatments or new ways of using existing treatments. Enrolling in a clinical trial gives you the chance to try out the latest in cancer treatment options, but clinical trials can't guarantee a cure. Ask your doctor whether you might be eligible to enroll in a clinical trial. Together you can discuss the benefits and risks of a trial and decide whether participating in a clinical trial is right for you.

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Thunderclap headaches

Thunderclap headaches

Definition:
Thunderclap headaches live up to their name, grabbing your attention like a clap of thunder. The pain of these sudden, severe headaches peaks within 60 seconds and can start fading after an hour. Some of these headaches, however, can last for more than a week.

Thunderclap headaches are uncommon, but they can be a warning sign of potentially life-threatening conditions — usually having to do with bleeding in and around the brain. That's why it's so important to seek emergency medical attention if you experience a thunderclap headache.

Symptoms:
Thunderclap headaches are dramatic. Symptoms include pain that:

• Strikes suddenly and severely — sometimes described as the worst headache ever experienced
• Peaks within 60 seconds
• Lasts for anywhere between an hour to 10 days
• Can occur anywhere in the head or neck
• Can be accompanied by nausea or vomiting

When to see a doctor
Seek immediate medical attention for any headache that comes on suddenly and severely.

Causes:
Some thunderclap headaches appear as a result of:

• No obvious physical reason

In other cases, potentially life-threatening conditions may be responsible, including:

• Bleeding between the brain and membranes covering the brain
• A rupture of a blood vessel in the brain
• A tear in the lining of an artery (for example, carotid or vertebral artery) that supplies blood to the brain
• Leaking of cerebrospinal fluid which when present is usually due to a tear of the covering around a nerve root in the spine
• A tumor in the third ventricle of the brain that blocks the flow of cerebrospinal fluid
• Death of tissue or bleeding in the pituitary gland
• A blood clot in the brain
• Severe elevation in blood pressure
• Infection such as meningitis or encephalitis

Treatments and drugs:
There's no single treatment for thunderclap headaches because so many potential causes exist. Treatment is aimed at the underlying cause of the headaches — if one is found.

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Thumb arthritis

Thumb arthritis

Definition:
Thumb arthritis is the most common form of osteoarthritis affecting the hand. Also called basal joint arthritis, thumb arthritis occurs when the cushioning cartilage wears away from the adjoining ends of the bones that form your thumb joint (carpometacarpal joint).

Thumb arthritis can cause severe hand pain, swelling, and decreased strength and range of motion, making it difficult to do simple household tasks, such as turning doorknobs and opening jars.
Treatment for thumb arthritis may include self-care measures, splints, medication or corticosteroid injections. If you have severe thumb arthritis, you may need surgery.

Symptoms:
The first and most common symptom of thumb arthritis is pain. Pain occurs at the base of your thumb when you grip, grasp or pinch an object between your thumb and forefinger or use your thumb to apply force — such as when turning a key, pulling a zipper or opening a jar. Eventually, you may even experience pain when not using your thumb.
Other signs and symptoms may include:

• Swelling, stiffness and tenderness at the base of your thumb
• Decreased strength when pinching or grasping objects
• Decreased range of motion
• Enlarged, bony or out-of-joint appearance of the joint at the base of your thumb

When to see a doctor
If you have persistent swelling, stiffness or pain at the base of your thumb, seek medical advice. If your doctor determines that you have thumb arthritis, he or she can work with you to develop a pain management and treatment plan.
Also seek medical advice if you experience side effects — such as nausea, abdominal discomfort, black or tarry stools, constipation, or drowsiness — from arthritis medications.

Causes:
Thumb arthritis usually occurs as a result of trauma or injury to the joint. Some people also develop thumb arthritis in association with osteoarthritis in larger joints.

The basal joint gives the thumb a wide range of motion, allowing you to pinch, grip and grasp objects. The bones in the thumb's basal joint are the first metacarpal bone, which runs through the heel of your hand, and the trapezium (truh-PEE-zee-um), a small bone at the base of your thumb.

In a normal basal joint, cartilage covers the ends of the bones — acting as a cushion and allowing bones to glide smoothly against each other. With thumb arthritis, the cartilage that covers the ends of the bones deteriorates and its smooth surface roughens. The bones then rub against each other, resulting in friction and joint damage.

The damage to the joint may result in growth of new bone along the sides of the existing bone (bone spurs), which can produce noticeable lumps on your thumb joint.

Treatments and drugs:
Your doctor may recommend a combination of treatments, including self-care measures, activity modification, splints, medications and physical therapy. In early stages, nonsurgical treatments are usually effective. In severe cases, surgery may be necessary.

Splints
Your doctor may recommend the use of a splint to support your joint and limit the movement of your thumb and wrist. Splints help:

• Decrease pain
• Encourage proper positioning
• Rest your joint

Depending on your needs, you may wear a splint just at night or throughout the day and night.

Medications
To relieve your pain, your doctor may recommend oral and topical medications, including:

• Acetaminophen (Tylenol, others). Acetaminophen may have fewer side effects than do other pain relievers.
• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, which decrease inflammation and relieve pain, include over-the-counter (OTC) medications such as ibuprofen (Advil, Motrin, others) and naproxen (Aleve, others).
• Prescription pain relievers. These include COX-2 inhibitors (Celebrex), meloxicam (Mobic) or tramadol (Conzip, Ultram, others).

NSAIDs have risks of side effects that increase when used at high doses for long-term treatment. Side effects may include ringing in your ears, gastric ulcers, cardiovascular problems, gastrointestinal bleeding, and liver and kidney damage.

Injections
If a combination of analgesics and splint use isn't effective, your doctor may recommend injecting a long-acting corticosteroid into your basal joint. Corticosteroid injections can offer temporary pain relief and reduce inflammation.

Surgery
If you don't respond to other treatments or if you're barely able to bend and twist your thumb, your doctor may recommend surgery.
You and your doctor can discuss surgical options and select the one best suited to you. Options include:

• Joint fusion (arthrodesis). In arthrodesis, your surgeon permanently fuses the bones in the affected joint to increase stability and reduce pain. The fused joint can then bear weight without pain, but has no flexibility.
• Osteotomy. In this procedure, sometimes called bone cutting, your surgeon repositions the bones in the affected joint to help correct deformities.
• Trapeziectomy. In this procedure, your surgeon removes the trapezium, one of the bones in your thumb joint.
• Joint replacement (arthroplasty). In this procedure, your surgeon removes part or all of the affected joint and replaces it with a graft from one of your tendons. New plastic or metal devices called prostheses also are being developed to replace the joint. Currently, however, doctors prefer to use a tendon arthroplasty.

Each of these surgical procedures can be done on an outpatient basis. After surgery, you can expect to wear a cast or splint over your thumb and wrist for up to six weeks. Once the cast is removed, you may work with a physical therapist to help regain hand strength and movement. Although recovery is slow, you should be able to resume your normal activities within six months of surgery.

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Thrombophlebitis

Thrombophlebitis

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Thrombocytosis

Thrombocytosis

Definition:
Thrombocytosis (throm-boe-sie-TOE-sis) is a disorder in which your body produces too many platelets (thrombocytes), which play an important role in blood clotting. The disorder is called reactive thrombocytosis when it's caused by an underlying condition, such as an infection.

Thrombocytosis may also be caused by a blood and bone marrow disease. When caused by a bone marrow disorder, thrombocytosis is called autonomous, primary or essential thrombocytosis or essential thrombocythemia.

Your doctor may detect thrombocytosis in routine blood test results that show a high platelet level. If your blood test indicates thrombocytosis, it's important for your doctor to determine whether it's reactive thrombocytosis or if you have thrombocythemia, which is more likely to cause blood clots.

Symptoms:
Reactive thrombocytosis rarely causes symptoms. More often, signs and symptoms relate to the underlying condition. If symptoms of reactive thrombocytosis do occur, they may include:

• Headache
• Dizziness or lightheadedness
• Chest pain
• Weakness
• Fainting
• Temporary vision changes
• Numbness or tingling of the hands and feet

When to see a doctor
Because thrombocytosis isn't likely to cause symptoms, you probably won't know you have the condition unless a routine blood test reveals a higher than normal number of platelets. If your blood test results show a high platelet count, your doctor will try to determine the reason.


Causes:

Bone marrow — spongy tissue inside your bones — contains stem cells that can become red blood cells, white blood cells or platelets. Platelets travel through your blood vessels. They stick together to form clots that stop the bleeding when you damage a blood vessel, such as when you get a cut. A normal platelet count ranges from 150,000 to 450,000 platelets per microliter of blood.

If you have thrombocytosis caused by a bone marrow disorder (essential thrombocythemia), your bone marrow overproduces the cells that form platelets (megakaryocytes), releasing too many platelets into your blood. If your blood test results reveal a high platelet count, it's important for your doctor to determine whether you have essential thrombocythemia or reactive thrombocytosis.
Reactive thrombocytosis causes include:

• Acute bleeding and blood loss
• Allergic reactions
• Cancer
• Chronic kidney failure or another kidney disorder
• Exercise
• Heart attack
• Infections
• Iron deficiency anemia
• Removal of your spleen
• Hemolytic anemia — a type of anemia in which your body destroys red blood cells faster than it produces them, often due to certain blood diseases or autoimmune disorders
• Inflammation, such as from rheumatoid arthritis, celiac disease, connective tissue disorders or inflammatory bowel disease
• Major surgery
• Pancreatitis
• Trauma

Medications that can cause reactive thrombocytosis include:

• Epinephrine (Adrenalin Chloride, EpiPen)
• Tretinoin
• Vincristine

Complications:
If your high platelet count results from a bone marrow disease (essential thrombocythemia), rather than reactive thrombocytosis, you may be at risk of developing blood clots, some of which can be life-threatening.

Treatments and drugs:
Treatment for reactive thrombocytosis is directed at the underlying cause. If a recent surgery or an injury that caused significant blood loss is the cause, your elevated platelet count may not last long. If the cause is a chronic infection or an inflammatory disease, your platelet count may remain high until the condition is brought under control. In most cases, your platelet count will return to normal after the underlying cause is resolved.

Removal of your spleen may cause lifelong thrombocytosis. In that case, your doctor may prescribe low-dose aspirin to help prevent bleeding or blood-clotting incidents, although these occur rarely in reactive thrombocytosis.

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Thoracic outlet syndrome

Thoracic outlet syndrome

Definition:
Thoracic outlet syndrome is a group of disorders that occur when the blood vessels or nerves in the thoracic outlet — the space between your collarbone and your first rib — become compressed. This can cause pain in your shoulders and neck and numbness in your fingers.

Common causes of thoracic outlet syndrome include physical trauma from a car accident, repetitive injuries from job- or sports-related activities, certain anatomical defects, such as having an extra rib, and pregnancy. Even a long-ago injury can lead to thoracic outlet syndrome in the present. Sometimes doctors can't determine the cause of thoracic outlet syndrome.

Treatment for thoracic outlet syndrome usually involves physical therapy and pain relief measures. Most people improve with these conservative approaches. In some cases, however, your doctor may recommend surgery.

Symptoms:
Generally, there are three types of thoracic outlet syndrome.

• Neurogenic (neurological) thoracic outlet syndrome. This form of thoracic outlet syndrome is characterized by compression of the brachial plexus. The brachial plexus is a network of nerves that come from your spinal cord and control muscle movements and sensation in your shoulder, arm and hand. In the majority of thoracic outlet syndrome cases, the symptoms are neurogenic.
• Vascular thoracic outlet syndrome. This type of thoracic outlet syndrome occurs when one or more of the arteries and veins under the collarbone (clavicle) are compressed.
• Nonspecific-type thoracic outlet syndrome. This is also called disputed thoracic outlet syndrome or common thoracic outlet syndrome. Some doctors don't believe it exists, while others say it's a common disorder. People with nonspecific-type thoracic outlet syndrome have chronic pain in the area of the thoracic outlet that worsens with activity, but the specific cause of the pain can't be determined.

Thoracic outlet syndrome symptoms can vary, depending on which structures are compressed. When nerves are compressed, signs and symptoms of neurological thoracic outlet syndrome often include:

• Wasting in the fleshy base of your thumb (Gilliatt-Sumner hand)
• Numbness or tingling in your fingers
• Pain in your shoulder and neck
• Ache in your arm or hand
• Weakening grip

Signs and symptoms of vascular thoracic outlet syndrome — compression of one or more of your veins and arteries — can include:

• Discoloration of your hand (bluish color)
• Blood clot under your collarbone (subclavian vein thrombosis)
• Arm pain and swelling, possibly due to blood clots
• Throbbing lump near your collarbone
• Lack of color (pallor) in one or more of your fingers or your entire hand
• Weak or no pulse in the affected arm
• Tiny, usually black spots (infarcts) on your fingers

When to see a doctor
See your doctor if you consistently experience any of the signs and symptoms of thoracic outlet syndrome.


Causes:
In general, the cause of thoracic outlet syndrome is compression of the nerves and blood vessels in the thoracic outlet, just under your collarbone (clavicle). The cause of the compression varies and can include:

• Anatomical defects. Inherited defects that are present at birth (congenital) may include a cervical rib — an extra rib located above the first rib — or an abnormally tight fibrous band connecting your spine to your rib.
• Poor posture. Drooping your shoulders or holding your head in a forward position can cause compression in the thoracic outlet area.
• Trauma. A traumatic event, such as a car accident, can cause internal changes that then compress the nerves in the thoracic outlet. The onset of symptoms related to a traumatic accident often is delayed.
• Repetitive activity. Doing the same thing over and over can, over time, wear on your body's tissue. You may notice symptoms of thoracic outlet syndrome if your job requires you to repeat a movement continuously, such as typing on a computer for extended periods, working on an assembly line or repeatedly lifting things above your head, as you would if you were stocking shelves. Athletes, such as baseball pitchers and swimmers, also can develop thoracic outlet syndrome from years of repetitive movements. If you repeatedly carry heavy loads low on your body (rather than against your chest), you may also notice signs and symptoms of thoracic outlet syndrome.
• Pressure on your joints. Obesity can put an undue amount of stress on your joints, as can carrying around an oversized bag or backpack.
• Pregnancy. Because joints loosen during pregnancy, signs of thoracic outlet syndrome may first appear while you're pregnant.

Complications:
Thoracic outlet syndrome left untreated can cause permanent nerve damage; however, surgery to treat thoracic outlet syndrome is considered risky. This is because the procedure involves dividing a muscle in the neck and removing a portion of the first rib or repairing the brachial plexus nerves. For this reason, most doctors initially recommend a conservative treatment approach



Treatments and drugs:
In most cases, a conservative approach to treatment is effective, especially when the condition is diagnosed early. Treatment may include:

• Physical therapy. You'll learn how to do exercises that strengthen your shoulder muscles to open the thoracic outlet, improve your range of motion and improve your posture. These exercises, done over time, will take the pressure off your blood vessels and nerves in the thoracic outlet.
• Relaxation. Techniques that help you relax, such as deep breathing, can keep you from tensing your shoulders and remind you to maintain good posture.
• Medications. Your doctor may prescribe pain medications, muscle relaxants and anti-inflammatory drugs — aspirin or ibuprofen (Advil, Motrin, others) — to decrease inflammation and encourage muscle relaxation.

If conservative treatments don't improve your symptoms or if you're experiencing signs of significant nerve damage, worsening muscle weakness or incapacitating pain, your doctor may recommend surgery. Your doctor also may recommend surgery if you've been diagnosed with true neurogenic thoracic outlet syndrome, for which surgery is often the only treatment option, and for certain blood vessel complications, such as obstructed blood flow (occlusion) or ballooning of a portion of an artery (aneurysm) due to weakness in the wall of the blood vessel.

Surgical options
Surgery is usually effective in relieving pain associated with thoracic outlet syndrome. It may not be as successful in treating muscle weakness, especially if the condition has gone untreated for an extended period.

A specialist in thoracic surgery or vascular surgery will perform the procedure. All surgical options to treat thoracic outlet syndrome pose a significant risk of injury to the brachial plexus. The most common surgical approaches for thoracic outlet syndrome treatment are:

• Anterior supraclavicular approach. This approach repairs compressed blood vessels. Your surgeon makes an incision just under your neck to expose your brachial plexus region. He or she then is able to look for signs of trauma or may discover fibrous bands contributing to compression near your first (uppermost) rib and can repair any compressed blood vessels.
• Transaxillary approach. In this surgery, your surgeon makes an incision in your chest to access the first rib, then removes a portion of the first rib to relieve compression. The advantage of this type of surgery is that it gives the surgeon easy access to the first rib without disturbing the nerves or blood vessels. But it also means the surgeon has limited access to the area's nerves and vessels, and most fibrous bands and cervical ribs that may be contributing to compression are hidden behind these nerves and blood vessels.

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