Physical Exam Findings in Superior Vena Cava Syndrome
The classic physical examination findings in superior vena cava syndrome include facial edema and plethora, dilated neck veins, and a prominent venous pattern on the chest. 1
Cardinal Physical Findings
Facial and Upper Body Changes
- Facial edema and plethora are among the most prominent early signs, presenting as swelling and a ruddy or cyanotic appearance of the face 1, 2
- Neck swelling with distended neck veins is a common presenting sign 1, 2
- Upper body edema affecting the face, neck, breast, and upper extremities represents a cardinal sign of SVC obstruction 2
- Cyanotic facial erythema may be present, particularly in more severe cases 3
Venous Distension Patterns
- Dilated neck veins are a characteristic finding on examination 1, 3
- Prominent venous pattern on the chest with numerous dilated, vertically oriented, and tortuous cutaneous venules or veins above the rib cage margin 1, 4
- These dilated chest wall veins represent collateral circulation attempting to bypass the obstruction 4
Additional Physical Signs
- Proptosis (bulging eyes) may occur due to increased venous pressure 4
- Conjunctival suffusion (redness and swelling of the conjunctiva) can be present 4
- Upper extremity edema affecting the arms bilaterally 2, 3
Less Common but Important Findings
- Hoarseness of voice is a less frequent but concerning sign 2
- Cyanosis of the upper body may be present, particularly in severe cases 2, 3
- Breast edema in the upper chest region 2
Clinical Context
The severity and rapidity of symptom development depends on the acuity of obstruction. When SVC becomes obstructed, blood is forced through smaller collateral vessels to reach the azygos vein or inferior vena cava 2. These venous collaterals dilate over several weeks, causing initially elevated upper body venous pressure that may decrease over time as collaterals develop 2.
Key Examination Pitfalls
- The gradual onset of symptoms and subtlety of physical findings can lead to late diagnosis 1
- Recognition of the characteristic cutaneous venous pattern above the rib cage can lead to early diagnosis, as this often represents the initial manifestation of underlying malignancy 4
- Chest radiographs typically show a widened mediastinum or right hilar mass but may appear normal, so physical examination findings remain crucial 1
Red Flag Physical Findings Requiring Immediate Assessment
- Stridor or severe respiratory distress indicates airway compromise requiring emergent intervention 2
- Confusion, altered mental status, or coma suggests cerebral edema from severe cerebral venous hypertension 2
- Rapid progression of facial and neck swelling despite treatment necessitates immediate escalation of care 2