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Austen 7
55 Fruit Street
Boston,
MA
02114
Phone: 617-724-0969
Fax: 617-726-7667
The Thoracic Outlet Syndrome Program in the Division of Thoracic Surgery at Massachusetts General Hospital provides expert diagnosis, treatment and support to patients with thoracic outlet syndrome (TOS).
Our doctors and nurses are highly skilled in properly diagnosing and treating thoracic outlet syndrome. Because of the pioneering work that our providers have done in all areas of TOS and their experience in treating both common and complex cases, the Thoracic Outlet Syndrome Program at Mass General is a major referral center for this disorder, helping patients from all over the U.S. and globally. Our physicians and care team have a long-standing history of offering solutions for patients whose prior treatments were unsuccessful.
We work collaboratively with specialists across various disciplines at Mass General to provide expert care to our patients with the goal of achieving the best possible outcomes.
These areas include:
Thoracic outlet syndrome is a group of disorders that occur when the nerves in the brachial plexus and the blood vessels of the subclavian artery and subclavian vein are compressed in the anatomic region known as the thoracic outlet (between the collarbone and the first rib). This includes the area from the neck to the underarm.
Thoracic outlet syndrome symptoms can include, but are not limited to, shoulder, neck, arm, hand and finger:
There are three types of TOS impacting different areas in the thoracic outlet:
Though it tends not to become prevalent until teenage years or young adulthood, thoracic outlet syndrome can occur across all ages and genders. Our team treats adults, young adults and pediatric patients whose TOS developed for a variety of reasons, including athletics.
Our doctors work with specialists across Mass General Brigham to treat patients who have developed TOS due to sports-related injuries. These patients can range from the youth level to professional athletes.
For many patients, our initial treatment includes a combination of physical therapy and medications, as many of our patients do not require surgery to improve their symptoms. Each treatment decision, including the decision to perform surgery, is specific to each patient.
Neurogenic thoracic outlet syndrome, a common form of TOS, results from compression of the brachial plexus nerves.
Physical therapy is the first line of treatment for many patients with neurogenic thoracic outlet syndrome. In some cases, several months of dedicated physical therapy may be required before a patient begins to notice improvement in their symptoms. Physical therapy may address:
Ultrasound-guided injections into specific neck and chest muscles with Botox® may be used to relieve compression of nerves in some patients. Many patients whose symptoms have improved following Botox injections may be able to participate more actively in a physical therapy, which can improve the overall results.
For neurogenic TOS, a successful surgical outcome depends on a combination of an accurate diagnosis and technical precision during surgery. Determination of whether surgery is a good option to treat neurogenic TOS can be difficult will be made by the care team and the patient.
Venous thoracic outlet syndrome results when the major veins in the lower neck and upper chest are damaged.
The treatment of venous TOS begins following the initial imaging. When a clot formation is identified, medication to dissolve this clot can be administered immediately. For most patients, the underlying problem is narrowing of the vein from thoracic outlet compression, so treating the clot alone is not always sufficient. If there is external vein compression, surgery may be recommended to relieve it, depending upon the severity. Patients may need to remain on medications (blood thinners) to prevent clotting for up to three months following surgery. After this timeframe, patients can return to normal activity.
Arterial thoracic outlet syndrome, the rarest and least common form of TOS, occurs when compression damages the blood vessel. Compression of this vessel does not equate to blood vessel damage, and detailed analysis using imaging with contrast is used to assess for damage.
Patients with arterial TOS often require surgical treatment and will meet with their surgeon to discuss their options.
When other therapies are not successful in relieving the compression or clotting in the thoracic outlet, surgery can create additional space in the area or repair blocked or damaged arteries and veins. Patients who require surgery can be confident that they will receive specialized care from an experienced team.
Surgery for TOS may involve:
The preferred surgical approach for thoracic outlet syndrome is a two-to-three-inch incision, or cut, above the collarbone at the base of the neck. Patients with venous or arterial TOS may require repair of veins and arteries, involving a second smaller incision below the collarbone.
The average stay at Mass General following surgery is one to two days.
The thoracic outlet may also become compressed in an area below the pectoralis minor muscle and shoulder. This is known as pectoralis minor syndrome. In our experience, this occurs in less than half of our patients. When this is present, it may require an additional surgical procedure performed through a two-inch incision in the armpit. This is a less extensive procedure than rib removal, and it is typically done on an outpatient basis.
Making the correct diagnosis of thoracic outlet syndrome is the key to successfully treating it. The Mass General Thoracic Outlet Syndrome care team customizes a diagnostic and treatment program for each patient.
Our thorough clinical assessment begins with a detailed history and physical examination during the initial office visit. Additional examinations/treatments are tailored to each patient’s needs and may include:
This is a unique scan developed at Mass General that shows a detailed view of the thoracic outlet region from the top of the neck to the mid-chest area. The three-dimensional images in this scan take approximately 10 days for the radiologists to reconstruct and read, so your results will not be immediately available. The results are an important piece of information that our team will use to determine how to treat your symptoms. To receive your results, please call the office approximately 10 days after the study.
Botox® changed my quality of life. I am able to be in less pain and have more of my regular life functionality brought back. I felt less pain at work, could sleep better at home and feel better overall. It is a miracle treatment and I’m grateful to live in a place that offers it. It has really been so life changing for me.
Julia
Thoracic Outlet Syndrome Patient
In some cases, the muscles in the neck and shoulder area contribute to compression or irritation of the nerves and blood vessels in the thoracic outlet. One way our team evaluates patients for thoracic outlet syndrome is by injecting Botox into certain muscles in the thoracic outlet. These injections are performed by physicians in the Department of Radiology using ultrasound to precisely target specific muscles. The injections may help relieve some of the compression in the thoracic outlet.
After your appointment is scheduled, the TOS administrator will send you Botox forms via email to help keep record of your symptoms before and after the injections. Depending on your body’s reaction to Botox, it can take up to one month for you to feel any effects.
Your care team will work with you to determine the best treatment options going forward. This is always a collaboration between you and the team.
The specialized CT scan and Botox injections require prior authorizations from your insurance company, which may take up to three weeks to process. We ask that you please be patient during this time.
Once the authorizations are approved by your insurance company, the TOS administrator will call you to schedule the CT scan and Botox injections. If you have not heard from our office within one month of your initial consult, please call us to check in.
The Mass General Thoracic Outlet Syndrome team is dedicated to ensuring that patients with TOS understand their health care choices and have the necessary information to make decisions affecting their health and well-being.
Below you will find information about the patient process for those who are new to Mass General and the Division of Thoracic Surgery, worker’s compensation and the international patient process.
Our mailing address is:
Dr. Dean Donahue
Massachusetts General Hospital
Thoracic Outlet Syndrome Program, Austen 7
55 Fruit Street
Boston, MA 02114
Learn how to request a copy of your medical records
If you have worker's compensation insurance, please inform our staff immediately.
The Mass General billing department will then contact your adjuster to agree on payment for this visit. Please inform our staff if the adjuster requires a request from our office. Once this information is processed, you will be scheduled for a new patient appointment.
The International Patient Center at Mass General is a dedicated, full-service and multilingual office that assists foreign patients seeking a consultation, a second opinion or medical treatment at Mass General. From appointment scheduling to travel arrangements, our International Patient Center staff’s sole purpose is to help make your Mass General journey as healing and stress-free as possible. International patients are encouraged to contact our International Patient Center team to learn more about starting your care journey at Mass General.
Visit the International Patient Center website for more information
Thoracic outlet syndrome — neurogenic, venous and, in rare cases, arterial — can affect both adults and children. Our team has deep experience in caring for patients of all ages, including those whose prior TOS treatments were unsuccessful. For pediatric patients with TOS, we most commonly see adolescents between the ages of 10-18, typically with neurogenic TOS or venous TOS. Though not considered pediatric, our team is also experienced in treating young adults with TOS between the ages of 19-25.
The symptoms of TOS in pediatric patients are frequently the same as adults. These symptoms can include:
In the initial appointment, pediatric patients will undergo a thorough evaluation process including a history and exam. Younger patients occasionally require anesthesia for imaging studies. Parents and caregivers are an important part of the child’s care team and will be involved every step of the way.
If surgery is required, pediatric patients will remain at the hospital to recover following surgery. If a combination of physical and drug therapy is the recommended treatment, pediatric patients are provided with ongoing support from the TOS surgery team at Mass General, when needed.
Children diagnosed with TOS will need to rest and refrain from any activities, including sports, that may aggravate the symptoms until they are treated and improved. It is always our goal to provide everything your child needs to recover and get back to what they love to do. Your care team will support you and your child through the treatment journey.
Enroll your child in Patient Gateway
Read a Pediatric TOS Patient Story
Mass General accepts most health insurance plans, including Medicare and Medicaid.
Before scheduling your hospital visit, check with your health insurance provider to see if you are covered and learn the specifics of your coverage. Insurance plans are agreements made between you and your insurer. Mass General cannot ensure that an insurance provider will pay for your care. It is your responsibility to understand what types of coverage your health insurance provides and to be sure that you meet all requirements stipulated by your specific plan.
Your health insurance provider will be able to inform you of your level of coverage and what, if any, copayments, coinsurances and deductibles will be your responsibility. If you do not contact your provider, you can ultimately be responsible for all or a large portion of your bill.
Learn more about billing and insurance at Mass General
As the key to treating thoracic outlet syndrome is correctly diagnosing it, our research efforts focus on improving diagnostic techniques. In collaboration with the Mass General Department of Radiology, our thoracic outlet syndrome researchers have developed unique protocols for using MRI and CT scans to diagnose TOS and have developed two new evaluation strategies that build upon the standard MRI and CT technologies. We recalibrated each technology to develop images that are more detailed than previously available, providing a more accurate diagnosis of thoracic outlet syndrome.
Our doctors are highly skilled in properly diagnosing and treating thoracic outlet syndrome.
Kerri Smart and three of her children were gradually diagnosed with thoracic outlet syndrome over a decade and treated at Massachusetts General Hospital. Kerri describes the family’s journey with this elusive disorder and the steps they took to pursue the best possible treatment for TOS.
If you would like to request an appointment with or refer a patient to the Thoracic Outlet Syndrome Program, please use the following contact information.
