see also: Lymphatic Malformation Rads

1. Prior to procedure
   1. Patient needs an order for doxycycline injection, 100 mg/10mL. This needs to come from pharmacy the day of the procedure. It is best to call the pharmacy as soon as the order is in so they can start preparing it. It will need to be picked up prior to the procedure.
2. Supplies and set up
   1. Alcohol swab for local skin prep
   2. Local anesthetic: 1% lidocaine with 1:100,000 epinephrine
   3. Marking pen
   4. Ultrasound machine with ultrasound probe and gel
   5. 20 gauge angiocatheter (shielded IV catheter, 1.1 x 30 mm)
   6. 3 way stopcock (Hi-Flo TM 3-way Stopcock, no IV tubing attached)
   7. 6 inch hep-lock tubing
   8. 20 cc syringe with Luer-Lok tip
   9. Doxycycline 100 mg/10 mL
3. Procedure description
   1. Consent patient
   2. Transport to minor room
   3. Minor room chair should be perpendicular to the door, with the ultrasound machine positioned at the patient's right shoulder
   4. Ultrasound is used to examine the contents of the cyst
   5. 1% lidocaine with 1:100,000 epinephrine is injected superficially into the skin at the site of the proposed needle insertion
   6. 20 gauge angiocather (IV catheter with needle) is placed into the cyst under ultrasound guidance
   7. Catheter is advanced, needle removed
   8. 3 way stopcock is attached to angiocatheter using a hemostat to stabilize the catheter while the stopcock is attached
   9. 20 cc syringe is attached to the opposite end of the stopcock prior to attaching the stopcock to the catheter
   10. Fluid is aspirated out of the cyst, keeping the catheter in the cyst space.
   11. Doxycycline sclerotherapy 100 mg/10 mL syringe is attached to a 6 inch hep lock IV tubing. The IV tubing is then attached to the 3 way stopcock once the tubing is primed. Stopcock is then turned to open the valve to the doxycycline arm. Doxycycline is then injected into the cyst space. Amount injected is often approximately 1/2 of what was aspirated.
   12. Catheter is removed.
   13. Bandaid can be placed over skin puncture site.

Sclerotherapy set up example:

Ultrasound images:

Prior to aspiration of cyst contents:

Angiocatheter in cyst:

Angiocatheter in cyst post-aspiration of contents:

Post doxycycline administration:

References

Jamal N, Ahmed S, Millter T. Bent J, Brook A, Parikh S, Ankola A: Coxycycline sclerotherapy for pediatric head and neck macrocystic lymphatic malformations: a case series and reivew of the literature. Int. J Pediatri Otorhinolaryngol. 2012 Aug;76(8):1127-31 

Wiegand S, Eivazi B, Zimmermann AP, Sesterhenn AM, Wermer JA: Sclerotherapy of lymphangiomas of the head and neck Head Necik 2011 Nov;33(11)