Case #7 -- Acute Illness in a Patient With Recurrent Ear Infections

L Kumar, MD, L Crews, MD, R Gacek, MD, ED Weber, MD, R Wesenberg, MD


August 28, 2003

Review of Diagnosis

What are the common complications of mastoiditis?

Conductive and sensory hearing loss; facial nerve palsy; sigmoid sinus thrombosis; osteomyelitis; inferior extension to form Bezold's abscess; superior extension leading to epidural abscess, cerebral, and cerebellar abscess; and meningitis are common complications of mastoiditis.[1,2]

What are the diagnostic tests and treatment methods for epidural abscess?

CT scan with contrast or MRI should be performed if an epidural abscess is suspected. To establish a diagnosis of underlying infection, sampling of the abscess is usually necessary. Treatment includes surgical drainage of the abscess and, depending on the growth of cultures, IV antibiotics should be administered for a total of 4-6 weeks.[3]

What are the causes of internal jugular vein thrombosis (IJT)?

The following can cause IJT:

  • Central venous or Swan-Ganz catheters in the internal jugular vein

  • Central venous or Swan-Ganz catheters in the subclavian vein

  • Individuals who abuse intravenous drugs using the IJ vein for access

  • Lemierre syndrome

  • Deep neck infections

  • Necrotizing soft-tissue infections

  • Complications of surgical neck dissection

  • Head and neck malignancy

  • Distant malignancy producing hypercoagulable state

  • Hypercoagulable state secondary to factor V Leiden, protein C, protein S, or antithrombin III deficiency

  • Jugular bulb catheters

  • Any neck surgery involving prolonged retraction of the internal jugular vein

  • Trauma

  • Ovulation induction with gonadotropins

  • Spontaneous - often secondary to undiagnosed malignancy or hypercoagulable state.[4]

What is Lemierre syndrome?

Lemierre syndrome consists of oropharyngeal infection (pharyngitis, tonsillar, or peritonsillar abscess/ mastoiditis) followed by IJT, anaerobic sepsis, and pulmonary septic emboli. This syndrome was first described in 1936.[5]

Lemierre syndrome must be considered in patients with sore throat or dental pain, lateral neck pain or swelling, pulmonary symptoms, and fever. The underlying infection is most often caused by the anaerobe Fusobacterium necrophorum (most common), bacteroides, Peptostreptococcus species, or Eikenella corrodens. The syndrome is most often seen in previously healthy adolescents and young adults.[5]

What are the diagnostic tests and therapeutic options for patients with IJT?

CT scan with intravenous contrast is considered by many to be the initial study of choice for suspected IJT. Doppler ultrasound is used for detecting flow changes secondary to the acute phase of thrombus formation and is used initially in settings where CT scan or MRI is not readily available.

MRI provides greater soft-tissue contrast and sensitivity to blood flow rates when compared with CT scan.[6]

Among patients with extensive thrombi extending into the sigmoid sinus, thrombolytic therapy has resulted in few complications. However, neither the indications for nor the safety of thrombolytic therapy has been defined.

In the setting of infection (Lemierre syndrome), use of anticoagulation is controversial and patients typically do well with antibiotic therapy alone. In the presence of septic emboli or with clear evidence of clot propagation, many physicians choose to add systemic anticoagulation.[6]

Deep neck infections require drainage of any fluid collections and debris in all infected tissue. Uncomplicated cases of IJT rarely require surgical intervention.