|Year : 2020 | Volume
| Issue : 4 | Page : 280-282
Lemierre's syndrome: A rare complication of otitis media
B Y Praveen Kumar, Kiran Mali, KC Sunil, M K Veena Pani
Department of Otolaryngology, Mysore Medical College and Research Institute, Mysore, Karnataka, India
|Date of Submission||28-Feb-2020|
|Date of Decision||24-Jun-2020|
|Date of Acceptance||29-Jun-2020|
|Date of Web Publication||23-Apr-2021|
Dr. Kiran Mali
Department of Otorhinolaryngology, Mysore Medical College and Research Institute, Mysore, Karnataka
Source of Support: None, Conflict of Interest: None
Lemierre's syndrome, also known as septic internal jugular vein thrombophlebitis, is an extremely rare complication of chronic otitis media, which can be fatal if not managed on time. A 28-year-old female presented to us with left sided otorrhea lasting from 1 month, headache, fever with chills and rigors since 10 days. This was accompanied by torticollis and tenderness along the course of the left internal jugular vein. Otological examination revealed features of chronic suppurative otitis media squamosal type. Computerized tomography revealed features of an occluding thrombophlebitis of the left internal jugular vein up to the left brachiocephalic vein. We performed a canal wall down mastoidectomy for the left ear. The internal jugular vein was not ligated. Patient recovered well after the surgery.
Keywords: Canal wall down mastoidectomy, chronic suppurative otitis media squamosal type, internal jugular vein thrombophlebitis, Lemierre's syndrome, torticollis
|How to cite this article:|
Kumar B Y, Mali K, Sunil K C, Pani M K. Lemierre's syndrome: A rare complication of otitis media. Indian J Otol 2020;26:280-2
| Introduction|| |
Chronic otitis media is a common disease treated by Otolaryngologists. Two varieties have been described: squamosal and mucosal type. Chronic otitis media can cause complications which can be temporal or extratemporal. Complications can be life-threatening, which should be managed promptly. However, due to wide antibiotic usage, the clinical presentation of these patients has altered. Hence, a high suspicion is required to make a diagnosis. Lemeirre's syndrome (LS), also called septic internal jugular vein thrombophlebitis is a very rare complication of otitis media, which can lead to mortality if not addressed on time.
| Case Report|| |
A 28-year-old female presented to us with the complaints of left-sided otorrhea for a month, fever, otalgia, and headache for 10 days. The aural discharge was scanty, purulent, and offensive. The febrile episodes had a picket fence pattern accompanied by chills and rigors. She was treated with antibiotics by her primary care physician, without resolution of symptoms, which prompted her referral to us.
General examination revealed a pale, toxic looking patient. She was febrile with a temperature of 100.4°F. Her pulse, blood pressure, and respiratory rate were normal. The patient had torticollis.
Examination of the left ear revealed an attic perforation with cholesteatoma. The Facial nerve was normal. Vestibular function tests were normal. Tuning fork tests revealed a conductive hearing loss in the left ear. The right ear, nose, and throat were normal. Neck examination revealed tenderness along the entire anterior margin of the left sternocleidomastoid muscle. Neurological, cardiac, and gastroenterological systems were normal. A provisional clinical diagnosis of chronic suppurative otitis media squamosal type with suspected lateral sinus thrombophlebitis was made.
An aural swab for culture and sensitivity was taken, which grew Pseudomonas aeruginosa sensitive to ciprofloxacin. Blood culture was not done because the patient was already receiving antibiotics. Blood examination revealed anemia and leukocytosis. The erythrocyte sedimentation rate was also elevated.
High resolution computed tomography temporal bones revealed erosion of scutum and soft tissue mass in the mesotympanum and epitympanum extending to the mastoid. Sinus plate erosion was present [Figure 1].
|Figure 1: High-resolution computed tomography temporal bones revealing soft tissue mass in the mastoid|
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Contrast computed tomography (CT) showed enhancement of the walls of the left internal jugular vein along with a filling defect suggestive of thrombophlebitis of the left internal jugular vein [Figure 2]. The lateral sinus was normal.
|Figure 2: Contrast-enhanced computed tomography Head and Neck revealing filling defect in the left internal jugular vein with enhancement of vessel wall|
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Parenteral antibiotic, thereby consisting of ciprofloxacin, gentamycin, and metronidazole, was begun and continued for 2 weeks. Two units of fresh blood were transfused.
A left mastoid exploration was done under general anesthesia. A cholesteatoma was present in the mastoid, epi, and mesotympanum, which was completely excised. The sinus plate was eroded. Inspection and palpation of the sigmoid sinus were normal. The head of the malleus was eroded, the incus was completely destroyed. The stapes was present. A canal wall down mastoidectomy with type III tympanoplasty was done. The internal jugular vein was not ligated, and anticoagulants were not administered to this patient. The patient recovered well after surgery. The mastoid cavity healed well after 10 weeks [Figure 3].
| Discussion|| |
Lemierre, in 1936, described a group of patients with tonsillar and pharyngeal infections (including quinsy) who developed septic thrombophlebitis of the internal jugular vein. This condition is caused by the anaerobic bacteria Fusobacterium necrophorum. Other organisms such as Staphylococcus aureus, Beta hemolytic Streptococcus, Proteus, Pseudomonas, Staphylococcus epidermidis, Acinetobacter baumannii, Eikenella, Prevotella, Peptostreptococcus have been isolated in patients with this disease.
The primary source of infection in these patients is the palatine tonsil. Infection arising in the middle ear and mastoid, teeth, parotid gland, skin, and soft tissues of the head and neck can also lead to Lemierre's syndrome (LS).
These patients present with fever, chills and rigors, neck pain and swelling anterior to the sternocleidomastoid muscle and torticollis. “Cord sign” an induration along the course of the internal jugular vein, has also been reported. Metastatic septic embolization can lead to an abscess in the lungs, joints, and soft tissues.
Patients diagnosed with LS should be aggressively managed. Radiological studies such as CT and magnetic resonance imaging should be done to confirm the diagnosis of Lemierre's syndrome. Aggressive surgical management with drainage of purulent exudates irrespective of the site should be performed in all these patients. Anticoagulant and IJV ligation are reserved for patients with disseminating septic emboli.
Lemierre's syndrome is a rare extracranial complication of tympanomastoid infection, which should be managed aggressively to prevent mortality.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]