Postauricular abscess leading to internal jugular vein thrombosis: a case report.

Abstract

Thrombosis of the internal jugular vein (IJV) is uncommon. It usually responds to conservative medical treatment. We describe a case of IJV thrombosis in a 31-year-old man. The patient was successfully treated with IJV ligation after conservative therapy had failed.

Introduction

Thrombosis of the internal jugular vein (IJV) is an uncommon but well-described condition precipitated by either acquired or iatrogenic causes. These causes include procedures for vascular access (including placement of an indwelling catheter during hospitalization as well as intravenous drug abuse), (1) regional infections, (2-3) dental procedures, (4) congenital and acquired coagulation disorders, (5) and spontaneous causes. (6) The general premise is that one or more of the factors that make up Virchow's triad--vascular stasis, endothelial injury, and hypercoagulability--should be present before the thrombosis can occur. We describe a case of IJV thrombosis that was successfully treated with IJV ligation after conservative therapy had failed.

Case report

A 31-year-old man with no significant medical history was admitted to the internal medicine service with complaints of fever, worsening scalp pain, right neck pain and swelling, and tenderness on the right side of his head and in the postauricular region. He had a 2-week history of a cystic mass on the right side of his head; the mass had drained spontaneously 3 days prior to admission. He refused to move his head because of the pain. He was on no medications, and he had no known drug allergies or history of IV drug abuse.

The patient's vital signs on admission were as follows: temperature, 105.0[degrees] F; blood pressure, 134/74 mm Hg; pulse rate, 119 beats per minute; respiration rate, 18 breaths per minute; and oxygen saturation, 94%. Laboratory values were as follows: white blood cell (WBC) count, 10.7 x [10.sup.9]/L with 93% leukocytes; hemoglobin, 10.7 g/dl; hematocrit, 30.8%; platelets, 118 x [10.sup.9]/L; sodium, 131 mEq/L; and glucose, 153 mg/dl. His other electrolyte and coagulation values were normal. Urinalysis was positive for glucose, ketones, protein, WBCs, and red blood cells (RBCs). A lumbar puncture revealed the following: WBC count, 7 x [10.sup.9]/L with 92% leukocytes; RBC count, 1 x [10.sup.12]/L; glucose, 110 mg/dl; and protein, 29 mg/dl. An assay for purified protein derivative was negative.

On examination, a scalp lesion was located approximately 5 cm behind the fight pinna. The lesion was crusted, it exhibited no evidence of fluctuance, and there was no palpable adenopathy. The right mastoid process was exquisitely tender to palpation, and significant torticollis was noted. Findings on the remainder of the head and neck examination and on neurotologic investigation were unremarkable. Specifically, the tympanic membrane was clear and intact, and no evidence of middle ear fluid or pus was observed. A Weber's tuning-fork test was midline, and a Rinne's tuning-fork test was positive bilaterally (air conduction was greater than bone conduction).

On hospital day 1, the patient was started on IV nafcillin at 1.0 g every 4 hours; on hospital day 4, the dosage was increased to 2.0 g every 4 hours. Contrast-enhanced computed tomography (CT) of the head and neck on hospital day 2 revealed a right IJV thrombosis 3 to 4 cm below the level of the skull base. The thrombosis appeared to extend into the sigmoid and transverse sinuses on the right side. Right-sided swelling of the superficial occipital tissues was also seen. There was no evidence of focal abscess. The right mastoid exhibited minimal mucosal thickening with no air-fluid levels. No pathologically enlarged lymph nodes were visible.

On hospital day 3, CT of the chest demonstrated evidence of multiple foci of septic pulmonary emboli, while angiography (figure) and magnetic resonance imaging of the head showed moderate inflammatory disease of the right mastoid and a filling defect of the right sigmoid and transverse sinuses consistent with thrombosis. The patient was started on low-molecular-weight heparin.

On hospital day 5, a chest radiograph detected right apical and right upper lobe consolidation and bilateral pleural effusions. Physical examination revealed increasing erythema and edema of the right neck. The patient's WBC count had peaked at 13.0 x [10.sup.9]/L, and his temperature continued to fluctuate throughout each day, reaching at least 101.8[degrees] F at least once a day. Secondary to his worsening pulmonary condition and a lack of response to anticoagulation and antibiotic therapy, he was taken to the operating room for ligation of the right IJV.

A curvilinear skin incision was made posterior to the sternocleidomastoid muscle low in the neck, and a subplatysmal flap was elevated. The sternocleidomastoid muscle was then retracted laterally, exposing the carotid sheath. The sheath was opened, exposing an apparently normal IJV without a palpable thrombus. However, the facial vein was enlarged, and it appeared to be compensating for the lack of IJV flow. Neither enlarged lymph nodes nor abscesses were found during the exploration. The IJV was suture-ligated at the level of the carotid bifurcation, and the wound was closed. A biopsy was taken of the occipital scalp lesion, and histopathology found that it was consistent with acute perifolliculitis.

The patient's maximum temperature was 101.8[degrees] F on postoperative day 1 and 100.0[degrees] F on postoperative day 2. He was discharged home on hospital day 9 on warfarin and nafcillin. The nafcillin was discontinued after 2 weeks. At the 2-month follow-up, the patient remained asymptomatic while continuing on warfarin anticoagulation.

Discussion

Our patient exhibited evidence of transverse and sigmoid sinus thrombosis that extended into the IJV. Both clinical and radiologic examinations failed to detect any evidence of mastoid disease. Historically, the standard of therapy for IJV thrombosis secondary to lateral sinus thrombosis has been a cortical mastoidectomy along with IV antibiotic therapy. (7) It has been suggested that patients who do not respond to this strategy should be placed on amikacin therapy and that IJV ligation be employed only after more conservative therapy has been attempted (8) or if evidence of septic emboli appears. (9) Spontaneous resolution of IJV thrombosis has also been reported. (10)

Our patient demonstrated no evidence of mastoid or middle ear infection. Conventional IJV ligation was performed because his physical condition had worsened, with continued fevers and evidence of septic emboli on CT, despite conservative medical treatment with IV antibiotics and anticoagulation. Within 24 hours of IJV ligation, he experienced a marked resolution of symptoms, including a reduction in fevers, suggesting a therapeutic benefit. We submit that IJV ligation is a viable option for septic IJV thrombosis in patients who fail to respond to medical therapy alone.

References

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(5.) Arullendran P, Jani P, Baglin T, Moffat DA. Internal jugular vein thrombosis in association with the factor V Leiden mutation. J Laryngol Otol 1998;112:383-6.

(6.) Kennedy KS, TamiTA, Friedman JC, et al. Spontaneous thrombosis of the internal jugular vein. Ann Otol Rhinol Laryngol 1987;96: 222-4.

(7.) Singh B. The management of lateral sinus thrombosis. J Laryngol Otol 1993:107:803-8.

(8.) Teichgraeber JF, Per-Lee JH, Turner JS Jr. Lateral sinus thrombosis: A modern perspective. Laryngoscope 1982;92:744-51. (9.) Hughes G, Pensak ML, eds. Clinical Otology. New York: Thieme; 1997:238.

(10.) Lin CH, Chou JC, Lin TL, Lou PJ. Spontaneous resolution of internal jugular vein thrombosis in a Salmonella neck abscess patient. J Laryngol Otol 1999;113:1122-4.

Robert Sean Miller, MD; David L. Steward, MD

From the Department of Otolaryngology-Head and Neck Surgery, University of Virginia School of Medicine, Charlottesville (Dr. Miller), and the Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine (Dr. Steward).

Reprint requests: Robert Sean Miller, MD, Department of Otolaryngology-Head and Neck Surgery, University of Virginia School of Medicine, P.O. Box 800713, Charlottesville, VA 22908. Phone: [phone]; fax: [phone]; e-mail: [e-mail]