Right tonsillar fossa inflammatory phlegmon with local mass effect

Case contributed by Dr Steve Lau

Presentation

Recurrent tonsillitis, recent episode lasting for 5/7. Right sided indurated and painful cord like structure felt on neck ?Lemierre's syndrome

Patient Data

Age: 19
Gender: Female

CT neck show a right palatine tonsil heterogenous mass with small amount of adjacent fat stranding. There is moderate local mass effect with partial obliteration of adjacent right parapharyngeal space and the orophraynx is moderately narrowed. The jugulodigastric nodes are prominent. 

There is no venous thrombosis seen adjacent to tonsillar phlegmon with normal opacification of right internal jugular vein and hence no evidence of Lemierre's syndrome.

 

Case Discussion

Lemierre's syndrome (postanginal septicaemia/necrobaccilosis) is a form of thrombophlebitis usually caused by an acute oropharyngeal infection with secondary septic thrombophlebitis of the internal jugular vein and frequent metastatic infections. 

Diagnosis

It is characterised by a history of recent oropharyngeal infection and clinical or radiological evidence of internal jugular venous thrombosis, and isolation of anaerobic pathogens. The most common organism isolated is Fusobacterium necrophorum. The onset between oropharyngeal infection and sepsis is usually short. The most common sites of septic embolisms are the brain, lungs and joints. 

Management

Treatment includes intravenous antibiotics and drainage of septic foci. In some cases, ligation or excision of internal jugular vein is required.

Conclusion

A high index of clinical suspicion is required to diagnose this condition. In this case, the patient's admission bloods show a normal WCC of 8.6 with the absence of neutrophilia, no clinical evidence of sepsis and no radiological evidence of right internal jugular vein thrombosis. Thus, is it unlikely that the patient has Lemierre's syndrome.

 

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Case Information

rID: 28720
Case created: 9th Apr 2014
Last edited: 26th Sep 2015
System: Head & Neck
Inclusion in quiz mode: Included

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