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The lemierre syndrome: Suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection
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though colonization of the sputum is universal, the rate of sepsis and mortality was not significantly increased by the presence of a tracheostomy. Twenty-eight patients developed late upper airway sequelae, including tracheal stenosis, tracheoesophageal fistula, and tracheoarterial fistula. The development of late upper airway sequelae continues to plague burn patients. No doubt, these are the result of a combination of factors including tracheal burns, infection, and the presence of rigid tubes in the upper airway. Inhalation injury, particularly in the young, when combined with intubation and infection, may result in hypertrophic reaction in the airway with development of tracheal granulation tissue and stenosis. Older patients are more likely to develop degenerative changes with tracheal necrosis, tracheal stenosis, and tracheoesophageal fistula formation. The authors conclude that nasotracheal intubation may be preferable to tracheostomy in the early management of compromised burned patients. However, they do acknowledge that a tracheostomy may be needed if intubation is expected to be maintained longer than 2 weeks. This is an interesting study from a large center and again brings into perspective the need for prophylactic tracheostomies in upper airway injury. It also includes a good analysis of the complications that may arise from rigid tubes in the upper airways or tracheostomies performed in burn-injured tracheas. The Lemierre Syndrome: Suppurative Thrombophlebitis of the Internal Jugular Vein Secondary to Oropharyngeal Infection. CP Sinave, GJ Hardy, PW Fardy. Medicine 1989; 68:85-94 In 1936, Lemierre first described a syndrome characterized by septicemia following pharyngitis. The disease has since been recognized as thrombophlebitis of the internal jugular vein with multiple metastatic infections secondary to acute oropharyngeal infection. This paper reviews two specific cases as well as the medical literature pertaining to this disease. Admittedly, this disease is uncommon, although a variant of it is seen in intravenous drug abusers who use the jugular vein. Characteristically, the disease afflicts teenagers and young adults who are otherwise healthy. Almost all patients have an acute tonsillar infection as their portal of entry, with some patients having odontogenic infection as well. The interval between the appearance of oropharyngeal infection and the septicemia was short (less than 1 week), with 40% of the cases having an unknown bacterial etiology. The diagnosis was a clinical one in most cases, with swelling and tenderness at the angle of the jaw and along the sternocleidomastoid muscle, as well as signs of severe sepsis with evidence of pleuropulmonary emboli. After reviewing the literature, the authors recommend high doses of intravenous antibiotics as a primary mode of therapy. Surprisingly, and contrary to the experience of most head and neck surgeons, they suggest that ligation of the internal jugular vein may be unnecessary. The authors conclude that the disease is not uncommon, even in this sophisticated antibiotic era, and should be searched for in patients with pharyngitis going on to severe sepsis. Patients with this syndrome may include intravenous drug abusers and
ABSTRACTS
immunocompromised hosts. At this point, the following principle should be considered: any source of recurrent infection, such as the jugular vein, should in all probability be ligated if there is overt metastatic infection. This is a good review of the medical literature that should be useful to head and neck surgeons when tempered by good clinical judgement in the face of progressive disease. Photodynamic Therapy for Esophageal Tumors. JS McCaughan, TA Nims, JT Guy, et al. Arch Surg 1989; 124:74-80 Esophageal tumors continue to have a poor prognosis regardless of the treatment modality. Less than 4% of patients achieve a 5-year survival rate, and 50% of tumors are unresectable when first seen. In 1978, the first report appeared on treating cutaneous and subcutaneous malignant neoplasms with photodynamic therapy [PDT). This technique involved presensitizing malignant neoplasms with a dye that would destroy cells when exposed to light. This report, an updated expansion of earlier studies, assesses the use of PDT in the treatment of 40 patients with esophageal tumors when conventional therapy was unsuccessful. Patients underwent endoscopy 2 to 3 days and 1 month after PDT and as needed when symptoms recurred. At 1 month, the average minimal diameter opening increased from 6 to 9 mm in 28 assessable tumors. Thirty-five patients evaluated 1 month after PDT progressed from a liquid to a soft diet. There were no major complications with PDT and there was a slight increase in objective criteria, denoting an improved quality of life. Survival rates were not significantly affected by this modality, although the ability to swallow definitely improved. The authors point out that despite improvement in oral intake following therapy, some patients did not gain weight because of cancer cachexia. They also recommend the use of feeding gastrostomies with PDT to control the problems of excess saliva. Patients undergoing PDT should also undergo bronchoscopy because a significant proportion will, not surprisingly, have synchronous lesions in the trachea-bronchial tree. Photodynamic therapy should be considered a useful palliative technique in the treatment of tumors of the esophagus. Post-Traumatic Parotid Fistulae and Sialoceles. D Parekh, G Glezerson, M Stewart, et al. Ann Surg 1989; 209:105-111 The management of parotid fistulae following penetrating parotid gland injuries can be divided into two categories. Most authorities agree that acute parotid duct injuries must be explored and accurately repaired. However, the treatment of the missed parotid injury appears to be controversial, with numerous methods of treatment advocated in the literature. These have had variable degrees of success in reducing the morbidity of chronic parotid sialoceles and fistulae. This paper is a prospective study reporting the results of conservative therapy in 51 patients over a d-year period. In 50 patients, the injury healed when conservative management was undertaken. Parotid injury presented clini-
though colonization of the sputum is universal, the rate of sepsis and mortality was not significantly increased by the presence of a tracheostomy. Twenty-eight patients developed late upper airway sequelae, including tracheal stenosis, tracheoesophageal fistula, and tracheoarterial fistula. The development of late upper airway sequelae continues to plague burn patients. No doubt, these are the result of a combination of factors including tracheal burns, infection, and the presence of rigid tubes in the upper airway. Inhalation injury, particularly in the young, when combined with intubation and infection, may result in hypertrophic reaction in the airway with development of tracheal granulation tissue and stenosis. Older patients are more likely to develop degenerative changes with tracheal necrosis, tracheal stenosis, and tracheoesophageal fistula formation. The authors conclude that nasotracheal intubation may be preferable to tracheostomy in the early management of compromised burned patients. However, they do acknowledge that a tracheostomy may be needed if intubation is expected to be maintained longer than 2 weeks. This is an interesting study from a large center and again brings into perspective the need for prophylactic tracheostomies in upper airway injury. It also includes a good analysis of the complications that may arise from rigid tubes in the upper airways or tracheostomies performed in burn-injured tracheas. The Lemierre Syndrome: Suppurative Thrombophlebitis of the Internal Jugular Vein Secondary to Oropharyngeal Infection. CP Sinave, GJ Hardy, PW Fardy. Medicine 1989; 68:85-94 In 1936, Lemierre first described a syndrome characterized by septicemia following pharyngitis. The disease has since been recognized as thrombophlebitis of the internal jugular vein with multiple metastatic infections secondary to acute oropharyngeal infection. This paper reviews two specific cases as well as the medical literature pertaining to this disease. Admittedly, this disease is uncommon, although a variant of it is seen in intravenous drug abusers who use the jugular vein. Characteristically, the disease afflicts teenagers and young adults who are otherwise healthy. Almost all patients have an acute tonsillar infection as their portal of entry, with some patients having odontogenic infection as well. The interval between the appearance of oropharyngeal infection and the septicemia was short (less than 1 week), with 40% of the cases having an unknown bacterial etiology. The diagnosis was a clinical one in most cases, with swelling and tenderness at the angle of the jaw and along the sternocleidomastoid muscle, as well as signs of severe sepsis with evidence of pleuropulmonary emboli. After reviewing the literature, the authors recommend high doses of intravenous antibiotics as a primary mode of therapy. Surprisingly, and contrary to the experience of most head and neck surgeons, they suggest that ligation of the internal jugular vein may be unnecessary. The authors conclude that the disease is not uncommon, even in this sophisticated antibiotic era, and should be searched for in patients with pharyngitis going on to severe sepsis. Patients with this syndrome may include intravenous drug abusers and
ABSTRACTS
immunocompromised hosts. At this point, the following principle should be considered: any source of recurrent infection, such as the jugular vein, should in all probability be ligated if there is overt metastatic infection. This is a good review of the medical literature that should be useful to head and neck surgeons when tempered by good clinical judgement in the face of progressive disease. Photodynamic Therapy for Esophageal Tumors. JS McCaughan, TA Nims, JT Guy, et al. Arch Surg 1989; 124:74-80 Esophageal tumors continue to have a poor prognosis regardless of the treatment modality. Less than 4% of patients achieve a 5-year survival rate, and 50% of tumors are unresectable when first seen. In 1978, the first report appeared on treating cutaneous and subcutaneous malignant neoplasms with photodynamic therapy [PDT). This technique involved presensitizing malignant neoplasms with a dye that would destroy cells when exposed to light. This report, an updated expansion of earlier studies, assesses the use of PDT in the treatment of 40 patients with esophageal tumors when conventional therapy was unsuccessful. Patients underwent endoscopy 2 to 3 days and 1 month after PDT and as needed when symptoms recurred. At 1 month, the average minimal diameter opening increased from 6 to 9 mm in 28 assessable tumors. Thirty-five patients evaluated 1 month after PDT progressed from a liquid to a soft diet. There were no major complications with PDT and there was a slight increase in objective criteria, denoting an improved quality of life. Survival rates were not significantly affected by this modality, although the ability to swallow definitely improved. The authors point out that despite improvement in oral intake following therapy, some patients did not gain weight because of cancer cachexia. They also recommend the use of feeding gastrostomies with PDT to control the problems of excess saliva. Patients undergoing PDT should also undergo bronchoscopy because a significant proportion will, not surprisingly, have synchronous lesions in the trachea-bronchial tree. Photodynamic therapy should be considered a useful palliative technique in the treatment of tumors of the esophagus. Post-Traumatic Parotid Fistulae and Sialoceles. D Parekh, G Glezerson, M Stewart, et al. Ann Surg 1989; 209:105-111 The management of parotid fistulae following penetrating parotid gland injuries can be divided into two categories. Most authorities agree that acute parotid duct injuries must be explored and accurately repaired. However, the treatment of the missed parotid injury appears to be controversial, with numerous methods of treatment advocated in the literature. These have had variable degrees of success in reducing the morbidity of chronic parotid sialoceles and fistulae. This paper is a prospective study reporting the results of conservative therapy in 51 patients over a d-year period. In 50 patients, the injury healed when conservative management was undertaken. Parotid injury presented clini-