Postoperative Lemierre's syndrome: a previously unreported complication of transoral surgery. Illustrative case

Abstract

Background: Lemierre's syndrome is a rare but potentially life-threatening clinical condition characterized by bacteremia and thrombophlebitis of the internal jugular vein, usually secondary to oropharyngeal infection and often caused by Fusobacterium necrophorum; rarely, it occurs after surgical procedures. The most common clinical presentation includes acute pharyngitis, high fever, and neck pain. The diagnosis is based on blood culture and cranial and cervical spine computed tomography (CT)/magnetic resonance imaging (MRI) with contrast. Antibiotic therapy for 3-6 weeks is the mainstay of treatment, while the use of anticoagulant drugs is controversial.

Observations: The authors describe a case of Lemierre's syndrome that occurred after transoral surgery. The patient underwent a combined surgical approach from above (transoral) and below (anterolateral transcervical) to the upper cervical spine for the resection of a large anterior osteophyte causing dysphagia, globus sensation, and dysphonia. Three weeks after the surgical procedure, she developed fever and severe neck pain.

Lessons: The aim of this paper is to consider Lemierre's syndrome as a possible complication after the transoral approach, underlining the importance of its early diagnosis and with a suggestion to perform cranial and cervical spine CT or MRI venous angiography in patients who undergo surgery with a transoral approach and exhibit local or systemic signs of infection such as neck pain, persistent fever, and positive blood culture results.

Keywords: CT = computed tomography; ENT = ear, nose, and throat; IJV = internal jugular vein; LS = Lemierre’s syndrome; Lemierre’s syndrome; MRI = magnetic resonance imaging; POD = postoperative day; WBC = white blood cell; cervical osteophyte; transoral approach.

FIG. 1.

A: Preoperative CT of the cervical spine showing large osteophyte spanning from C1 to superior edge of C4 body. B: Oral cavity examination: macroscopic view of anterior bulging of the posterior oropharyngeal wall (black arrows). C: Preoperative barium contrast swallow showing defect of the filling along the oropharyngeal segment and lateral displacement of the esophagus. D: Preoperative MRI of the cervical spine, sagittal sequence, showing disc herniation at C2–3 level.

FIG. 2.

C-arm radiographic intraoperative fluoroscopy of the cervical spine. The black arrow shows surgical target area of transoral approach (C1–2 vertebral osteophyte).

FIG. 3.

Postoperative CT of the cervical spine showing satisfactory resection of the large osteophyte and pharyngoesophageal tract’s decompression.

FIG. 4.

A: Postoperative MRI with contrast of the skull and cervical spine showing good resection of the anterior osteophyte, with diffuse inflammatory hyperintensity of the prevertebral tissues at C1–3 (white arrows) and posterior cervical muscles with inhomogeneous contrast enhancement. B and C: Postoperative MRI with contrast showing thrombophlebitis of the right IJV extended to the homolateral transverse-sigmoid sinuses (white arrows).

FIG. 5.

Doppler ultrasound of the right jugular vein after 1 week of heparin anticoagulant therapy showing an almost complete flow rehabilitation.