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Thrombosis of the internal jugular (IJ) vein is an underdiagnosed condition that may occur as a complication of head and neck infections, surgery, central venous access, local malignancy, polycythemia, hyperhomocysteinemia, neck massage, and intravenous drug abuse. It is also reported to occur spontaneously. IJ thrombosis itself can have serious potentially life-threatening complications that include systemic sepsis, chylothorax, papilledema, airway edema, and pulmonary embolism. The diagnosis often is very challenging and requires, first and foremost, a high degree of clinical suspicion.
IJ vein thrombosis refers to an intraluminal thrombus occurring anywhere from the intracranial IJ vein to the junction of the IJ and the subclavian vein to form the brachiocephalic vein.
The thrombosis may become secondarily infected, producing a septic thrombophlebitis. An infected IJ thrombus caused by extension of an oropharyngeal infection is referred to as Lemierre syndrome. This has also been termed necrobacillosis or postanginal septicemia.
Thrombosis associated with central venous catheters occurs more frequently than previously believed. One study found that 66% of patients who had an IJ vein catheter in place at some time during their hospital course had either ultrasonographic or autopsy evidence of IJ thrombus. The frequency was even greater in more critically ill patients, especially those with low cardiac output or shock syndromes.
The causes of IJ thrombosis include the following :
Signs and Symptoms
The symptoms and signs of IJ thrombosis can often be very subtle, making it easy to overlook the diagnosis. Pain and swelling at the angle of the jaw and a palpable cord beneath the sternocleidomastoid muscle both may be absent in a significant minority of patients. Once infection has set in, other objective findings may be found. Tovi et al described the following clinical manifestations in their 1991 series of patients with septic IJ thrombosis as follows :
Clinical manifestations of IJ thrombosis occur in the following percentages of patients :
Rare indications for a superior vena cava filter are similar to those of deep venous thrombosis in the lower extremity when an upper extremity deep vein thrombosis is associated with an internal jugular thrombosis. These include a clinical setting of pulmonary embolism in which therapeutic anticoagulation has failed or is contraindicated.
Uncomplicated cases of IJ thrombosis seldom require surgical intervention. However, cases associated with deep neck infections require drainage of any fluid collections and debridement of all infected tissue. Likewise, cervical necrotizing fasciitis requires extensive and complete debridement.
Cases of intraluminal abscesses may require excision of the IJ vein in order to prevent subsequent serious complications. However, most cases of postanginal sepsis can be managed medically, without the need for resection of the infected vein. Cases that do not respond to antibiotic therapy are unusual, and, importantly, remember that fever may persist for some time, especially in cases of metastatic infection.
The carotid sheath often protects the carotid artery. However, if it becomes involved, early and prompt surgical intervention is required to prevent devastating neurologic or airway complications.
Indications for a superior vena cava (SVC) Greenfield filter are rare. No reports demonstrate the use of a SVC filter for an isolated IJ thrombosis. Indications for a superior vena caval filter with axillary/subclavian vein thrombosis are similar to those of deep venous thrombosis in the lower extremity. These include upper extremity deep vein thrombosis that extended to the IJ. Therefore, in the clinical setting of an axillary/subclavian vein thrombosis alone or combined with an IJ thrombus with a pulmonary embolism in which therapeutic anticoagulation has failed or is contraindicated, a SVC filter should be inserted.
Superior vena cavograms are obtained in all patients prior to filter placement to determine caval size and to exclude venous abnormalities and SVC thrombus.4
Whenever possible, the filters are placed via the right common femoral vein. Filter placement in the SVC is more difficult than in the inferior vena cava (IVC) secondary to the relatively small area for appropriate filter placement. For femoral insertion of the SVC filter, a jugular insertion kit is used for correct filter orientation. For jugular vein insertion, a femoral insertion kit is used.
A chest radiography should be obtained to access for filter migration, dislodgement, or fracture.
For excellent patient education resources, visit eMedicine's Lung and Airway Center and Circulatory Problems Center. Also, see eMedicine's patient education articles Pulmonary Embolism, Venous Access Devices, Phlebitis, and Blood Clot in the Legs.
Once a diagnosis of internal jugular (IJ) thrombosis is made, be vigilant for the following complications :
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