0:01

Well, we're done with the "V" of vitamin C and D.

0:04

"V" for vascular, infectious, traumatic, acquired,

0:07

metabolic, and neopathic neoplastic,

0:09

congenital, and drugs.

0:09

So we did the "V" as well as the "C",

0:12

which were some of the congenital disorders that

0:15

cause a vascularopathy of the carotid space.

0:19

Let's move from the "V" to the "I".

0:21

The "I" stands for infectious or

0:22

inflammatory ideologies.

0:25

Most of the infections that involve

0:27

the carotid are secondary.

0:29

And we're going to look at the secondary spread of

0:33

infections to the carotid, leading

0:35

to arteritis or thromboflabitis.

0:39

Most of these occur secondary to spread from

0:42

odontogenic lesions involving the teeth and the

0:45

mouth through the masticator space

0:47

and spread to the carotid sheath.

0:50

And we will be talking about three "L"s: Ludwig's,

0:53

angina,

0:54

Lemierre's disease, and Lymphaticis here

0:57

on the CT scan to the right.

1:00

On the image,

1:01

you can see that there is inflammation

1:03

which is in the strap muscles.

1:05

This is pretty well seen here on the right side when

1:08

you compare it to the much cleaner-looking

1:10

strap muscle on the left side.

1:13

There's also some inflammation here in the

1:15

submental region. But more importantly,

1:18

what we see is clean fat around the carotid sheath.

1:22

On the left side,

1:26

nice black fat.

1:27

But on the right side, you see that there's

1:31

intermediate density tissue surrounding the internal

1:35

carotid artery. Not so much the jugular vein,

1:38

but the internal carotid artery.

1:40

And this is secondary spread of an infection which

1:44

was again coming from the teeth going down the neck

1:48

to involve the carotid sheath on the right side,

1:53

one of the eponyms that you should know

1:56

is Lemierre's syndrome, which is also

2:00

synonym for postanginal sepsis.

2:03

And this is one of the articles I wrote in my second

2:07

year of residency on Lemierre's Syndrome entitled

2:12

"CT Demonstration of Postanginal Sepsis".

2:14

And I was a good boy.

2:16

I was writing it with my program director

2:18

in radiology, Stan Siegelman.

2:21

And this is an example of a case showing

2:25

inflammation that is basically coming from the teeth

2:29

and spreading to the post-thyroid parapharyngeal

2:33

space involving the jugular vein.

2:36

So Lemierre's syndrome is a complication usually of

2:40

pharyngitis or tonsillitis and/or odontogenic

2:44

disease that is usually characterized

2:46

by Fusobacterium as the pathogen,

2:50

usually affects adolescents,

2:51

and is characterized by thrombophlebitis of the

2:54

internal jugular vein with septic emboli going from

2:59

the internal jugular vein into the lung.

3:01

It can also go into the joints.

3:04

And you may see the disease also in the kidneys.

3:06

And Lemierre's, just to refresh your memory,

3:10

was a bacteriologist who described

3:14

this syndrome in 1936.

3:17

At the time,

3:18

90% of his patients died from their infection.

3:22

Currently,

3:22

we say that the more mortality associated

3:26

with Lemierre's syndrome is only 10%.

3:29

Here is an example.

3:30

We have a patient who has inflammation in the left

3:35

tonsil. Here we see that the tonsil is enlarged.

3:40

There's a low-density area which is likely to

3:43

represent a peritonsillar abscess or PTA.

3:47

We notice on the lower images that the internal

3:50

jugular vein has a filling defect within it,

3:53

Representing the thrombosis of the

3:57

left internal jugular vein and.

4:00

All around the carotid, chief,

4:02

we can see a clot in the left internal jugular vein,

4:09

contrast-enhancing component,

4:11

more superiorly, and contrast enhancement of the

4:14

internal jugular vein on the right side,

4:16

but a clotted left internal jugular vein.

4:20

And if we look in the chest,

4:22

we see multiple embolic phenomena.

4:25

And these are septic emboli coming from

4:29

that left internal jugular vein.

4:31

Thromboflabitis associated with

4:34

the left-sided tonsillitis.