title: To anticoagulate? Controversy in the management of thrombotic complications of head & neck infections.
abstract: OBJECTIVE
  To review the thrombotic complications of head and neck infections, including Lemierre's syndrome, and their management.
  
  
  METHODS
  A retrospective review of pediatric patients presenting to McMaster Children's Hospital from 2009 to 2013 was undertaken. The literature was reviewed for evidence regarding the use of anticoagulation therapy in this population.
  
  
  RESULTS
  Eleven cases (6 males, 5 females) were identified. The median age was 10.9 (range 14 months-17 years). The most frequent head and neck infection causing a thrombotic complication was mastoiditis (n = 6). All had thrombi identified on imaging, with the most common location being the sigmoid sinus (n = 6) followed by the internal jugular vein (n = 5). All 11 patients were anti-coagulated with low molecular weight heparin (LMWH) within a median of 2 days of diagnosis (average duration 105.8 days). Ten patients (90.9%) had thrombus improvement or resolution within a median of 3.4 months (range 1.0-13.9). Adverse sequelae from the thrombi were MCA infarct (n = 1), septic pulmonary emboli (n = 4), cranial nerve palsies (n = 3) and Horner's syndrome (n = 2). There were no adverse effects from anti-coagulation therapy. Review of the literature revealed anticoagulant use in 63.7% of pediatric cases reported since 2002.
  
  
  CONCLUSIONS
  Anticoagulation remains controversial in the management of thrombotic complications from head and neck infections. Based on this case series, certain recommendations can be made regarding the benefits of anticoagulation, which appear to outweigh the risks. Further research is required to establish evidence for consensus in the antithrombotic management of thrombotic sequelae of head and neck infections.
authors: Division of Otolaryngology-Head and Neck Surgery McMaster University, Hamilton, Canada. Electronic address: jenna.rebelo@medportal.ca.
authors: Jenna
authors: J
authors: Rebelo
authors: Division of Otolaryngology-Head and Neck Surgery McMaster University, Hamilton, Canada; Department of Surgery, Cambridge Memorial Hospital, Cambridge, ON, Canada.
authors: Smriti
authors: S
authors: Nayan
authors: Division of Critical Care Medicine, Department of Pediatrics, McMaster University, Hamilton, Canada.
authors: Karen
authors: K
authors: Choong
authors: Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Canada.
authors: Martha
authors: M
authors: Fulford
authors: Department of Pediatrics, McMaster University, Hamilton, Canada.
authors: Anthony
authors: A
authors: Chan
authors: Division of Otolaryngology-Head and Neck Surgery McMaster University, Hamilton, Canada.
authors: Doron D
authors: DD
authors: Sommer
mesh_terms: D000293:Adolescent; D000925:Anticoagulants / Q000627:therapeutic use*; D001241:Aspirin / Q000627:therapeutic use; D020226:Cavernous Sinus Thrombosis / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology; D002533:Cerebral Angiography; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D000072226:Computed Tomography Angiography; D019468:Disease Management; D017984:Enoxaparin / Q000627:therapeutic use; D005260:Female; D005674:Fusobacterium Infections / Q000150:complications; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use; D006801:Humans; D007223:Infant; D057831:Lemierre Syndrome / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology; D018810:Magnetic Resonance Angiography; D008297:Male; D008417:Mastoiditis / Q000150:complications; D000039:Peritonsillar Abscess / Q000150:complications; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D017703:Retropharyngeal Abscess / Q000150:complications; D012189:Retrospective Studies; D012852:Sinusitis / Q000150:complications; D000078222:Tinzaparin; D020246:Venous Thrombosis / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology
chemical_list: D000925:Anticoagulants; D017984:Enoxaparin; D006495:Heparin, Low-Molecular-Weight; D010975:Platelet Aggregation Inhibitors; D000078222:Tinzaparin; D001241:Aspirin
keywords: Anti-coagulation; Infection; Lemierre's; Pediatric; Pharyngitis; Thrombophlebitis