Thrombophlebitis Of Jugular Vein Research Articles

Lemierre syndrome due to Klebsiella pneumoniae: a rare case report with review of literature

Lemierre’s syndrome, a forgotten clinical entity, is characterised by septic thrombophlebitis of the internal jugular vein due to oropharyngeal infection. In the past, it was mainly associated with Fusobacterium necrophorum infections. We present a unique case report of Lemierre’s syndrome due to Klebsiella pneumoniae. Patient reported with progressive swelling involving right side of the neck that eventually increased in size. After confirming the diagnosis through CECT, patient was managed through combined medical and surgical therapy in the form of incision and drainage, targeted antibiotic therapy, glycaemic control and anticoagulation therapy. This case report highlights the association of poor glycaemic control in the pathogenesis and the isolation of Klebsiella pneumoniae as the rare organism of Lemierre’s syndrome.

Use of clopidogrel for treatment of jugular vein thrombophlebitis in horses with gastrointestinal disease

Use of clopidogrel for treatment of jugular vein thrombophlebitis in horses with gastrointestinal disease

Lemierre's Syndrome and Nasopharyngitis in Children: DIAGNOSIS and Treatment

Introduction: Lemierre’s syndrome (LS) is a rare but serious infectious emergency. It can be life threatening. It is a sepsis difficult to recognize and most often due to Fusobacterium necrophorum. The purpose of this case report was to discuss the diagnosis and treatment of Lemierre syndrome in children. Observation: A three-year-old child consulted for rhinopharyngitis complicated by an abscessed cervical adenophlegmon. The symptomatology had been evolving for 7 days with a notion of self-medication. The blood cell count showed hyperleukocytosis at 14.06.10<sup>3</sup> elements/mm<sup>3</sup>, anemia at 8.2.10<sup>6</sup> elements/mm<sup>3</sup>, and platelets at 102.10<sup>3</sup> elements/mm<sup>3</sup>. CRP was 258.5 mg/dL. HIV serology was negative. Bacteriological culture of the biological fluids collected (abscess pus, blood and joint fluid) was sterile. The CT scan revealed a collection of abscesses in the right sub-angulo-mandibular region. It was associated with thrombophlebitis of the internal jugular vein, as well as pulmonary and joint infections. The diagnosis of Lemierre syndrome was done. Cervicotomy allowed drainage of the abscess. A triple parenteral antibiotic therapy (Ceftriaxone, Metronidazole, Gentamycin) with per-os relay by Amoxicillin + Clavulanic Acid allowed to obtain the cure in one month of treatement without complications. Conclusion: LS is difficult to diagnose due to its non-specific clinical presentation and low incidence. Early clinical and imaging diagnosis guarantees a good outcome by allowing adequate treatment.

Pediatric Lemierre's Syndrome: A Comprehensive Literature Review.

Lemierre syndrome is a rare, potentially fatal complication of oropharyngeal infections characterized by septic thrombophlebitis of the internal jugular vein. It primarily affects healthy adolescents and young adults. Its incidence declined after the antibiotic era, but it may have resurged in recent decades, likely due to judicious antibiotic use and increasing bacterial resistance. Prompt diagnosis and treatment are imperative to prevent significant morbidity and mortality. Lemierre syndrome has been called "the forgotten disease," with a reported incidence of around 3.6 cases per million. The mean age at presentation is around 20 years old, though it can occur at any age. Lemierre Syndrome follows an oropharyngeal infection, most commonly pharyngitis, leading to septic thrombophlebitis of the internal jugular vein. F. necrophorum is the classic pathogen, though other organisms are being increasingly isolated. Metastatic infections, especially pulmonary, are common complications. Contrast-enhanced CT of the neck confirming internal jugular vein thrombosis is the gold standard for diagnosis. Long-course broad-spectrum IV antibiotics covering anaerobes are the mainstays of the disease's treatment. Anticoagulation may also be considered. Mortality rates are high without treatment, but most patients recover fully with appropriate therapy. Lemierre syndrome should be suspected in patients with prolonged pharyngitis followed by unilateral neck swelling and fevers. Early diagnosis and prompt antibiotic therapy are key, given the potential for disastrous outcomes if untreated. An increased awareness of Lemierre syndrome facilitates its timely management.

Un imprevisto tra capo e collo: la sindrome di Lemierre

A healthy 15-year-old boy was hospitalized due to the persistence of lateral cervical swelling associated with fever and worsening of headache. He underwent a neck and facial mass CT scan showing a thrombophlebitis of the internal jugular vein extended to the intracranial sinuses. The diagnosis of Lemierre syndrome (LS) was formalized with positive blood colture for Fusobacterium necrophorum. Intravenous antibiotic therapy associated with anticoagulant therapy was started with complete clinical recovery after 4 weeks of treatment. A close clinical-instrumental follow-up was set up. Lemierre syndrome is a thrombophlebitis of the internal jugular vein, that in this case was extended to the intracranial sinuses. It is a rare condition, secondary to the extension of an infectious process starting from the oropharynx. The clinical picture is characterized by high fever, persistent pharyngitis followed by sepsis, pneumo-nia or atypical laterocervical pain. Fusobacterium necrophorum, a gram-negative anaerobe bacteriu,, is the responsible pathogen in most of the cases (>90%). The antibiotic treatment is prolonged (at least 4-6 weeks); occasionally a parallel surgical approach is necessary. The start of anticoagulant thera-py for internal venous thrombosis associated with LS is still matter of debate.

Diffuse Maculopapular Eruption in a Patient with Lemierre’s Syndrome

Lemierre’s syndrome is a potentially fatal septic thrombophlebitis of the internal jugular vein (IJV) requiring prompt diagnosis and treatment. In this report, we document a unique presentation of an EBV-associated morbilliform eruption coincident with the onset of Lemierre’s syndrome. Furthermore, we argue that a diffuse maculopapular eruption in patients with Lemierre’s syndrome should prompt workup for EBV infection.

Liver Abscesses Due to Fusobacterium nucleatum: A Case Series

Abstract Fusobacteriae are anaerobic gram-negative bacilli, classically involved in the development of septic thrombophlebitis of the internal jugular vein in Lemierre syndrome. The goal of this study is to describe the various presentations, treatment course, and outcomes of patients with Fusobacterium liver abscess(es) and review available literature on this topic. We retrospectively reviewed our microbiologic database for positive cultures of Fusobacteriae species in a tertiary care hospital from July 2018 through November 2022 and identified 5 cases of liver abscess that involved Fusobacterium nucleatum species. Patients presented with a syndrome of fever and chills, abdominal pain, and nausea and vomiting. Laboratory investigations revealed leukocytosis and transaminitis, and imaging revealed liver abscess(es). The identification of the F. nucleatum bacteria involved invasive aspiration of the abscess in all but one case, where it was identified on blood cultures. One patient had a florid picture of sepsis and acute respiratory distress syndrome. All patients responded well with intravenous antibiotics and were discharged home to complete a prolonged course until radiographic resolution. In 3 patients, history and imaging were suggestive of possible sources that may have hematogenously spread to the liver, with history of recent appendectomy in 1 patient, possible appendicitis on computed tomography of the abdomen in another patient, and recent dental manipulation in the third patient. In conclusion, Fusobacteriae should be included in the differential diagnosis of liver abscess, especially in the setting of recent appendicitis or dental disease. Effective treatment includes surgical drainage when feasible and prolonged course of antibiotics with goal of radiologic resolution.

Septic thrombophlebitis of portal and splenic vein secondary to Fusobacterium nucleatum: A case report of an abdominal variant of lemierre syndrome.

Septic thrombophlebitis of the internal jugular vein also known as Lemierre syndrome occurs secondary to an oropharyngeal infection often leading to septic embolisms to distant sites. Anaerobic gram-negative bacillus, Fusobacterium nucleatum and Fusobacterium necrophorum are commonly isolated organisms. Fusobacterium species has also been reported to complicate an intra-abdominal infection leading to septic thrombophlebitis of portal vein also known as pylephlebitis or abdominal variant of lemierre syndrome. The patient was a middle-aged female patient with chief complaints of abdominal discomfort, intermittent fever and vomiting for one month. The final diagnosis was septic thrombophlebitis of portal and splenic vein secondary to Fusobacterium nucleatum. Patient was managed with broad spectrum intravenous antibiotics with coverage against gram-negative bacilli, anaerobes, and aerobic streptococcus species with therapeutic anticoagulation. Patient gradually improved and was discharged on oral apixaban. She was instructed to follow up with gastrointestinal specialist upon discharge in anticipation of the need for liver transplant in future. Due to its high mortality and associated long term disease morbidity, clinicians should always strive towards early diagnosis and treatment of the condition with involvement of multidisciplinary teams.

A DEVASTATING COMPLICATION OF DENTAL EXTRACTION: LEMIERRE’S SYNDROME WITH NECK AND MEDIASTINAL ABSCESS

A dental extraction is a frequently performed procedure in daily routine. Fatal infections may occur after dental extraction due to the richness of the oropharyngeal flora from aerobic and anaerobic microorganisms. Oropharyngeal infections can extend into the neck and mediastinum via cervical fascia leading to severe inflammation in soft tissues and vessels with life-threatening complications. We present a patient with complications after dental extraction procedure including severe deep neck inflammation, thrombophlebitis of jugular vein (Lemierre’s syndrome), mediastinal abscess, and empyema. A dental extraction is the most frequent cause of the oral infection that may cause coexisting and individually life-threatening complications in diabetic patients.

SAT141 A Case Of Non-islet Cell Tumor Hypoglycemia Which Was Ameliorated By Pazopanib Treatment

Abstract Disclosure: N. Yamamoto: None. M. Yamamoto: None. N. Kiyota: None. Y. Inaba: None. K. Kanie: None. S. Urai: None. M. Suzuki: None. Y. Sasaki: None. Y. Oi: None. Y. Tsujimoto: None. Y. Motomura: None. Y. Ohmachi: None. H. Bando: None. G. Iguchi: None. M. Nagao: None. I. Fukuda: None. H. Fukuoka: None. W. Ogawa: None. Introduction: Non-islet cell tumor hypoglycemia (NICTH) is a rare paraneoplastic syndrome caused by insulin-like growth factor II (IGF-II) hypersecretion from the tumors. It is characterized by incompletely processed big IGF-II with potent insulin-like activity. We present a case of NICTH complicated with solitary fibrous tumor (SFT) which was ameliorated with the administration of pazopanib, a multi-targeted tyrosine kinase inhibitor. Clinical Case: A 57-year-old man went into a coma and was hospitalized. His plasma glucose levels were 26 mg/dL, and he regained consciousness after glucose administration, leading to a diagnosis of hypoglycemic coma. Moreover, a contrast-enhanced CT scan showed multiple tumors in his liver and right kidney. He was referred to our hospital for further management. After 5 hours of fasting, he had a cold sweat, and his plasma glucose levels dropped to 32 mg/dL with suppressed serum insulin levels of 0.2 U/mL. Serum 3-hydroxybutyrate levels were as low as 21 μmol/L, and plasma glucose levels increased to 83 mg/dL after glucagon administration, suggesting an agent mimicking insulin. Percutaneous liver biopsy was performed, and the tumors were diagnosed with SFT. Immunoblotting for his serum showed big IGF-II, leading to a diagnosis of NICTH, and hypoglycemia due to hypersecretion of IGF-II. Due to multiple metastases, surgery was not indicated and pazopanib was administered. Hypoglycemia during the night was prevented by glucose infusion through the central venous port, and he was discharged. Three months later, when he was re-hospitalized for thrombophlebitis of the right jugular vein, hypoglycemia did not occur even after 10 hours of fasting and CT scan showed the necrotic change of the tumor. Two weeks later of pazopanib discontinuation due to the thrombogenic adverse effect, hypoglycemia recurred accompanied by the tumor enlargement. When the anticoagulation therapy regressed the thrombosis and pazopanib was re-administered, hypoglycemia improved reproducibly and remained stable for more than 2 years although the tumor showed gradual progression. Conclusion: This is the first case in which pazopanib was effective in suppressing NICTH associated with SFT. Presentation: Saturday, June 17, 2023

Lemierre's Syndrome in the 21st Century: A Literature Review.

Lemierre's syndrome is a rare, life-threatening complication of an acute oropharyngeal infection. It is generally characterised by pharyngitis secondary to Fusobacterium necrophorum, causing thrombophlebitis of the internal jugular vein and sepsis, with subsequent formation of septic emboli that can rapidly spread to different organ sites. The condition is associated with high mortality if treatment with antibiotics is delayed, and recent evidence suggests that patients are at significant risk of in-hospital morbidity and long-term neurological sequelae. Although it is agreed that antibiotics are the mainstay of treatment, there is currently no consensus on the use of anticoagulation in the condition. This review article aims to summarise our current understanding of Lemierre's syndrome with regard to its definition, epidemiology, microbiology, presentation, diagnosis, and treatment.

Lung abscess as a complication of Lemierre Syndrome in adolescents: a single center case reports and review of the literature

BackgroundFusobacterium necrophorum is an anaerobic, gram-negative, non-motile, filamentous, non-spore forming bacillus found in the oral cavity, gastrointestinal tract, and female genital tract, responsible of a rare disease named Lemierre Syndrome, characterized by septic thrombophlebitis of the internal jugular vein, which mainly affects previously healthy adolescents and young adults; some risk factors are reported, as smoking or primary viral or bacterial infection leading to the disruption of mucosa. The syndrome originates commonly from an upper respiratory infection such as pharyngotonsillitis, acute otitis media, cervical lymphadenitis, sinusitis, or odontogenic abscess, and may result in multiorgan metastasis, more frequently leading to pulmonary complications, especially lung abscesses.Case presentationWe describe two cases of adolescents with atypical Lemierre Syndrome evaluated in a tertiary care center, one with a confirmed infection by Fusobacterium necrophorum and one with a presumptive diagnosis based on clinical features, who developed lung abscesses needing a prolonged antibiotic course and hospitalization. Of interest, both were user of electronic cigarette, configuring a possible new risk factor. The proper diagnosis of Lemierre Syndrome is often difficult to establish, so a high degree of suspicion is needed, especially in the case of lung abscesses in otherwise healthy adolescents.ConclusionThe current study will contribute to providing insight into Lemierre Syndrome clinical presentation and management in adolescents, promoting awareness for a rare but potentially fatal disease. Moreover, it suggests a possible relationship between Lemierre syndrome and the use of electronic cigarette, that should be investigated by future studies.

Emergency Department Point-of-care Ultrasound Identification of Suspected Lemierre's Syndrome: A Case Report.

Lemierre's syndrome is septic thrombophlebitis of the internal jugular vein, most commonly associated with head and neck infections. While central catheters are associated with venous thromboembolism and catheter-associated bacterial infections, cases of Lemierre's syndrome caused by central catheters are extraordinarily rare. We detail a case of Lemierre's syndrome resulting from a peripherally inserted central catheter in a pregnant female patient. Diagnosis of this rare and potentially life-threatening disease process was expedited using point-of-care ultrasound. Diagnosis of rare but potentially life- or limb-threatening pathologies is paramount to the successful practice of emergency medicine. Identifying these rare disease processes requires a high index of suspicion and a work-up strategy that includes consideration of medical history in combination with lab and imaging findings to determine appropriate interventions.

Lemierre syndrome: a hidden complication of sore throats

BackgroundLemierre syndrome is a rare but potentially life-threatening condition characterized by septic thrombophlebitis of the internal jugular vein, most commonly caused by Fusobacterium necrophorum.Case presentationA 46-year-old woman with no significant medical history presented with generalized neck swelling and fever. Despite seeking medical attention at multiple outpatient clinics for upper respiratory symptoms lasting 10 days, she only received symptomatic treatment for acute viral pharyngitis. A computed tomography (CT) scan of her neck revealed thrombophlebitis in the left internal jugular vein, and subsequent cultures indicated the presence of Klebsiella pneumoniae. The patient’s oxygen saturation levels suddenly dropped, and the CT scan identified bilateral peripheral consolidation areas in both lungs, consistent with septic emboli. These findings were consistent with a diagnosis of Lemierre syndrome. The patient was treated with 2 weeks of intravenous piperacillin/tazobactam and vancomycin, as well as anticoagulation therapy using heparin, and her symptoms resolved completely.ConclusionThis report presents an unusual occurrence of Lemierre syndrome caused by K. pneumoniae, a less frequently encountered causative pathogen in patients without diabetes mellitus. The case highlights the significance of timely and appropriate antibiotic use to prevent potential complications.

Case Report: Abdominal variant of Lemierre’s syndrome

Lemierre's syndrome is a rare condition characterized by Fusobacterium bacteremia from an oropharyngeal source with septic emboli causing internal jugular vein (IVJ) thrombophlebitis in an otherwise young and healthy host. Rare variants of this rare disease have been described impacting the gastrointestinal, pulmonary, neurologic, musculoskeletal, soft tissue, and genitourinary systems. We discuss a case of an abdominal variant of Lemierre's syndrome. An otherwise young and healthy male presented with two pyogenic hepatic abscesses, Fusobacterium necrophorum bacteremia, and local hepatic venous thrombosis. The hepatic abscesses were percutaneously drained, he received broad-spectrum antibiotics and therapeutic-level anticoagulation, and he showed marked clinical improvement over a six-day hospital course. He was discharged with four weeks of daily oral and intravenous (IV) antibiotics, six months of direct oral anticoagulation, and close follow up. Clinicians should consider thrombophlebitis in more anatomical locations than the IVJ which is found classically in Lemierre’s syndrome in the setting of Fusobacterium bacteremia.

Acute Cerebellar Stroke of Unclear Etiology Complicated by Lemierre’s Disease and Papillary Thyroid Carcinoma (P2-10.001)

<h3>Objective:</h3> NA <h3>Background:</h3> Lemierre’s Disease is a rare condition that is usually caused by bacterial oropharyngeal infection, most common organism being Fusobacterium necrophorum, that is complicated by thrombophlebitis of the internal jugular vein. Below, is a case in which our stroke patient was found to have Lemierre’s Disease after obtaining a Karius panel. <h3>Design/Methods:</h3> Chart review for case report presentation. <h3>Results:</h3> 53-year-old female with no known medical history presented with headache, nausea, vomiting, fever and chills for three days. Lumbar puncture obtained was suggestive of bacterial source with elevated WBCs, nucleated cells with neutrophilic predominance, though her meningitis/encephalitis PCR panel was negative. Broad spectrum antibiotics was started. MRI brain showed a large ischemic right cerebellar infarct with mass effect. CTA of the head and neck, CT venography and MR venography showed nonocclusive thrombi of right proximal internal jugular vein and sigmoid sinuses. Repeat scans showed increasing hydrocephalus requiring EVD placement with eventual removal after improvement of mental status and serial imaging. Karius panel was positive for Fusobacterium nucleatum and porphyromonas gingivalis, and patient’s antibiotics was narrowed to reflect results. CT maxillofacial and neck showed extensive cervical lymphadenopathy and multiple periapical lucencies in teeth. IR guided cervical lymph node biopsies confirmed papillary thyroid carcinoma. Dentistry removed patient’s affected teeth. <h3>Conclusions:</h3> Although our patient had a large ischemic infarct, the more concerning issue was her concurrent meningitis from a bacterial source that caused a hypercoagulable state. With the Karius panel’s result, we promptly localized the infection and adjusted the patient’s antimicrobial management accordingly. Her clinical presentation continued to improve with treatment, and she was discharged to acute rehabilitation. Given the Karius panel’s rapid turnaround, in comparison to other metagenomic sequencing of CSF, we conclude that it is imperative to consider utilizing Karius panel testing for meningitis evaluation, especially in the setting of unremarkable meningitis/encephalitis PCR panel. <b>Disclosure:</b> Dr. Ho has nothing to disclose. Dr. Long has nothing to disclose. Dr. Kronfeld has nothing to disclose.

Investigation of the Association between Recreational Scuba Diving and a Case of Acute Lemierre’s Syndrome: Will it Recur?

Lemierre’s Syndrome (LS) is a septic thrombophlebitis of the internal jugular vein following acute pharyngitis commonly caused by anaerobic bacteria. We postulate a rare source of infection in a young male never before cited in the literature, scuba diving. We discuss the patient’s risk factors which we postulate likely caused an altered innate immunity, and when combined with superimposed barotrauma, likely provoked the infection. We then consider the possibility of disease recurrence and make certain recommendations for prevention. Additionally, we highlight the importance of early diagnosis in potentially critical diseases such as LS.

Lemierre's syndrome: an evolving disease

Lemierre’s syndrome is characterized by thrombophlebitis of the internal jugular vein with resulting systemic septic emboli. Most cases occur following an oropharyngeal infection and have been historically caused by the bacterial pathogen Fusobacterium necrophorum. However, infection from other pathogens is becoming more common in recent years. Our case is special in the sense that Lemierre’s syndrome was caused by staphylococcus aureus after influenza infection. A 23-month-old male presented with complaints of left neck swelling and recurrent fever for one week, following influenza A infection. The child was ill-appearing with fever, tachycardia, tachypnea, and erythematous swelling on the left cheek. Laboratory results revealed elevated inflammatory markers. Computed tomography (CT) scan of the neck showed loculated fluid collection suggesting an intra parotid abscess with poor visualization of the internal jugular vein (IJV). Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Due to high clinical suspicion of Lemierre’s syndrome, a doppler ultrasound was obtained which showed a left IJV thrombus. CT scan of the chest after the clinical suspicion showed multiple bilateral pulmonary nodules suggesting septic emboli. He was treated with antibiotics and a six-week course of the anticoagulant with a resolution of his thrombus. Though historically, Lemierre’s disease is caused by Fusobacterium necrophorum, other causative organisms such as methicillin-sensitive Staphylococcus aureus are increasingly being recognized. Lemierre’s disease can present as a complication of influenza. A high index of clinical suspicion based on the location of the abscess helped us delineate diagnostic tests and treatment.

Two cases of aseptic internal jugular vein thrombophlebitis associated with hemodialysis catheter, presenting as sore throat: case report and literature review

BackgroundNon-cuffed hemodialysis (HD) catheters are often used for emergency or temporary vascular access. Its complications include thrombosis and catheter-related bloodstream infection (CRBSI); however, thrombophlebitis can also occur. Thrombophlebitis of the internal jugular vein (IJV) may present with symptoms, such as fever, lateral neck pain, and swelling, regardless of the presence or absence of infection; however, symptoms may be minor and easily overlooked. Sore throat is a well-known symptom of Lemierre's syndrome, but has not been reported in cases of thrombophlebitis without infection. We report two cases of HD catheter-associated IJV thrombophlebitis in patients that were diagnosed with sore throat.Case presentationCase 1 included a 58-year-old woman with diabetic nephropathy on HD. She was admitted to our hospital due to the occlusion of an arteriovenous fistula (AVF) for dialysis. A temporary HD catheter was placed in the right IJV until an arteriovenous graft (AVG) was fabricated. After admission, CRBSI was suspected because she developed fever; however, bacteremia was ruled out and a sore throat gradually developed. Contrast-enhanced computed tomography (CT) revealed thrombophlebitis of the right IJV. Anticoagulation therapy was initiated and she was discharged due to an improvement of symptoms. Case 2 included an 83-year-old man with end-stage renal disease due to hypertensive nephrosclerosis. He was admitted to our hospital because of AVF occlusion. A temporary HD catheter was inserted into the right IJV and an AVG was created. He had elevated C-reactive protein levels after catheter placement but was asymptomatic. When removing the catheter, he complained of throat discomfort. Ultrasonography of the neck revealed thrombotic obstruction of the right IJV, and contrast-enhanced CT revealed thrombophlebitis of the right IJV. Blood culture results were negative. He was discharged after anticoagulation therapy was started and symptoms improved.ConclusionsThe presence of sore throat leads to the diagnosis of IJV thrombophlebitis. Pharyngeal symptoms that develop after central venous catheter (CVC) placement should be differentiated from thrombophlebitis using a minimally invasive vascular ultrasound.

LEMIERRE'S SYNDROME: A REVIEW

Lemierre's syndrome is a rare and less commonly occurring clinical condition that generally relates to the septic thrombophlebitis of the Internal Jugular vein. Mostly the clinicians have forgotten about this due to less incidence, the most common bacteria causing infection are and Streptococci followed by styaphylococci and Klebsiella [1] . The major proportion of cases that come to light are due to deep neck space infections that ultimately leads to thrombotic involvement of IJV, accounts for for majority of the cases. The other causes include complications of chronic suppurative otitis media and thrombosis occurring in deep veins. Since the Internal Jugular Vein is involved the infection can also undergo hematogenous spread. The infection generally spreads to Spleen, Liver, Kidney, Heart and Brain. [3][4] Lemierre's syndrome can be diagnosed on the basis of clinical symptoms, multitude of blood series and Imaging. Since it is an infectious condition the treatment involves systemic antibiotic therapy and early administration of broad spectrum antibiotics in high dose become necessary for prevention of complications and systemic spread of infection. [3][4] We are presenting a case series of 5 cases over a period of six years from November 2015 to November 2021.