Huge save in a patient with neck swelling

Dr. Joel Turner , the fellowship director in Emergency Medicine Ultrasound in McGill’s department of Emergency Medicine at the Jewish General Hospital in Montreal presents the following case.  If this doesn’t make you reach for your ultrasound probe, nothing will!

 

55 year old female sent to the ED because of progressive, non-traumatic swelling of the left side of her neck and cheek. Her endocrinologist sent her in with a referral to rule out abscess or sialoadenitis.

Other than some mild discomfort, she had no other symptoms (no severe pain, no trismus, no fever, no redness). She was seen in our ambulatory area.

Her exam revealed a patient in no distress with a small amount of swelling (figure 1). There was minimal tenderness. Oral pharynx was clear. Middle ear canal normal. There is no doubt that there are many physicians who would have sent this patient home with a presumptive diagnosis of sialoadenitis. with conservative management such as hydration, NSAIDS, sialogogues and gentle massage.

So of course, if I can access it, I will scan it with POCUS, wondering if I will be able to identify a salivary gland stone, or fluid collection.

I did not expect to see what I discovered: Complete thrombosis of the left Internal Jugular vein with some surrounding edema ! (Video 1 and 2)

 

A CT angiogram was performed:

Findings: Complete thrombosis of left internal jugular and subclavian veins, with multiple bilateral pulmonary emboli!!!

Holy crap!!