Thrombophlebitis of pinna a rare condition: Role of heparin spray.

Sir,

Thrombophlebitis of pinna is extremely rare in Intensive Care Unit (ICU). Thrombophlebitis is due to inflammation and thrombosis of vein, due to injury of wall of vein, prolonged immobility, infection, and due to various clotting disorder and malignancy.[1] Sign and symptoms are swelling, redness, pain, and tenderness of affected area. Diagnosis is usually clinical, but sometimes Doppler ultrasound required for confirmation. In general, treatment consists of support stockings and wraps, elevate the affected area to reduce swelling, keep pressure off of area to reduce pain, analgesics, anticoagulant and thrombolytic. Rarely, surgical removal or stripping of the vein is needed.

We are reporting a case of 15-year-old male patient admitted in trauma ICU with diagnosis of right temporoparietal contusion on noncontrast computed tomography scan, following a road traffic accident. The patient managed according to ICU protocol for head injury and started to improve. On the 5th day of ICU admission during routine care of the patient, staff nurse noticed that the right pinna was swollen, dark red, and tender on palpation [Figure 1a]. This thrombophlebitis of the right pinna may be due to prolonged pressure following immobilization or due to underlying bone fracture/scalp swelling over right temporal area. The rich network of veins in the temporal bone is in direct communication with extracranial veins which can lead to spread of underlying inflammation or infection to external ear. We manage this case by ensuring proper positioning and use of topical anticoagulant. As an anticoagulant, we used topical heparin preparation (Phlebotroy QPS, Troikaa Pharmaceutical Ltd.) containing 1000 IU/ml of heparin unlike other conventional gel or ointment containing only 200 IU/ml of heparin, 6–8 drops over affected area three times a day. After 3 days of local application, inflammation was resolved, and the color returned to normal [Figure 1b].

Figure 1

(a) Thrombophlebitis over the right pinna. (b) Resolving thrombophlebitis after topical heparin application

On reviewing the literature, it was observed that thrombophlebitis of extremities is very common but rare of pinna in ICU setting. There are various predisposing factors such as vessel wall trauma, multiple irritant drugs infusions, pressure on dependent part, and alteration in blood clotting time in ICU setting. In our case, thrombophlebitis was mainly due to prolonged pressure on the right pinna. Heparin is a naturally occurring anticoagulant, used to reduce extension of inflammation and recurrence of thrombotic events. American College of Chest Physicians guidelines recommends topical heparin for the transfusion-related thrombophlebitis.[2] Poor penetration of drug through the skin limits the efficacy of currently available heparin formulations in the management of inflammation involving skin structures. We successfully used topical anticoagulant containing 1000 IU/ml of heparin with good skin penetration technology without any unwanted side effect.[3] With the experience of managing this case, it can be suggested that topical anticoagulant containing 1000 IU/ml of heparin ensures greater efficacy along with safety compared to conventional gels/ointments of topical heparin.

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