Lateral sinus thrombophlebitis
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Transcript of Lateral sinus thrombophlebitis
Lateral sinus thrombophlebitis
PresentorKamal Ghimire
Lateral sinus thrombophlebitis
Inflammation of inner wall of lateral venous sinus (sigmoid sinus and transverse sinus) with the formation of intrasinus thrombus
Etiology
Occurs as a complication of acute coalescent mastoiditismasked mastoiditis or chronic suppuration of middle ear and cholesteatomaBacteria: In acute: hemolytic streptococcus, pneumococcus or
staphylococcusIn chronic: bacillus proteus,pseudomonas
pyocyaneus,E.coli and staphylococci
Pathogenesis
Formation of perisinus abscess (either by bony erosion of bony dural plate overlying sinus or by thrombosis of emissary vein)
Endophlebitis mural thrombus formation
Occlusion of sinus lumen intrasinus abscess
Extension of infected thrombus
Extension of thrombus• Proximal: confluence of sinus, superior sagittal
sinus, cavernous sinus• Distal : mastoid emissary vein to jugular bulb
and jugular vein
Clinical features
• Hectic picket fence fever with rigors: high fever, irregular, one or more spikes per day Each spike is due to release of fresh septic embolus Fever accompained by chills and rigors Temperature subsides with sweating
• Headache
• Anemia and emaciation
Clinical features…….
• Griesinger’s sign: edema over posterior part of mastoid due to thrombosis of mastoid emissary vein
• Papilloedema: blurring of disc margins, retinal hemorrhages or dilated veins in fundoscopy
• Tenderness along jugular vein
Some tests
Tobey-Ayer test: compression of I.J.V. rapid rise of C.S.F. pressure (50 – 100 mm water rapid fall on release of compression. In thrombosed side no rise.
Crowe - Beck test: pressure on I.J.V. on normal side engorgement of retinal veins + papilloedema seen in fundoscopy due to lateral sinus thrombosis on opposite side.
Investigations
• Blood smear: to rule out malaria• Blood culture• CSF analysis: normal except for rise in pressure• ImagingContrast enhanced CT scanContrast enhanced MRIMR venography• Culture and sensitivity of ear swab
Delta sign
Delta sign(red arrow): traingular area with rim enhancement and central low density area
Complications
• Septicemia and abscess in lung,bone,joints, or subcutaneous tissue
• Meningitis and subdural abscess• Cerebellar abscess• Thrombosis of jugular bulb and jugular vein with
associated cranial nerves involvement• Cavernous sinus thrombosis: proptosis,fixation of
eyeball, and papilloedema• Otitic hydrocephalous
Treatment
• Urgent complete cortical or modified radical mastoidectomy: Sinus wall incised. Infected clots removed & abscess drained
• Antibiotics: broad spectrum antibiotics. Can be changed once culture and sensitivity report is available. Should be continued at least for a week after operation• Anticoagulants: in cavernous sinus thrombosis
4. Internal jugular vein ligation: for embolism not responding to antibiotics & surgery
5. Blood transfusion: for anaemia
Otitic hydrocephalous
Increase in CSF pressure in the presence of acute or chronic otitis media not secondary to brain abscess or meningitis, almost exclusively associated with sigmoid sinus thrombosis.
Etiology
:1. Associated lateral sinus thrombosis obstruction of cerebral venous return.
2. Superior sagittal sinus thrombosis ed C.S.F. absorption
Both of these factors result in raised ICP
Clinical features
• Symptoms1. Severe headache,nausea and vomiting2. Diplopia involving VI cranial nerve3. Blurring of vision• Signs1. Papilloedema with hemorrhages2. Nystagmus3. CSF pressure rises(>300 mm H2O)
TREATMENT
1. Treating L.S.T2. reducing CSF pressure:• I.V. Dexamethasone 4mg Q6H • I.V. 20% Mannitol 0.5 gm/kg • Repeated lumbar puncture / lumbar drain • Ventriculo-peritoneal shunt
References:
• Dhingra ENT and head and neck surgery• Ballenger’s otorhinolaryngology17 head and
neck surgery