Otogenic Lateral Sinus Thrombosis in Children: A Review … · One patient with cavernous sinus...
1
CASE EXAMPLE A ten-year old female presented to the emergency room with a history of ataxia and blurry vision. On physical exam she was noted to have papilledema and right otorrhea. CT scan demonstrated mastoid and ethmoid opacification on the right and a triangle of contrast-enhanced dura at the level of the sigmoid sinus, the so-called “delta” sign (Fig. 1). MRV was obtained and demonstrated right sigmoid and transverse sinus thrombosis, right proximal internal jugular vein thrombosis, and bilateral cavernous sinus thrombosis (Fig. 2). The patient underwent urgent tympanomastoidectomy with unroofing of the sigmoid sinus, BMTT, and right-sided FESS. In addition to IV antibiotics, the patient was anticoagulated post-operatively. The patient recovered well, but she was left with a persistent right visual field deficit. Repeat MRV two months post-op showed a persistent thrombosis. An MRV obtained nine months after surgery demonstrated improved flow on the right side, but the thrombosis had not yet fully resolved. Otogenic Lateral Sinus Thrombosis in Children: A Review of Seven Cases Jesse T. Ryan MD 1 , Diego A. Preciado MD PhD 2,3 , Maria Pena MD 2,3 , George H. Zalzal MD 2,3 1 Department of Otolaryngology, National Naval Medical Center, Bethesda, MD 2 Divisions of Pediatric Otolaryngology-Head and Neck Surgery, Children’s National Medical Center, Washington, DC 3 George Washington University School of Medicine and Health Sciences, Washington, DC ABSTRACT Objective: Otogenic lateral sinus thrombosis (LST) is a rare but serious intracranial complication of acute or chronic otitis media (OM). Mortality rates for LST are quoted as 8-25% in most recent larger case series. Controversy exists regarding the surgical and medical management of LST. We sought to clarify this by reviewing our experience in patients who presented with otogenic LST in the past eight years. Method: A retrospective chart review was conducted. Seven patients were identified and charts were examined for presentation, co-existing intracranial complications, treatment, cultured organisms, and outcome. Result: Patients most commonly presented with fever (5/7), otalgia (5/7), and mastoid tenderness (4/7). Co-existing intracranial complications were present in 4/7 patients, including meningitis (1/7), epidural abscess (2/7), otitic hydrocephalus (2/7), and cavernous sinus thrombosis (1/7). All patients received IV antibiotics and underwent mastoidectomy with unroofing of the sigmoid sinus and tympanostomy tube placement. Thrombectomy was not performed on any patient. Anticoagulation was used on 5/7 patients without complication. Streptococcus sp. was the most common organism isolated (2/7). All patients recovered well without major sequelae. One patient with cavernous sinus thrombosis and otitic hydrocephalus had a persistent right visual field deficit. Conclusion: In this limited series, we demonstrate good outcomes by emergently treating LST from an otitic source with mastoidectomy and unroofing of the sigmoid sinus, IV antibiotics, and selective anticoagulation. We did not find thrombectomy to be necessary. REFERENCES 1. Samuel et al. Lateral sinus thrombosis (a review of 45 cases). The Journal of laryngology and otology (1987) vol. 101 (12) pp. 1227-9 2. Mathews. Lateral sinus pathology (22 cases managed at Groote Schuur Hospital). The Journal of laryngology and otology (1988) vol. 102 (2) pp. 118-20 3. Teichgraeber et al. Lateral sinus thrombosis: a modern perspective. Laryngoscope (1982) vol. 92 (7 Pt 1) pp. 744-51 4. Kangsanarak et al. Intracranial complications of suppurative otitis media: 13 years' experience. The American journal of otology (1995) vol. 16 (1) pp. 104-9 5. Wong et al. Pediatric lateral sinus thrombosis: retrospective case series and literature review. The Journal of otolaryngology (2005) vol. 34 (2) pp. 79-85 6. Kuczkowski et al. Intracranial complications of acute and chronic mastoiditis: report of two cases in children. Int J Pediatr Otorhinolaryngol (2001) vol. 60 (3) pp. 227-37 7. Azzi et al. Lateral sinus thrombosis: serious complication of otitis media. The Journal of otolaryngology (2005) vol. 34 (6) pp. 427-31 8. Lubianca Neto et al. Lateral sinus thrombosis and cervical abscess complicating cholesteatoma in children: case report and review. Int J Pediatr Otorhinolaryngol (1998) vol. 42 (3) pp. 263-9 9. Kaplan et al. Otogenic lateral sinus thrombosis in children. Int J Pediatr Otorhinolaryngol (1999) vol. 49 (3) pp. 177-83 10. Garcia et al. Lateral sinus thrombosis associated with otitis media and mastoiditis in children. Pediatr Infect Dis J (1995) vol. 14 (7) pp. 617-23 11. Ooi et al. Management of lateral sinus thrombosis: update and literature review. The Journal of laryngology and otology (2003) vol. 117 (12) pp. 932-9 12. Holzmann et al. Lateral dural sinus thrombosis in childhood. Laryngoscope (1999) vol. 109 (4) pp. 645- 51 13. Tov et al. Conservative nonsurgical treatment of a child with otogenic lateral sinus thrombosis. Am J Otolaryngol (2008) vol. 29 (2) pp. 138-41 RESULTS Seven patients with otogenic lateral sinus thrombosis were treated at our institution in the eight years from 2000 to 2008. Patients most commonly presented with fever (5/7) and otalgia (5/7), followed by mastoid tenderness (4/7). Co-existing intracranial complications were present in four patients (57%). These included epidural abscess (2/7), otitic hydrocephalus (2/7), meningitis (1/7), and cavernous sinus thrombosis (1/7). Streptococcus sp. was the most common organism isolated (2/7). Table 1 summarizes the clinical presentations, intracranial complications, treatments, organisms isolated, and outcomes for our seven patients. All patients recovered well without major sequelae. One patient with cavernous sinus thrombosis and otitic hydrocephalus had a persistent right visual field deficit. All patients received intravenous antibiotics and underwent mastoidectomy with unroofing of the sigmoid sinus and tympanostomy tube placement. Sinus exploration with thrombectomy was not performed on any patient. Anticoagulation was used perioperatively on five patients (71%) without complication. INTRODUCTION Otogenic lateral sinus thrombosis is a rare but serious intracranial complication of acute or chronic otitis media. Mortality rates are quoted as 8-25% in most recent, larger case series 1-4 , but pediatric mortality rate may be as low as 5% 5 . Controversy still exists over the medical and surgical management of this condition. Management has traditionally included intravenous antibiotic therapy and mastoidectomy with thrombus removal 1,6-9 . Anticoagulation is used perioperatively in some cases, and its use continues to be an area of debate. Internal jugular vein ligation, historically a common part of surgical intervention, is no longer routinely employed 10-12 . Successful non-surgical management of otogenic lateral sinus thrombosis has recently been reported in highly selected patients 5,13 . We examined our recent experience in treating this rare condition. METHODS & MATERIALS A retrospective chart review was conducted from January 2000 to January 2008. Seven patients were identified with a diagnosis of otogenic lateral sinus thrombosis and their charts were examined for presentation, co-existing intracranial complications, treatment, cultured organisms, and outcome. CONCLUSIONS In this limited series of seven patients treated in our institution over an eight year period, we demonstrate good outcomes by emergently treating lateral sinus thrombosis from an otitic source with mastoidectomy and unroofing of the sigmoid sinus, tympanostomy tube placement, intravenous antibiotics, and selective anticoagulation. In agreement with the trend toward more conservative surgical management, we did not find thrombectomy to be necessary. Case/Age(y) / Sex Presentation Intracranial Complication Treatment Organism Outcome 1/11/M Fever, right frontal headache, nuchal rigidity, otalgia Right lateral, transverse and internal jugular thrombosis, left transverse sinus thrombosis Right simple mastoidectomy, right myringotomy and tube, right maxillary sinus irrigation, anticoagulation ------- No sequelae 2/8/M Fever, otalgia, mastoid tenderness Left lateral sinus thrombosis and left peri-sinus epidural abscess Left complete mastoidectomy with drainage of peri-sinus epidural abscess, left myringotomy and tube No growth No sequelae 3/15/M Fever, otalgia, mastoid tenderness Right lateral and transverse sinus thrombosis and internal jugular vein thrombosis Right simple mastoidectomy, right myringotomy and tube Streptococcus pneumoniae No sequelae 4/15/M Fever, otalgia, otorrhea, headache, nuchal pain/rigidity Right sigmoid sinus thrombosis, meningitis Right simple mastoidectomy, right myringotomy and tube, anticoagulation Streptococcus Group A No sequelae 5/6/F Ophthalmoplegia and papilledema present 4 days after discharge from initial hospitalization Bilateral lateral sinus thrombosis, right internal jugular vein thrombosis, bilateral posterior fossae epidural abscesses, right middle fossa epidural abscess, otitic hydrocephalus Bilateral complete mastoidectomies with drainage of abscesses, anticoagulation No growth No sequelae 6/10/F Blurry vision, papilledema, ataxia Right sigmoid and transverse sinus thrombosis, Right proximal internal jugular vein thrombosis, bilateral cavernous sinus thrombosis, otitic hydrocephalus Right tympanomastoidectomy, right endoscopic sinus surgery, bilateral myringotomy and tympanostomy tube, anticoagulation No growth Right visual field deficit 7/13/F Fever, altered mental status, nausea, vomiting, diarrhea, otalgia, otorrhea, nuchal rigidity, mastoid tenderness Right sigmoid and transverse sinus thrombosis, Right internal jugular vein thrombosis with extension into right innominate vein, right subperiosteal abscess Bilateral myringotomy and tympanostomy tube placement, incision and drainage subperiosteal abscess, staged tympanomastoidectomy (delayed due to low hematocrit), anticoagulation Proteus mirabilis; Corynebacterium sp. No sequelae Figure 2: Right sigmoid sinus, transverse sinus, and IJV thrombosis Figure 1: Delta sign Table 1: Summary of clinical presentation, intracranial complications, treatments, organisms isolated, and outcomes for our seven patients.
Transcript of Otogenic Lateral Sinus Thrombosis in Children: A Review … · One patient with cavernous sinus...
CASE EXAMPLEA ten-year old female presented to the emergency room with a history of ataxia and blurry vision. On physical exam she was noted to have papilledema and right otorrhea. CT scan demonstrated mastoid and ethmoid opacification on the right and a triangle of contrast-enhanced dura at the level of the sigmoid sinus, the so-called “delta” sign (Fig. 1). MRV was obtained and demonstrated right sigmoid and transverse sinus thrombosis, right proximal internal jugular vein thrombosis, and bilateral cavernous sinus thrombosis (Fig. 2). The patient underwent urgent tympanomastoidectomy with unroofing of the sigmoid sinus, BMTT, and right-sided FESS. In addition to IV antibiotics, the patient was anticoagulated post-operatively. The patient recovered well, but she was left with a persistent right visual field deficit. Repeat MRV two months post-op showed a persistent thrombosis. An MRV obtained nine months after surgery demonstrated improved flow on the right side, but the thrombosis had not yet fully resolved.
Otogenic Lateral Sinus Thrombosis in Children: A Review of Seven Cases
Jesse T. Ryan MD1, Diego A. Preciado MD PhD2,3, Maria Pena MD2,3, George H. Zalzal MD2,3
1Department of Otolaryngology, National Naval Medical Center, Bethesda, MD2Divisions of Pediatric Otolaryngology-Head and Neck Surgery, Children’s National Medical Center, Washington, DC
3George Washington University School of Medicine and Health Sciences, Washington, DC
ABSTRACTObjective: Otogenic lateral sinus thrombosis (LST) is a rare but serious intracranial complication of acute or chronic otitis media (OM). Mortality rates for LST are quoted as 8-25% in most recent larger case series. Controversy exists regarding the surgical and medical management of LST. We sought to clarify this by reviewing our experience in patients who presented with otogenic LST in the past eight years.
Method: A retrospective chart review was conducted. Seven patients were identified and charts were examined for presentation, co-existing intracranial complications, treatment, cultured organisms, and outcome.
Result: Patients most commonly presented with fever (5/7), otalgia (5/7), and mastoid tenderness (4/7). Co-existing intracranial complications were present in 4/7 patients, including meningitis (1/7), epidural abscess (2/7), otitic hydrocephalus (2/7), and cavernous sinus thrombosis (1/7). All patients received IV antibiotics and underwent mastoidectomy with unroofing of the sigmoid sinus and tympanostomytube placement. Thrombectomy was not performed on any patient. Anticoagulation was used on 5/7 patients without complication. Streptococcus sp. was the most common organism isolated (2/7). All patients recovered well without major sequelae. One patient with cavernous sinus thrombosis and otitic hydrocephalus had a persistent right visual field deficit.
Conclusion: In this limited series, we demonstrate good outcomes by emergently treating LST from an otitic source with mastoidectomy and unroofing of the sigmoid sinus, IV antibiotics, and selective anticoagulation. We did not find thrombectomy to be necessary.
REFERENCES1. Samuel et al. Lateral sinus thrombosis (a review of 45 cases). The Journal of laryngology and otology
(1987) vol. 101 (12) pp. 1227-92. Mathews. Lateral sinus pathology (22 cases managed at Groote Schuur Hospital). The Journal of
laryngology and otology (1988) vol. 102 (2) pp. 118-203. Teichgraeber et al. Lateral sinus thrombosis: a modern perspective. Laryngoscope (1982) vol. 92 (7 Pt 1)
pp. 744-514. Kangsanarak et al. Intracranial complications of suppurative otitis media: 13 years' experience. The
American journal of otology (1995) vol. 16 (1) pp. 104-95. Wong et al. Pediatric lateral sinus thrombosis: retrospective case series and literature review. The
Journal of otolaryngology (2005) vol. 34 (2) pp. 79-856. Kuczkowski et al. Intracranial complications of acute and chronic mastoiditis: report of two cases in
children. Int J Pediatr Otorhinolaryngol (2001) vol. 60 (3) pp. 227-377. Azzi et al. Lateral sinus thrombosis: serious complication of otitis media. The Journal of otolaryngology
(2005) vol. 34 (6) pp. 427-318. Lubianca Neto et al. Lateral sinus thrombosis and cervical abscess complicating cholesteatoma in
children: case report and review. Int J Pediatr Otorhinolaryngol (1998) vol. 42 (3) pp. 263-99. Kaplan et al. Otogenic lateral sinus thrombosis in children. Int J Pediatr Otorhinolaryngol (1999) vol. 49
(3) pp. 177-8310. Garcia et al. Lateral sinus thrombosis associated with otitis media and mastoiditis in children. Pediatr
Infect Dis J (1995) vol. 14 (7) pp. 617-2311. Ooi et al. Management of lateral sinus thrombosis: update and literature review. The Journal of
laryngology and otology (2003) vol. 117 (12) pp. 932-912. Holzmann et al. Lateral dural sinus thrombosis in childhood. Laryngoscope (1999) vol. 109 (4) pp. 645-
5113. Tov et al. Conservative nonsurgical treatment of a child with otogenic lateral sinus thrombosis. Am J
Otolaryngol (2008) vol. 29 (2) pp. 138-41
RESULTSSeven patients with otogenic lateral sinus thrombosis were treated at our institution in the eight years from 2000 to 2008. Patients most commonly presented with fever (5/7) and otalgia (5/7), followed by mastoid tenderness (4/7). Co-existing intracranial complications were present in four patients (57%). These included epidural abscess (2/7), otitic hydrocephalus (2/7), meningitis (1/7), and cavernous sinus thrombosis (1/7). Streptococcus sp. was the most common organism isolated (2/7). Table 1 summarizes the clinical presentations, intracranial complications, treatments, organisms isolated, and outcomes for our seven patients. All patients recovered well without major sequelae. One patient with cavernous sinus thrombosis and otitic hydrocephalus had a persistent right visual field deficit. All patients received intravenous antibiotics and underwent mastoidectomy with unroofing of the sigmoid sinus and tympanostomy tube placement. Sinus exploration with thrombectomy was not performed on any patient. Anticoagulation was used perioperatively on five patients (71%) without complication.
INTRODUCTIONOtogenic lateral sinus thrombosis is a rare but serious intracranial complication of acute or chronic otitis media. Mortality rates are quoted as 8-25% in most recent, larger case series1-4, but pediatric mortality rate may be as low as 5%5. Controversy still exists over the medical and surgical management of this condition. Management has traditionally included intravenous antibiotic therapy and mastoidectomy with thrombus removal1,6-9. Anticoagulation is used perioperatively in some cases, and its use continues to be an area of debate. Internal jugular vein ligation, historically a common part of surgical intervention, is no longer routinely employed10-12. Successful non-surgical management of otogenic lateral sinus thrombosis has recently been reported in highly selected patients5,13. We examined our recent experience in treating this rare condition.
METHODS & MATERIALSA retrospective chart review was conducted from January 2000 to January 2008. Seven patients were identified with a diagnosis of otogenic lateral sinus thrombosis and their charts were examined for presentation, co-existing intracranial complications, treatment, cultured organisms, and outcome.
CONCLUSIONSIn this limited series of seven patients treated in our institution over an eight year period, we demonstrate good outcomes by emergently treating lateral sinus thrombosis from an otitic source with mastoidectomy and unroofing of the sigmoid sinus, tympanostomy tube placement, intravenous antibiotics, and selective anticoagulation. In agreement with the trend toward more conservative surgical management, we did not find thrombectomy to be necessary.
Case/Age(y)/ Sex
Presentation Intracranial Complication
Treatment Organism Outcome
1/11/M Fever, right frontal headache, nuchalrigidity, otalgia
Right lateral, transverse and internal jugular thrombosis, left transverse sinus thrombosis
Right simple mastoidectomy, right myringotomy and tube, right maxillary sinus irrigation, anticoagulation
- - - - - - - No sequelae
2/8/M Fever, otalgia, mastoid tenderness
Left lateral sinus thrombosis and left peri-sinus epidural abscess
Left complete mastoidectomy with drainage of peri-sinus epidural abscess, left myringotomy and tube
No growth No sequelae
3/15/M Fever, otalgia, mastoid tenderness
Right lateral and transverse sinus thrombosis and internal jugular vein thrombosis
Right simple mastoidectomy, right myringotomy and tube
Streptococcus pneumoniae
No sequelae
4/15/M Fever, otalgia, otorrhea, headache, nuchal pain/rigidity
Right sigmoid sinus thrombosis, meningitis
Right simple mastoidectomy, right myringotomy and tube, anticoagulation
Streptococcus Group A
No sequelae
5/6/F Ophthalmoplegia and papilledema present 4 days after discharge from initial hospitalization
Bilateral lateral sinus thrombosis, right internal jugular vein thrombosis, bilateral posterior fossae epidural abscesses, right middle fossaepidural abscess, otitichydrocephalus
Bilateral complete mastoidectomies with drainage of abscesses, anticoagulation
No growth No sequelae
6/10/F Blurry vision, papilledema, ataxia
Right sigmoid and transverse sinus thrombosis, Right proximal internal jugular vein thrombosis, bilateral cavernous sinus thrombosis, otitichydrocephalus
Right tympanomastoidectomy, right endoscopic sinus surgery, bilateral myringotomy and tympanostomy tube, anticoagulation
No growth Right visual field deficit
7/13/F Fever, altered mental status, nausea, vomiting, diarrhea, otalgia, otorrhea, nuchal rigidity, mastoid tenderness
Right sigmoid and transverse sinus thrombosis, Right internal jugular vein thrombosis with extension into right innominate vein, right subperiostealabscess
Bilateral myringotomyand tympanostomy tube placement, incision and drainage subperiostealabscess, staged tympanomastoidectomy(delayed due to low hematocrit), anticoagulation
Proteus mirabilis; Corynebacteriumsp.
No sequelae
Figure 2: Right sigmoid sinus, transverse sinus, and IJV thrombosis
Figure 1: Delta sign
Table 1: Summary of clinical presentation, intracranial complications, treatments, organisms isolated, and outcomes for our seven patients.
