Visual and neurologic deterioration in otogenic lateral sinus thrombosis: 15 year experience

Objectives

Otogenic lateral sinus thrombosis is a rare complication of acute otitis media whose clinical presentation has changed with the early use of antibiotics. The aim of this study was to analyze the changing clinical signs, vaccination status, therapeutic management and outcome of these patients.

Methods

Retrospective chart review of 10 children treated with otogenic lateral sinus thrombosis in a tertiary level teaching hospital in Budapest, Hungary, from January 1998 till August 2013.

Results

Patients were divided into Early and Late presenting groups. In the Early presenting group, sepsis developed within one week after the onset of acute otitis media. At admission otological symptoms were predominant. The Late presenting group experienced acute otitis media several weeks prior to presentation and in this group neurologic symptoms dominated the clinical picture at admission. All patients received antibiotics. Eight of them were also treated with low molecular weight heparin. All children underwent cortical mastoidectomy. After surgery, the clinical signs of elevated intracranial pressure transiently worsened. This manifested as progression of papilledema in seven children, causing severe visual disturbance in two cases. After medical treatment and serial lumbar punctures all patients except one recovered. This child has permanent visual acuity failure of 0.5 D unilaterally. At one year follow up complete and partial recanalization were noted in five and two patients, respectively.

Conclusions

After mastoidectomy the signs of elevated intracranial pressure can transiently worsen, papilledema can progress. Daily bedside monitoring of visual acuity and regular ophthalmoscopy with neurologic examination is recommended during hospitalization. Close follow up is advised up to one year. When the dominant sinus is occluded, the clinical scenario is more protracted and severe.     

Management of lateral sinus thrombosis.

OBJECTIVES: Review the clinical signs and symptoms, management, bacteriology and outcomes of patients treated for lateral sinus thrombosis. STUDY DESIGN: A retrospective review of six patients, treated from 1993 through 1998, with an intraoperatively confirmed diagnosis of lateral sinus thrombosis. METHODS: All charts from 1993 through 1998 coded for sinus thrombosis, meningitis, brain abscess, otitic hydrocephalus, subdural abscess, and mastoidectomy were reviewed. Operative reports, radiological examinations, laboratory data, culture data and other pertinent data were reviewed. RESULTS: The presenting symptoms ranged from headache to mental status changes. All patients had a history of chronic ear disease and all had at least one additional intracranial complication. The range of additional intracranial complications included otitic hydrocephalus, epidural abscess, and brain abscess. All of the infections were polymicrobial, with a predominance of anaerobes. There were no mortalities; morbidities included anacusis, acute respiratory distress syndrome, reoperation, seizures, septic cardiomyopathy, transfusion, ventriculoperitoneal shunt and nutritional supplementation. CONCLUSION: In patients with otologic disease, complaints of headache, earache or photophobia should warrant an evaluation. The presence of lateral sinus thrombosis mandates further investigation for additional intracranial complications. Conservative surgical intervention, consisting of removal of all perisinus infection and needle aspiration of the sinus, has been found to be effective. Lateral sinus thrombosis is an uncommon complication of otitis media, with potentially significant morbidities, necessitating a high index of suspicion.     

Persistent petrosquamosal sinus: Underlying cause of otitic hydrocephalus with lateral sinus thrombosis

Lateral sinus thrombosis (LST) occurs when a middle ear infection disseminates directly via bone erosion or disseminates indirectly through the venous networks. The petrosquamosal sinus (PSS) is the residual accessory dural sinus connecting intracranial to extracranial drainage. This report describes a case of a patient with persistent PSS running through the mastoid in context of otitic hydrocephalus with LST. To identify PSS, enhanced CT and reconstructed image from CT venography were more useful than MRI. The possibility of persistent PSS running through the mastoid should be considered if LST without marked inflammation and bone erosion is noted.     

Management of otogenic lateral sinus thrombosis

ObjectiveTo evaluate the changing clinical course and trends in management of otogenic lateral sinus thrombosis (OLST), in view of the rarity of the said lesion and antibiotic abuse.MethodsA retrospective case study was done in 6 patients referred to our tertiary care centre with OLST over a period of three years from May 2007 to May 2010: Department of Otorhinolaryngology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi – a tertiary care university teaching hospital under central government of India.Medical records of all the patients were scrutinized and data pertaining to patient profile, type of chronic suppurative otitis media (CSOM), clinical course with any other complication and management were tabulated. The said data was scientifically analyzed w.r.t. current medical literature on the subject.ResultsClinically, it was observed that all patients had protracted CSOM – attico antral type, with history of rampant misuse of antibiotics. The attack of OLST in each case was triggered off by an acute attack of suppurative otitis media. Moreover, in all the cases OLST was masquerading as an intra-cranial complication, with no specific clinical features thereby causing missed diagnosis initially. All these patients were diagnosed by CT scan, and underwent modified radical mastoidectomy (MRM) with needle aspiration of sinus under antibiotic cover. The said treatment protocol resulted in excellent prognosis with no morbidity or mortality whatsoever. Pathologically, cholesteatoma was detected in 5 of the six cases with one case having only granulations.ConclusionsIn this era of antibiotic abuse, the clinical presentation of OLST has altered substantially, and mimics other intra-cranial complication with vague signs and symptoms. There are conflicting views in contemporary medical literature regarding management of OLST. In our experience, MRM with needle aspiration under antibiotic cover is the treatment of choice for all cases of OLST associated with CSOM attico antral disease/cholesteatoma disease.     

Pediatric otogenic lateral sinus thrombosis recanalization

Objective

To describe the recovery outcomes in pediatric patients with otogenic lateral sinus and internal jugular vein thrombosis.

Methods

An inpatient database from a tertiary care pediatric hospital was queried from 1999 to 2010 for the diagnosis code [325] thrombosis of intracranial venous sinus. Demographics, extent of thrombosis, surgical intervention, use of anticoagulation, and the presence of recanalization on follow-up imaging was collected.

Results

Fifteen patients (10 male, 5 female) were identified with otogenic lateral sinus thrombosis. Eleven patients (73.3%) had evidence of thrombus in the transverse sinus, while 10 patients (66.7%) had thrombus in the internal jugular vein, and one patient (6.7%) had thrombus in the cavernous sinus. Five patients (33%) had otitic hydrocephalus. Twelve patients (80%) underwent operative manipulation of the lateral sinus including: three decompressions 20%, three needle aspirations 20%, and six venotomies with evacuation of clot or pus 40%. Twelve patients were anticoagulated with low molecular weight heparin, and three patients were not anticoagulated. Ten of fourteen patients (71.4%) who underwent follow-up magnetic resonance venography had evidence of partial (57.1%) or complete (14.3%) recanalization of the lateral sinus. All five patients with otitic hydrocephalus recovered as determined by a normal fundoscopic exam and recovery of abducens paresis.

Conclusion

Recanalization of the lateral intracranial venous sinus occurred in the majority of the patients in this series. The role of operative intervention and/or anticoagulation remains unclear.     

Prothrombotic factors in children with otitis media and sinus thrombosis

OBJECTIVE: Venous sinus thrombosis (VST) is the second most common intracranial complication of acute otitis media (AOM). There is some evidence that hereditary and acquired prothrombotic disorders are risk factors for VST. The aim of the present study was to evaluate whether children with AOM complicated VST have a prothrombotic tendency, which might have important therapeutic and preventive implications. STUDY DESIGN: Retrospective. METHODS: The files of children hospitalized at Schneider Children's Medical Center of Israel, a tertiary referral center, from 1999 to 2002, because of AOM complicated by acute mastoiditis and VST were reviewed. All children underwent laboratory work-up for hypercoagulability. RESULTS: Seven children met the study criteria. Of these, five had prothrombotic disorders, namely elevated levels of lipoprotein apolipoprotein (Lp[a]) (n = 4), antibodies to beta 2-glycoprotein and to cardiolipin (markers of antiphospholipid syndrome) (n = 4), and heterozygosity for factor V Leiden mutation (n = 1). One child had three abnormalities, two children had two abnormalities, and two children had one abnormality. CONCLUSIONS: A prothrombotic tendency may exist in children with AOM complicated by mastoiditis and VST. Further studies are needed to evaluate its extent.     

Intratemporal and intracranial complications of acute otitis media in a pediatric population

ObjectiveTo review all cases intratemporal and intracranial complications of acute otitis media (AOM) in infants and children from 1998 to 2013.MethodsRetrospective chart review of 109 consecutive patients admitted for complications of AOM during a 15-year period at a tertiary-care children's hospital. The main outcomes are: (1) complications of AOM, (2) bacteriology, (3) management strategies.ResultsIn our population, complications included mastoiditis (86.1%), subperiosteal abscess (38%), facial nerve palsy (16.7%), sigmoid sinus thrombosis (8.3%) and epidural abscess (7.4%). Other complications included post-auricular cellulitis, otic hydrocephalus and elevated intracranial pressure, internal jugular thrombosis, cranial nerve VI palsy and Gradenigo's syndrome, labyrinthine fistula, sensorineural hearing loss, and cerebellar infarct. Sixty-one patients (56%) received antibiotics prior to presentation. Cultures revealed Streptococcus pneumoniae in 36 patients (33.3%), other bacteria in 30 patients (27.8%), and “no growth” in 33 patients (30.5%). Nine patients (8.3%) did not undergo culture. Of the patients with S. pneumoniae, 20 cultures (55%) were found to be multidrug-resistant. Eleven patients (10.2%) were treated non-surgically, 31 (31%) were treated with myringotomy and intravenous antibiotics. Forty patients (97.5%) presenting with subperiosteal abscess required mastoid surgery. Thirteen of 18 (72.2%) patients with facial paralysis had full recovery. Eight of 10 (80%) patients with epidural abscess empyema required mastoid surgery and incision and drainage of the abscess.ConclusionComplications of AOM are uncommon, yet continue to have potentially serious consequences. The bacteriology in this population reveals an increasing trend of multi-drug resistant S. pneumoniae as the causative organism.     

An unusual complication of CSOM — Lateral sinus thrombosis with lung abscess: A clinicoradiological study

Aims To present a case report of a child presenting with lateral sinus thrombosis with bilateral multiple lung abscesses as a rare consequence of CSOM with an emphasis on the radiological findings. Material and methods An 11-year-old male child with a history of pyrexia of unknown origin, right-sided torticollis, cough with expectoration and right ear discharge was referred to us from department of paediatric medicine. Chest examination revealed dull areas on percussion and areas with bronchial breath sounds on auscultation bilaterally. Otological examination revealed right attic retraction pocket filled with cholesteatoma, post-auricular tenderness and Greisinger’s sign along with foul smelling muco-purulent discharge. Results Routine blood investigations revealed normocytic normochromic anaemia, polymorpho-nuclear leucocytosis and raised ESR. Audiological investigations showed a right-sided mixed hearing loss. Digital radiography of chest showed multiple thin walled cavities involving all of the lung zones bilaterally. USG (Ultrasonography) of neck showed thrombosis of right internal jugular vein. CT scanning of head, neck and thorax showed soft tissue collection within the right mastoid with erosion of posterior wall & presence of gas bubble in the right sigmoid sinus and thrombosis of right internal jugular vein and multiple abscess cavities occupying both lung parenchyma. The patient was initially managed with conservative antibiotic therapy for lung abscess followed by radical mastoidectomy and thromboembolectomy from the lateral sinus. Conclusion Otogenic lung abscess though rare in this present postantibiotic era, it can occur in underprivileged and poor population like our country.     

Delayed otogenic hydrocephalus after acute otitis media in pediatric patients: the changing presentation of a serious otologic complication

Conclusions. The clinical presentation of otogenic dural sinus thrombosis (DST) as a complication of acute otitis media (AOM) can be masked by antibiotic treatment. Morning episodes of vomiting and/or headache, visual impairment and a history of AOM seem to be indicative of otogenic hydrocephalus. We therefore advocate that the MRI scans of patients with similar symptoms should be carefully studied to facilitate the early diagnosis of a potentially life-threatening complication. Objective. To describe the frequency, pathognomonic signs, clinical course and outcome of otogenic hydrocephalus and DST as complications of AOM in pediatric patients. Material and methods. We undertook a retrospective chart review of all pediatric patients (age 1–14?years) treated for otitis media and its complications at an academic medical center between 1999 and 2003. The main outcome measures were otologic and ophthalmologic findings and CT and MRI scans at the beginning of treatment and 3?months later. Results. We report on five cases with otogenic DST following AOM. All but one of them presented initially with diplopia caused by otogenic hydrocephalus. In four cases the otologic complaints had already disappeared by the time of MRI confirmation of the diagnosis. Only one child was referred with severe otologic symptoms. Management included systemic antibiotics, short-term heparin anticoagulation and surgical decompression. In our cases, even after intensive i.v. antibiotic treatment, only surgery led to a significant improvement in the clinical condition.     

Cavernous sinus thrombosis following odontogenic and cervicofacial infection

Summary Cavernous sinus thrombosis (CST) is rarely seen clinically as a complication of infectious processes since the discovery of penicillin. At the present time, dental abscess is an uncommon cause of CST. We now report our experiences with a 60-year-old diabetic male, who developed CST 38 days after extraction of an infected upper third molar tooth. The importance of eradicating regional cervicofacial foci of infection is stressed.     

A caution regarding the use of low-molecular weight heparin in pediatric otogenic lateral sinus thrombosis

Lateral sinus thrombosis (LST), a rare complication of otitis media, is managed by antibiotics, surgery and anticoagulation. Traditionally, post-operative anticoagulation has been achieved by intravenous unfractionated heparin followed by oral warfarin. Fractionated, or low-molecular weight heparin derivatives (LMWH) have been introduced recently. There has been minimal literature to date regarding their use for the management of LST. We present use of the LMWH enoxaparin (Lovenox) for otogenic LST in two children, both of whom experienced hemorrhagic complications. On this basis and in the context of a literature review, we urge caution when using LMWH for pediatric otogenic LST.     

Pediatric lateral sinus thrombosis: retrospective case series and literature review

OBJECTIVE: A comparison between the literature and our management of pediatric patients presenting with otogenic lateral sinus thrombosis. DESIGN: A retrospective case series of five pediatric patients. SETTING: Four patients were treated at BC Children's Hospital, whereas the fifth patient was treated in New Westminster, BC. All were treated between 1994 and 2001. METHODS: A retrospective chart review was conducted with a literature review for otogenic lateral sinus thrombosis. MAIN OUTCOME MEASURES: Treatment success was based on resolution of acute infection and neurologic symptoms. RESULTS: Five patients, four males and one female, aged 2 to 14 years were reviewed. Three patients were treated successfully without mastoidectomy. One patient received a mastoidectomy that yielded no pus or granulation tissue within the mastoid cavity. One patient required a mastoidectomy after failure to respond to bilateral myringotomy and tympanostomy tube insertion. Although no pus was seen in the mastoid cavity, perisinus pus was found after unroofing the sigmoid sinus plate; free flow of blood was obtained on needle aspiration of the sinus, and the sinus was not surgically opened. CONCLUSION: The current literature states that the management of otogenic lateral sinus thrombosis includes high-dose intravenous antibiotics with a mastoidectomy and possible opening of the sinus. In our retrospective case series, three of five patients recovered completely without mastoidectomy, and a fourth had a mastoidectomy deemed to have been unnecessary. We conclude that intravenous antibiotics and insertion of a tympanostomy tube are sufficient treatment for selected cases of otogenic lateral sinus thrombosis. Mastoidectomy with possible opening of the sinus should be reserved for patients refractory to the above conservative treatment.     

Myxoma of the lateral skull base: clinical features and management

OBJECTIVE: To evaluate the clinical features and incidence of true myxomas affecting the lateral skull base. MATERIAL AND METHODS: Illustrative case report and review of the relevant literature. Included are all reports of myxomas according to the histopathologic definition of Stout. RESULTS: Despite nine case reports, only four patients matched the histopathologic criteria of a true myxoma growing in the lateral skull base. Facial palsy occurred in three adults with additional otalgia in one and progressive hearing loss (HL) in another patient. Our patient initially presented with signs of recurrent otitis media. The mastoid cavity was involved in all patients. CONCLUSION: Differential diagnosis of lesions occurring in the lateral skull base should include true myxoma. Correct diagnosis should be based on immunohistopathology to rule out malignant tumors. Radical surgery is the treatment of choice, but surgeons should respect vital structures and esthetic consequences.     

Intracranial complications of otitis media: In retrospect

Objective  Evaluating intracranial complications of otitis media. Design  An Evaluative study of 106 cases of intracranial complications secondary to otitis media. Intervention  Diagnosis is based on history, clinical exam (general, systemic and ENT), investigations hemogram, X-ray mastoid CT scan brain and mastoid. Treatment