Otogenic lateral sinus thrombosis in children

Intracranial complications of chronic suppurative otitis media in children

In spite of significant decrease after antibiotic advent, intracranial complications of otitis media still represent a challenging situation owing to its high mortality rate (36%). The most common presentations are meningitis, cerebral abscess, extradural abscess and lateral sinus thrombophlebitis. For early management, it is necessary to have a high index of suspicion. It is important to identify non-typical cases because they might be masqueraded by antibiotic use.

AIM

We present six cases of intracranial complications due to otitis media in children and adolescents at Complexo Hospitalar Santa Casa de Porto Alegre for the past two years.

STUDY DESIGN

Series review.

Diagnosis and Management of Lateral Sinus Thrombosis

OBJECTIVES

To define the contemporary management of septic otogenic lateral sinus thrombosis.

STUDY DESIGN

Retrospective case series identified through database search of otologic surgical cases managed by a single surgeon in four teaching hospitals over a 6-year period.

METHODS

Twelve patients presenting with lateral sinus thrombosis of otogenic cause were the subjects of this study. Patients with incomplete medical records or unknown outcomes were excluded.

RESULTS

Lateral sinus thrombosis was the result of chronic otitis media in 50% of cases, with five of these patients having cholesteatoma. In addition, there were seven associated intracranial complications in six patients in this series. All patients underwent medical and surgical treatment. Aggressive and early surgical treatment was tailored to the degree of preoperative and intraoperative findings. The sigmoid sinus was resected in six of the patients with a variable degree of inferior margin proportional to the extent of thrombosis. Thrombectomy alone under vascular control with reestablishment of flow was used to remove the septic thrombus in the other six patients. There were no complications in these patients.

CONCLUSION

Early and aggressive surgical intervention of this otogenic complication can potentially minimize mortality, hospital stay, and length of medical treatment.

Intracranial abscesses associated with chronic suppurative otitis media

Intracranial abscesses are serious complications of chronic suppurative otitis media (COM). This study included 32 patients presenting with intracranial abscesses from 780 patients hospitalized for treatment of COM. The 32 patients had 59 intracranial complications. Perisinus abscess (13 of 32) was the most common intracranial abscess, followed by temporal lobe abscess (8 of 32), epidural abscess (7 of 32), cerebellar abscess (6 of 32) and subdural empyema (2 of 32). Headache (93%), fever (87%) and altered mental status (62%) were the most common presenting symptoms and signs, along with symptoms of COM. All patients were treated with intravenous antibiotics and canal wall down mastoidectomy. Cholesteatoma with granulation tissue and bony defects at the sinus plate and/or dural plate were seen in most of the patients. Gram negative bacilli and anaerobes were the most common organisms cultured from the abscesses. Three patients had neurological sequels. One patient died. The early diagnosis of these complications requires a high index of suspicion and imaging studies. A multidisciplinary and coordinated approach is important for the management of these patients.

Management of otogenic lateral sinus thrombosis

PURPOSE

Lateral sinus thrombosis (LST) is a rare but potentially devastating complication of otitis media. We review the clinical presentation, evaluation, management, operative findings, and outcomes of this serious complication.

MATERIAL AND METHODS

A retrospective chart review was performed at a teaching hospital of all patients diagnosed with an otogenic lateral sinus thrombosis between 1992 and 2002. Data on patients with otogenic LST were collected and analyzed.

RESULTS

Eleven patients were identified with a diagnosis of lateral sinus thrombosis, and all had a chronic otitis media. The most common presenting symptoms were headache, otalgia, and fever. Radiologic evaluation included computed tomography scan, magnetic resonance imaging, or magnetic resonance venography. All patients had radiographic evidence of LST preoperatively. The thrombosed sinus was on the right side in 6 patients and on the left side in 5 patients. The majority of patients (8 of 11) had a second concomitant intracranial complication. All patients underwent a mastoidectomy. The thrombus was removal in 7 cases, whereas only needle aspiration of the sinus was performed in 4 cases. Gram-negative bacilli and anaerobes were the most common organisms. There were no deaths but sequelae included VI nerve palsy, ataxia, and dead ear.

CONCLUSION

LST as a complication of otogenic infections may still pose a serious threat that warrants immediate attention and care. It is frequently associated with other intracranial complications. Contrast-enhanced computed tomography scan and magnetic resonance imaging plays a major role in determining diagnosis and treatment plans. The availability of broad-spectrum antibiotics has improved our management significantly. Conservative surgical intervention including eradication of all perisinus infection and needle aspiration of the sinus seems to be effective.

Medical and surgical management of otitis media in children

OM, though frequent and seemingly simple to evaluate and manage, remains a treatment challenge. Increasingly sophisticated clinical trials assessing OM medical treatment efficacy and outcome have demonstrated that many treatment regimens that were commonly used a decade ago are no longer recommended. Surgical therapy for OM, though remaining the same, has come under intense scrutiny from several angles but still plays a central role for this disease. Given the multiple facets of OM, its frequency, and its potential to cause short- and long-term morbidity in children, the next decade is sure to bring further treatment innovations.

[Acute external mastoiditis in children: report of a series of 48 cases]

DESIGN

To determine the impact of the emergence of penicillin-resistant strains of pneumococci on the frequency of acute mastoiditis in children, and to assess the importance of laboratory and imaging studies in the treatment of acute mastoiditis.

METHOD

Retrospective review of the medical records of children with postauricular swelling and otoscopic signs of acute otitis media from January 1993 through December 2000.

RESULTS

Forty-eight children aged three months to 14 years (median 17 months) were identified. The number of cases was almost the same from one year to another. All children had bacteriological examinations. The mastoid pus and the otorrhea was sterile in 22 cases. The most frequent pathogen was Streptococcus pneumoniae (17 cases), which was resistant to penicillin in 71% of cases. The initial body temperature, the number of polymorphonuclears and the CRP were not different between the group of 18 children with periostitis, which required medical treatment alone, and the group of 30 children who had a mastoid abscess which required surgery. The difference between periostitis and mastoid abscess was seen on clinical examination and CTscan.

Intracranial complications of acute and chronic mastoiditis: report of two cases in children

OBJECTIVE

The clinical picture of mastoiditis, sigmoid sinus thrombosis and brain abscess has changed with the advent of antibiotics. A delay in the recognition of intracranial complications in children and in the institution of appropriate therapy may result in morbidity and mortality. Increased mortality of the children has been correlated with the neurological status of the patient on admission to hospital.

METHOD

A retrospective study was made of two children with acute mastoiditis and sigmoid sinus thrombosis and chronic mastoiditis with cerebellar abscess treated in 1997 in the ENT Department of the Medical University of Gdansk.

RESULTS

We present two cases of intracranial complications in children (13 and 11 years old) originating from acute and chronic otitis media. The first case, of a 13-year-old boy with sigmoid sinus thrombosis as a complication of acute otitis media took its course as a typical Symonds Syndrome. Mastoidectomy, thrombectomy and jugular vein ligation associated with antibiotics and edema-reducing drugs and anticoagulants proved to be successful. The second case of an 11-year-old boy with exacerbated chronic otitis media with cholesteatoma and mastoiditis, was complicated by suppurative meningitis, cerebellar abscess, perisinual abscess and sigmoid sinus thrombophlebitis. Neurosurgical approach by suboccipital craniotomy and abscess drainage was ineffective. Otological treatments of modified radical mastoidectomy, thrombectomy, jugular vein ligation, perisinual and cerebellar abscess drainage associated with wide-spectrum antibiotics and edema-reducing drugs were performed with a very good outcome. After 3 years of follow-up the patients remain without any neurological and psychiatric consequences.

CONCLUSION

The authors show different courses of both presented complications and imaging techniques and surgical procedures performed in these children. The sigmoid sinus trombosis with Symonds Syndrome may be difficult to diagnose due to previous antibiotics valuable in establishing the diagnosis and the extent of disease. The successful therapy is based on understanding of pathogenesis of the intracranial complication and the cooperation of an otolaryngologist, a neurologist, a neurosurgeon and an ophthalmologist.

Complications of Acute Otitis Media and Sinusitis

Otitis media and sinusitis are clinically identifiable infections of the middle ear and sinuses. Both conditions should be regarded as dynamic processes with a clinical spectrum, which may extend from a self-limiting condition to a prolonged and sometimes complicated disease. With the advent of antibiotics, the natural course of these diseases has changed significantly. Severe complications once characterized by high mortality and morbidity have become rare. This has led to a generation of general practitioners, otolaryngologists, and pediatricians trained in an atmosphere of complacency in the treatment of otitis media and sinusitis. However, several recent publications report an increasing incidence of serious complications associated with otitis and sinusitis, probably due to rising antibiotic resistance. A high index of suspicion, based on clinical grounds, is therefore warranted. The ultimate goal in the approach of these conditions is pharmacotherapeutic management, resorting to surgery for the restoration of function rather than for the eradication of the infectious disease. As new information becomes available on the etiology, pathogenesis, and bacteriology of these conditions, new strategies are being used to improve treatment and to prevent complications. These measures should include a more appropriate choice of antibiotics, the determination of the role of adjuvant therapy and surgical procedures, and the development of new vaccines.