[Clinical analysis of 11 cases of otogenic intracranial complications treated by multidisciplinary collaboration]

Objective:To analyze the clinical diagnosis, treatment ，and surgical timing of otogenic intracranial complications. Methods:The clinical data of 11 patients with intracranial complications with ear symptoms as the first manifestation in Department of Otorhinolaryngology Head and Neck Surgery, Qilu Hospital of Shandong University（Qingdao） from December 2014 to June 2022 were collected, including 8 males and 3 females, aged from 4 to 69 years. All patients had complete otoendoscopy, audiology, imaging and etiology examination, and the diagnosis and treatment plan was jointly developed through multidisciplinary consultation according to the critical degree of clinical symptoms and imaging changes. Among the 11 patients, 5 cases were treated with intracranial lesions first in neurosurgery department and middle ear lesions later in otolaryngology, 3 cases of meningitis, were treated with middle ear surgery after intracranial infection control, 1 case was treated with middle ear lesions and intracranial infection simultaneously, and 2 cases were treated with sigmoid sinus and transverse sinus thrombosis conservatively. They were followed up for 1-6 years. Descriptive statistical methods were used for analysis. Results:All the 11 patients had ear varying symptoms, including ear pain, pus discharge and hearing loss, etc, and then fever appeared, headache, disturbance of consciousness, facial paralysis and other intracranial complication. Otoendoscopy showed perforation of the relaxation of the tympanic membrane in 5 cases, major perforation of the tension in 3 cases, neoplasia in the ear canal in 1 case, bulging of the tympanic membrane in 1 case, and turbidity of the tympanic membrane in 1 case. There were 4 cases of conductive hearing loss, 4 cases of mixed hearing loss and 3 cases of total deafness. Imaging examination showed cholesteatoma of the middle ear complicated with temporal lobe brain abscess in 4 cases, cerebellar abscess in 2 cases, cholesteatoma of the middle ear complicated with intracranial infection in 3 cases, and sigmoid sinus thrombophlebitis in 2 cases. In the etiological examination, 2 cases of Streptococcus pneumoniae were cultured in the pus of brain abscess and cerebrospinal fluid, and 1 case was cultured in streptococcus vestibularis, Bacteroides uniformis and Proteus mirabilis respectively. During the follow-up, 1 patient died of cardiovascular disease 3 years after discharge, and the remaining 10 patients survived. There was no recurrence of intracranial and middle ear lesions. Sigmoid sinus and transverse sinus thrombosis were significantly improved. Conclusion:Brain abscess, intracranial infection and thrombophlebitis are the most common otogenic intracranial complications, and cholesteatoma of middle ear is the most common primary disease. Timely diagnosis, multidisciplinary collaboration, accurate grasp of the timing in the treatment of primary focal and complications have improved the cure rate of the disease.

Profile and Outcome of Prospective Non-Septic Lateral Sinus Thrombosis Patients from a Stroke Unit of a Developing Country

Background

Due to effective treatment of middle ear infections there is a change in etiologies causing lateral sinus thrombosis (LST) and outcome. There is a paucity of literature describing homogenous group of patients with nonseptic LST (NS-LST).

Objective

To describe the clinical profile, risk factors, outcome of patients of NS-LST seen at a single center from South India.

Methods and Materials

Prospective, observational study of 100 patients of NS-LST patients, diagnosed by magnetic resonance imaging (MRI) seen at the stroke unit.

Results

During 2 years, 100 patients of NS-LST (isolated: combined: 27:73) (male: female: 44:56), mean age: 31.45 ± 11.13 years, were seen. Subacute presentation (74%) with headache, seizures, focal deficits, and features of raised intracranial pressure were presenting features. Hyperhomocysteinemia (61%), anemia (57%), postpartum state (41%), OCP use (37%), and low VitB12 (32%) were commonly seen risk factors. Imaging with MRI compared withcomputerized tomography (CT) had better diagnostic sensitivity (100% vs. 67%), detection of parenchymal (81% vs. 67%)/hemorrhagic (79% vs. 74%) lesions, and cortical vein thrombosis (31% vs. 15.46%). Treatment with anticoagulation and supportive therapy resulted in good outcome (mRS (0-2)) at 3 months in 81%.There were four deaths, all during admission (one - isolated, three - combined) and 11 patients underwent decompressive surgery. Patients with low GCS level of sensoriumat admission, hemiparesis, combined LST, cerebellar involvement, and decompressive craniectomy had a poor outcome.

Conclusion

This single-center large cohort study of NS-LST patients brings out the clinical features, risk factors (peculiar to developing countries), and the superiority of MRI in the diagnosis. Majority of patients have good outcome, with low mortality with 10% requiring decompressive surgery.

Dulaglutide-induced cerebral venous thrombosis in a patient with type 2 diabetes mellitus

Though patients with diabetes mellitus are at a high risk of atherothrombotic events, every such event should not be attributed to the disease itself. We present a case of a patient with diabetes with headache and blurring of vision for 3 days. Brain imaging revealed right transverse sinus thrombosis and acute infarct of the right posterior parieto-occipital region, predominantly in the posterior cortical watershed zone. The patient was on subcutaneous dulaglutide for 3 weeks and was having nausea and vomiting. Various causes of cerebral venous thrombosis were ruled out with appropriate laboratory investigations. Finally, cerebral venous thrombosis was attributed to dulaglutide-induced nausea and vomiting which led to severe dehydration.

Treatment of the superior sagittal sinus and transverse sinus thrombosis associated with intracranial hemorrhage with the mechanical thrombectomy and thrombolytics: Case report

RATIONALE

The superior sagittal sinus (SSS) and transverse sinus are the major dural sinuses that receive a considerable amount of venous drainage. The occlusion of them has been suggested to cause intracranial hypertension, hemorrhage, and lead to potentially fatal consequences.

PATIENT CONCERNS

We reported a 35-year-old woman with headache presented to our emergency department with a decreased level of consciousness and epileptic seizures. The examination of speech, higher mental function, and cranial nerve were normal. Computed tomography (CT) demonstrated both subarachnoid and intraparenchymal hemorrhage and brain edema at the right temporal lobe accompanied by high density shadow in the right transverse sinus. Digital subtraction angiography (DSA) revealed extensive thrombosis of the SSS and bilateral transverse sinus.

DIAGNOSES

The SSS and transverse sinus thrombosis, accompanied by right temporal lobe hemorrhage, subarachnoid hemorrhage (SAH).

INTERVENTIONS

An emergent mechanical thrombectomy by placed Solitair AB stent in the SSS, respectively, passed left and right sigmoid sinus-transverse sinus route. We removed the most clots, DSA revealed recanalization of the SSS and left transverse sinus was seen with normalization of the venous outflow, the occlusion of right transverse sinus was still present. There were 4 hours after patient back to neurosurgical intensive care unit (NICU), patient appeared anisocoria (R/L:4.0/2.5 mm), bilateral light reflexes disappeared, then we took a CT reexamination revealed intraparenchymal hemorrhage increased, brain edema was aggravated at the left temporal lobe, and mild midline shift. Subsequently, we performed decompressive hemicraniectomy and puncture the hematoma supplemented by B ultrasonic. Anticoagulation treatment was initiated 24 hours after surgery, and follow-up DSA showed gradually improved patency in the SSS and bilateral transverse sinus.

OUTCOMES

Despite occlusion of the SSS and bilateral transverse sinus, patient's symptoms resolved after the operations and he was discharged without complications.

LESSONS

The favorable clinical outcome after complete occlusion of the SSS and transverse sinus, accompanied by right temporal lobe hemorrhage, SAH has rarely been reported and it might be explained by our timely surgical intervention and development of compensatory cerebral collateral circulation.

Diagnosis and management of a young woman with acute isolated lateral sinus thrombosis

Isolated lateral sinus thrombosis (LST) was mentioned in the past as a complication of middle ear infection. In the recent years, it was not frequently studied. Our patient, a 23-year-old woman who was taking an oral contraceptive pill, displayed 24 hours of migraine, such as headache; her systemic examinations were normal. She underwent neuroimaging examinations in the first 36 hours of admission. Native head computed tomography (CT) revealed hyperdensities along the left tentorium, involving the left lateral sinus (LS). Cranial magnetic resonance imaging (MRI) showed hypointense signal on MRI T2*SW (susceptibility-weighted) in the region of the left LS. MR venography noted the absence of flow-related signal within the left LS. The clinical symptoms, signs and neuroimaging results formulated the diagnosis of left isolated LS thrombosis. Laboratory data demonstrated an elevated D-dimer and homozygosity for the factor V Leiden mutation. She was immediately started on anticoagulation in the form of low-molecular-weight Heparin; then, she was treated with Warfarin for an indefinite duration. The headaches resolved within two days and her neurological examination was also normal. A second MR venography achieved after two weeks demonstrated complete recanalization of the venous sinuses. We did not observe any LST recurrence, deep vein thrombosis or pulmonary embolism during one year of follow-up. The early initialization of anticoagulation produced a favorable evolution. An acute isolated left LST could be identified in her case on the head CT combined with MRI and MR venography.

Otogenic lateral sinus thrombosis in children: A review of 7 cases

Otogenic lateral sinus thrombosis (LST) is a rare but serious intracranial complication of acute or chronic otitis media. Reported mortality rates have ranged from 8 to 25%; the pediatric mortality rate might be as low as 5%. Controversy still exists over the medical and surgical management of this condition. We conducted a retrospective chart review of 7 cases of pediatric otogenic LST that were treated at our institution over a period of 8 years. We hypothesized that good outcomes in very sick patients can be achieved by aggressively managing the mastoid cavity and without the need for a thrombectomy. Our study group was made up of 4 boys and 3 girls, aged 6 to 15 years (mean: 11.1). All patients received intravenous antibiotics and underwent mastoidectomy with unroofing of the sigmoid sinus and placement of a tympanostomy tube. Sinus exploration with thrombectomy was not performed in any patient. Anticoagulation was used perioperatively in 5 patients (71%) without complication. All patients recovered well without major sequelae, which supports our hypothesis. We also describe the case of a patient with multiple concomitant intracranial comorbidities associated with this rare condition.

Intracranial venous sinus thrombosis as a complication of otitis media in children: Critical review of diagnosis and management

OBJECTIVES

Otogenic lateral sinus thrombosis (LST) is a rare intracranial complication of acute otitis media (AOM), which can lead to severe neurological sequelae and death. The aim of this study was to analyze the clinical presentation, management and outcome of LST in children, investigating a possible correlation between clinical aspects, radiological findings and anatomical variations.

METHODS

At a tertiary Italian hospital, a retrospective review was conducted on the medical records of eight patients diagnosed with otogenic LST over a 3-year period. Four children were males and mean age was 4.7 years.

RESULTS

All patients had a history of otitis media at diagnosis and 4/8 presented also with more than one neurological sign or symptom. Mastoiditis signs were detected in 5/8 patients. Thrombosis was diagnosed by computed tomography, enhanced magnetic resonance and magnetic resonance venography. Treatment was medical, alone or combined with surgery. Medical treatment consisted in anticoagulants eventually combined with anti-edema medication on clinical basis. Mastoidectomy and/or myringotomy±trans-tympanic drainage placement were performed in 7/8 patients. Complete vessel recanalization was obtained in 6/8 children after a median follow-up time of 4.8 months. No complications, neither clinical sequelae occurred. In our series, neurological signs and symptoms were significantly associated with the presence of hypoplasia of the contralateral venous sinus (p=0.029).

CONCLUSION

LST is a severe condition occurring even in absence of otological signs, and despite adequate antibiotic therapy for AOM, which should be ruled out and promptly treated. A dominant neurological presentation is associated in our series with anatomical variations of cerebral sinus venous drainage patterns. This should be carefully evaluated and considered in diagnosis, treatment planning and prognosis.

Otogenic lateral sinus thrombosis: case series and controversies

OBJECTIVES

The aim of this study is to (1) report the clinical presentation, treatment, and sequelae in a series of pediatric patients with otogenic lateral sinus thrombosis and (2) to review the most controversial aspects of management of this rare intracranial complication of otitis media.

METHODS

Retrospective chart review of inpatients treated for central venous thrombosis at a tertiary care facility between 1996 and 2012.

RESULTS

Five pediatric patients (four male, one female) were identified with otogenic lateral sinus thrombosis. Age at presentation ranged from 13 months to 15 years. All underwent a surgical procedure, ranging from a simple myringotomy with tympanostomy tube placement to tympanomastoidectomy and internal jugular vein ligation or craniotomy. Three were anticoagulated with unfractionated heparin with subsequent transition to low molecular weight heparin of variable duration. One patient developed a non-life-threatening intracranial hemorrhage while on long-term anticoagulation. Follow-up imaging, when available, did not directly correlate complete thrombus resolution with use of anticoagulation or with persistent symptoms.

CONCLUSIONS

Otogenic lateral sinus thrombosis is a rare intracranial complication of otitis media with significantly reduced morbidity and mortality in the modern era of antibiotic treatment, surgical intervention, and anticoagulation therapy. Due to the rarity of this condition today, the recommended extent of surgical intervention and need for routine anticoagulation are unclear, and requires further data to determine definitively.

Contemporary management of pediatric lateral sinus thrombosis: a twenty year review

OBJECTIVES

A case of pediatric otogenic lateral sinus thrombosis is reported, followed by a substantive literature review.

DESIGN

104 patients were reviewed, culled from published case reports from 1993 to 2011 on the PubMed database.

METHODS

All full text case reports on the PubMed database from 1993 to 2011 with patients less than or equal to 16 years of age that outlined specific treatments were included.

RESULTS

73% of patients were male and average age of presentation was 7.7 years. The most common symptoms were fever, headache, and otalgia, while the most common signs included otorrhea and neck stiffness. CT scans had a sensitivity of 87% and MR studies had a sensitivity of 100%. Single bacterial organisms were isolated in 46% of cases, with beta hemolytic streptococcus, streptococcus pneumoniae, and staphylococcus aureus being most common. Management included broad spectrum antibiotics (100%), mastoidectomy (94%), manipulation of the thrombosed sinus (50%), and anticoagulation (57%). The mortality rate was one in 104 patients. Morbidities occurred in 10% of patients and included cranial nerve palsy, sensorineural hearing loss, stroke, and septic hip joint.

CONCLUSION

Lateral sinus thrombosis is a rare but treatable complication of otologic disease in the pediatric population, warranting a high index of suspicion. Management should include broad spectrum antibiotics and surgical removal of all perisinus infection. Anticoagulation is not definitively associated with improved outcomes and warrants further investigation.

[Some clinical and imaging aspects of lateral sinus thrombophlebitis]

AIM

This article focuses on the lateral sinus thrombophlebitis, which is a serious complication of the supurated otopathies.

MATERIAL AND METHODS

It is based on a study of a significant number of both exo- and endocranial complications treated in the the "Sf Spiridon" Hospital- ORL department and at the "Prof. dr. N. Oblu"- Neurosurgery department (57 out of 251 cases admitted in the past 5 years).

RESULTS

Among the 57 cases, there were 8 lateral sinus thrombophlebitis, as well as 6 cases where meningitis coexisted with other endocranial complications, such as lateral sinus thrombophlebitis or brain abscess. The article contains details about some cases with special problems of diagnostic and treatment.

CONCLUSIONS

The symptoms of the presented cases are completely different from the common symptomatology. However, the diagnostic of such cases is possible due to the modern imaging methods as well. The lateral sinus thrombophlebitis is usually determined by different causes, one of them being the misuse of the antibiotics (class and daily/total dose). When endocranial complications occur the symptoms of the meningitis are masking the symptoms of other complications. Even if the CT scan or MRI exams performed right on the patient's admission show no other complications, the patient should be followed for a period of 15 up to 30 days after the treatment of the meningitis, by repeating imaging tests to identify a possible complication.

Management of Lateral Sinus Thrombosis in Chronic Otitis Media

OBJECTIVE

To present our experience with the diagnosis and treatment of lateral sinus thrombosis (LST) secondary to otogenic disease.

PATIENTS AND METHODS

We have retrospectively reviewed all the cases of LST caused by chronic otitis media in ten years.

RESULTS

In our series of five patients, four patients were successfully treated by surgery without opening the sigmoid sinus. On the other hand, one of our patients developed hydrocephalus and ataxia during preoperative antibiotic treatment.

CONCLUSION

Most patients with thrombotic/nonabscessed sinuses will have successful outcomes with this approach, but careful observation is needed, given the possibility of advancing disease.

Otitic hydrocephalus associated with lateral sinus thrombosis and acute mastoiditis in children

The incidence of intracranial complications of acute otitis media (AOM) has decreased and the need for operative and medical treatment is declined during the antibiotic era. To describe pathognomonic signs, evaluation management, operative findings, clinical course and outcome of otitic hydrocephalus and lateral sinus thrombosis as complications of AOM and mastoiditis in pediatric patients. Two children, 9 and 13 years old, with the diagnosis of OH and TK and MRI findings are presented. Intracranial complications in children resulted from unsuccessful treatment of AOM, which led to acute mastoiditis and lateral sinus thrombosis. Both of the presented children had thrombus in their sigmoid sinus preoperatively, demonstrated by MRI, causing decreased blood flow. Both patients underwent a mastoidectomy and delamination of sigmoid sinus with puncture of sinuses. After medical and surgical treatment, blood flow through the sinus increased significantly. In both cases signs of increased intracranial pressure ceased. The clinical presentation of otogenic lateral sinus thrombosis (LST) as a complication of acute otitis media (AOM) can be masked by antibiotic treatment. The episodes of vomiting, headache, visual impairment and a history of AOM seem to be indicative for otitic hydrocephalus. MRI scans of patients with similar symptoms should be carefully studied to facilitate the early diagnosis of dural sinus thrombosis with increased intracranial pressure. Contrast-enhanced computed tomography scan and magnetic resonance imaging play a major role in determining diagnosis and treatment plans in this intracranial complications. Management included systemic antibiotics, short-term heparin anticoagulation and surgical decompression. In our patients intensive i.v. antibiotic treatment, steroids, anticoagulants and surgery led to a significant improvement in the clinical condition.

Complicated otitis media caused by Fusobacterium necrophorum

Fusobacterium necrophorum is implicated as an aetiological agent in a variety of necrotic diseases, such as Lemièrre’s syndrome (LS) in humans. LS was initially described as septic thrombophlebitis of the internal jugular vein secondary to an acute oropharyngeal infection. Other primary sources of infection include parotitis, otitis media, sinusitis, odontogenic infection and m stoiditis. In the pre-antibiotic era LS carried a high mortality. This has been reduced as a result of the widespread use of antibiotics, butthere is still a definite morbidity and mortality associated with infection with this virulent organism. We report three cases of complicatedotitis media caused by Fusobacterium necrophorum. The patients were treated successively with intravenous metronidazole and surgery.

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.

Contraceptive-Related Cerebral Venous Thrombosis With Profuse Vaginal Bleed

INTRODUCTION

Women on hormonal therapy for menorrhagia are at risk for cerebral venous thrombosis.

CASE REPORT

This scenario may become complicated when there is profuse vaginal bleed with the withdrawal of hormonal therapy. There are no reports describing the possible therapeutic approaches in this clinical situation.

RESULTS

A 42-year-old female with a history of uterine fibroids and menorrhagia taking an estrogen-progesterone combination pill presented with seizure clusters. Neuro-imaging showed lateral sinus thrombosis and biparietal hemorrhagic infarcts. Withdrawal of the contraceptive pill was associated with profuse vaginal bleed, leading to hemodynamic instability and the need for multiple blood transfusions. As an emergent procedure to stop the vaginal bleeding, the patient was implanted with a levonorgestrel intrauterine system; with this, vaginal bleed stopped within 12 hours with hemodynamic stability. Subsequently, the patient was treated with unfractionated heparin followed by warfarin (target international normalized ratio: 2.5-3). She made a good neurological recovery.

CONCLUSION

This case illustrates that LNG-IUS can be an innovative choice for local hormonal therapy in a patient with OCP-related cerebral venous thrombosis and simultaneous vaginal bleeding.

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.

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.

Management of lateral sinus thrombosis: update and literature review

The management of four cases of lateral sinus thrombosis (LST) over a four-year period at the Royal Darwin Hospital is presented in this retrospective review. The patients were aboriginal and presented with otalgia, otorrhoea and sepsis. Two cases had an associated complication of an otitic hydrocephalus and a subperiosteal abscess. Cholesteatoma was found in three cases. Computed tomography (CT) scan confirmed the LST in three cases. Three patients were anaemic and thrombocytopenic. All patients had positive blood cultures. The organisms were predominantly mixed anaerobes and Bacteroides species. Three patients were managed surgically as a two-stage procedure. One patient was managed as a single-stage procedure with a modified radical mastoidectomy. Therapeutic anticoagulation was utilized in one case. There were no deaths. The prognosis of LST is good if treatment is instituted early with broad-spectrum intravenous antibiotics and surgery. The role of clot removal at surgery and the use of anticoagulation are discussed in this paper.

A rare and serious complication of chronic otitis media: lateral sinus thrombosis

Before the antibiotic era, lateral sinus thrombosis (LST) was the most frequent complication of otitis media. With the widespread usage of antibiotics, its occurrence is rare. Nevertheless, it is still a major complication of middle ear disease. LST mortality fluctuates between 5 and 35%. The major clinical symptoms of patients with LST are pain in the mastoid region, spiking fever, anemia and general health disorders. Computed tomography, magnetic resonance imaging and angiography are the most helpful in diagnosis, but the final diagnosis is made by surgical exploration. Three cases with LST are presented, and signs, diagnosis and treatment of disease are discussed.

A unique case of Bezold's abscess associated with multiple dural sinus thromboses

OBJECTIVES/HYPOTHESIS

Bezold's abscess and dural sinus thromboses are rare complications of otitis media in the era of antibiotics. Although potentially fatal, they are treatable. We present a unique case report of Bezold's abscess in association with multiple dural sinus thromboses.

STUDY DESIGN

Single case report.

METHODS

A young female patient's clinical course is presented and discussed. We review the anatomy, incidence, pathogenesis, and treatment of Bezold's abscess and dural sinus thrombosis.

RESULTS

After mastoidectomy, neck exploration, broad-spectrum intravenous antibiotics, and anticoagulation therapy, the patient recovered fully and has remained asymptomatic since her discharge from the hospital at 12 months' follow-up.

CONCLUSIONS

This is the first reported case of Bezold's abscess associated with a cavernous sinus thrombosis and the third reported case of Bezold's abscess associated with lateral sinus thrombosis. Despite its rarity, Bezold's abscess must be recognized and treated aggressively. Dural sinus thrombosis is relatively more common, and treatment of the underlying cause is essential. The diagnosis and rapid, aggressive treatment of these conditions are essential for an optimal clinical outcome.

Combined risk factors contributing to cerebral venous thrombosis in a young woman

Cerebral venous thrombosis is a rare condition affecting predominantly adolescents or young adults. The presentation is often non-specific, and delay in diagnosis is common. The otolaryngologist may be consulted about the radiological findings of lateral sinus thrombosis and mastoid changes. The association of congenital thrombophilia with unusual presentations of venous thrombosis, especially in young individuals is now well documented. We present a case of lateral and sagittal sinus thrombosis complicated by cerebral venous infarction in a girl with protein C deficiency and masked mastoiditis. Unusual forms of venous thrombosis, including cerebral venous thrombosis may develop in association with a single risk factor for thrombosis, but additional risk factors should be sought especially when thrombosis presents in very young individuals. This case draws attention to the multi-causal nature of cerebral venous thrombosis in young adults, and highlights the issue of masked mastoiditis. A coordinated approach by otolaryngological and haematological teams is recommended in such cases.

Otogenic lateral sinus thrombosis--a case report

INTRODUCTION

We portray and discuss a case of lateral sinus thrombosis following acute otitis media and mastoiditis.

CLINICAL PICTURE

The patient presented with otorrhoea, otalgia, neck pain, fever and chills.

TREATMENT

Cortical mastoidectomy was performed. Intravenous antibiotics and heparin were administered.

OUTCOME

The patient had a complete recovery with no sequelae.

CONCLUSIONS

Neurotologic complications of suppurative otitis media like meningitis, cerebral abscess, extradural abscess and dural sinus thrombosis are rare in the antibiotic era. Hence, doctors today have to maintain extra vigilance and a high index of suspicion for such complications.

Otogenic lateral sinus thrombosis in children

INTRODUCTION

The clinical picture of lateral sinus thrombosis (LST) has changed with the advent of antibiotics, as have the utility of various diagnostic tests. LST may appear in children as a complication of acute otitis media, but nowadays it is more frequently encountered in adults with long-standing chronic ear disease.

METHOD

A retrospective study of all the pediatric patients with LST between 1982 and 1997.

RESULTS

Thirteen cases of LST were diagnosed and treated by our department. In six cases, LST was due to acute otitis media and in the remaining cases it was due to chronic otitis media. Headache, fever, aural discharge and mastoid tenderness were the most frequent findings in these patients and four patients were initially diagnosed with meningitis. In the majority of the patients, LST was accompanied with other intracranial complications, such as perisinus abscess, brain abscess and meningitis. One patient with multiple brain abscesses, unresponsive to several drainage procedures, died. The other patients recovered and have since been followed-up as out-patients.

CONCLUSION

LST may be difficult to diagnose due to previous antibiotic treatment and to the overlap of clinical findings with other entities such as meningitis. Despite the value of modern imaging techniques in the investigation of the disease, a high index of suspicion based on the clinical picture is warranted. Our results are consistent with those of other recent studies, who found that mortality of LST has dropped below 10%.