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