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Conservative nonsurgical treatment of a child with otogenic lateral sinus thrombosis
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American Journal of Otolaryngology – Head and Neck Medicine and Surgery 29 (2008) 138 – 141 www.elsevier.com/locate/amjoto
Conservative nonsurgical treatment of a child with otogenic lateral sinus thrombosis Ella Even Tov, MD a , Alberto Leiberman, MD a , Ilan Shelef, MD b , Daniel M. Kaplan, MD a,⁎ a
Department of Otolaryngology—Head & Neck Surgery, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, PO Box 151, Beer-Sheva, Israel b Radiology Institute, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, PO Box 151, Beer-Sheva, Israel Received 20 February 2007
Abstract
We present the case of a 5-year-old boy with otogenic lateral sinus thrombosis that developed after acute mastoiditis, with no prior ear disease. He was treated with myringotomy and antibiotics alone, with no surgical intervention. This approach was followed owing to his good general condition, the prompt response to the antimicrobial treatment, and no evidence of suppurative disease. Sinus recanalization was evident on the follow-up computed tomography 4 months later. We believe that in selected cases of otogenic lateral sinus thrombosis, secondary to an acute ear infection with early response to antibiotic therapy, conservative treatment may be considered and surgical intervention may be withheld. © 2008 Published by Elsevier Inc.
1. Introduction With the advent of antibiotics, intracranial complications of otitis media, including otogenic lateral sinus thrombosis (OLST), are considered rare [1,2]. However, OLST continues to be a life-threatening condition, with mortality reaching 10% [3,4]. Management of OLST in the antibiotic era has traditionally included antibiotic therapy and mastoidectomy with evacuation of the thrombus, with or without anticoagulation medication. In recent years, modifications of this surgical approach have been offered, treating patients with mastoidectomy without evacuation of the clot from lateral sinus [5,6]. Some recent reports propose nonsurgical management of OLST [7-9]. We report a case of a child who developed OLST; however, his prompt response to conservative antibiotic therapy convinced us to pursue this strategy rather than
⁎ Corresponding author. Department of Otolaryngology—Head & Neck Surgery, Soroka University Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel, PO Box 151, Beer-Sheva 84101, Israel. Tel: +972 54 7499234, +972 8 6400635; fax: +972 8 6403037. E-mail addresses: [email protected] (E.E. Tov), [email protected] (A. Leiberman), [email protected] (I. Shelef), [email protected] (D.M. Kaplan). 0196-0709/$ – see front matter © 2008 Published by Elsevier Inc. doi:10.1016/j.amjoto.2007.04.004
intervening surgically. We review the rationale and indications for this nonsurgical approach. 2. Case report A 5-year-old white boy was transferred to a tertiary care otolaryngology department from a community hospital, with the diagnosis of OLST. His present illness started 17 days previously when he complained of right-sided otalgia and was treated with anesthetic eardrops by his general physician. Two weeks later, he presented to the local hospital with right otalgia, a protruded auricle, high fever, and general weakness. The patient and parents denied symptoms of headache and vomiting, as well as any prior ear infections. The rest of his medical history was normal. Erythema of postauricular area on the right was noted, with an edematous tympanic membrane. White blood cell count was 23 700/μL. He was hospitalized with the diagnosis of acute mastoiditis, and parenteral ceftriaxone (1 g daily) was administered. Although fever subsided during the following 3 days, postauricular swelling got worse. A cranial and temporal bone computed tomographic (CT) scan with contrast material was performed. The suspicion of OLST arose after the CT scan, and he was transferred to our medical center for surgical treatment.
E.E. Tov et al. / American Journal of Otolaryngology – Head and Neck Medicine and Surgery 29 (2008) 138–141
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Fig. 3. Posterior fossa CTV on admission. A filling defect with high attenuation of the sinus walls (delta sign) is demonstrated in the right lateral sinus. On the left side is a normal-appearing sinus enhanced with contrast material.
On arrival, the patient was afebrile, in a good general condition, conscious, with normal neurologic status. The right auricle was protruded with local swelling, erythema, and tenderness in the retroauricular region without fluctuation (Fig. 1). Otomicroscopy revealed a normal external auditory canal and a hyperemic, opaque tympanic membrane. Laboratory test results were as follows: hemoglobin level of 9.6 g/dL; white blood cell count of 8170/μL; electrolyte levels within the reference range. A chest x-ray
was normal. The fundus was examined by an ophthalmologist, and bilateral mild disc edema was noted, with normal sight and visual field. Serous fluid was aspirated by needle from the middle ear, and bacteriological culture failed to demonstrate bacterial growth. A high-resolution temporal bone CT scan showed an opaque middle ear and mastoid air cells, with no bone destruction on the right side (Fig. 2). On postcontrast CT of the posterior fossa in the venous stage (CTV), a highly attenuated right transverse and sigmoid sinus with a filling defect was observed, as well as soft tissue edema of retroauricular tissues without abscess formation (Fig. 3). No other intracranial complications were evident. The antibiotic treatment was changed to intravenous meropenem 1500 mg divided into 3 daily doses.
Fig. 2. An axial high-resolution CT scan of the temporal bone at the level of the mesotympanum performed after admission. The right mastoid air cells are partially opaque without bone erosion.
Fig. 4. Posterior cranial fossa CTV performed 4 months later at a similar level. The right lateral sinus is enhanced normally with contrast material.
Fig. 1. The right auricle is protruded with local swelling and redness in the
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E.E. Tov et al. / American Journal of Otolaryngology – Head and Neck Medicine and Surgery 29 (2008) 138–141
At this point, the medical staff considered surgical intervention, including mastoidectomy with exploration of the lateral sinus. During the next 24 hours, the child felt better, there was no progression in the otologic findings, and there were no signs of sepsis. After the parents were advised on the options of surgery vs a conservative approach, they opted for close observation, repeated scans, and withholding of surgery. During the next 3 days, there was a complete resolution of symptoms and signs. On a repeat CT on the fourth day of admission, there was no evidence of thrombus propagation. At the end of the first week of hospitalization, the patient underwent duplex of the upper neck, demonstrating a patent internal jugular vein on the right. Repeated ophthalmologic examination showed no change. The patient was discharged after 10 days and continued the same intravenous antibiotic therapy for an additional 2 weeks at home. Four months after hospitalization, a follow-up postcontrast CT scan was performed, demonstrating normal venous flow of the right lateral sinus (Fig. 4). Optic discs were considered normal by the ophthalmologist.
3. Discussion Otogenic lateral sinus thrombosis is a rare complication of acute and chronic otitis media nowadays. It usually develops as an extension of perisinus infection eroding the bone by coalescence, by granulation tissue, or by cholesteatoma. Except for bone erosion, OLST may also be caused by osteothrombophlebitis of emissary mastoid veins, with an intact bony sinus plate at the time of surgical exploration [10]. The first descriptions of OLST report mortality rates of 100%. This figure dropped dramatically to 35% because surgical intervention has been offered [11]. In the antibiotic era, there has been a further decline of mortality [4,8]. In recent years there have been less reports of OLST-related mortality, and these were usually associated with concomitant intracranial complications. This dramatic decline in mortality can be attributed to early diagnosis, including highresolution CT and magnetic resonance imaging (MRI), and intensive care unit postoperative care [3,4]. Clinical symptoms and signs of OLST include headache, fever, and prolonged ear infection—manifestations that overlap with otitis, mastoiditis, and other intracranial complications. The classic “picket-fence fever pattern,” described in the preantibiotic era, reflecting clots with bacteremia, occurs relatively infrequently today. When OLST is suspected, a high-resolution CT scan of the temporal bone and postcontrast CT of the posterior cranial fossa demonstrating venous phase should be performed. The “delta sign,” caused by the enhancement of the lateral sinus wall, is considered diagnostic. This finding is more sensitively demonstrated by MRI with gadolinium; the thrombus has low signal intensity on T2-weighted images,
with an absence of flow on MRI venography [12]. Magnetic resonance imaging is also superior in demonstrating abscess formation within the sinus and for excluding an adjacent subdural empyema, cerebritis, or cerebral abscess. Despite these advantages, MRI is very costly and not readily available in many centers, including our own, at the time the child presented to us. Magnetic resonance imaging is the test of choice for confirming the diagnosis. When CT is performed and fails to demonstrate the thrombus, MRI is mandatory. With the help of modern radiologic techniques that detect the thrombus with high sensitivity and accuracy, there should be no difficulties in establishing the correct diagnosis when OLST is suspected and in following up possible thrombus propagation. In our patient, the diagnosis of OLST was established conclusively by clinical appearance and unilateral delta sign on CTV. Early bilateral papillary edema was noted in the patient, probably implying the development of otitic hydrocephalus, which is commonly referred to today as pseudotumor cerebri. This complication has been reported in 26% of children with OLST [8]. The management of OLST includes antibiotic therapy and prompt mastoid surgery with or without anticoagulation. Internal jugular vein ligation is rarely indicated nowadays and is usually reserved for unresponsive cases with lung thromboemboli or deep neck infection. More conservative approaches to OLST treatment have been suggested in recent years. Intraoperative aspiration of the sinus during mastoidectomy is commonly used to confirm the diagnosis and for deciding whether to surgically open and then to obliterate the sinus. When no free blood flow is recovered, the sinus has traditionally been incised and the clot has been removed. Interestingly, several studies have reported similar favorable outcome when the clot was left untouched [4,5,13]. Kutluhan et al [6] managed 4 cases of OLST with radical mastoidectomy. In 2 of them, no pus was aspirated intraoperatively from the sinus; and accordingly, no further procedure on the sinus was performed, and the patients had full recovery. Bradley et al [2] reported a series of 9 patients with OLST of which only 7 patients underwent mastoidectomy. Intraoperative needle aspiration of the sinus was performed in 4 of them, and incision of the sinus with thrombus evacuation was performed in only 2 of the patients. In their study, most of the patients were treated with anticoagulation therapy, and they reported a good short-term outcome. However, the rationale for choosing the type of intervention was not discussed. Agarwal et al [14] described a case of OLST with concomitant epidural abscess and occipital osteomyelitis that required posterior fossa craniectomy, leaving the thrombus untouched. Surgery left a window in the parietooccipital bone that allowed serial follow-up with ultrasound while the patient was recovering. Normal venous flow within sigmoid sinus was demonstrated at week 5 after surgery. This case strengthens the argument that the natural history of OLST is of resolution as soon as the source of infection is managed.
E.E. Tov et al. / American Journal of Otolaryngology – Head and Neck Medicine and Surgery 29 (2008) 138–141
There have been 2 previous case reports on patients with OLST who did not undergo mastoid surgery at all; one was in a 7-year-old and the other in a 14-year-old [7,8]. In both cases, the patients were transferred from other medical centers after initial antibiotic treatment and were afebrile at diagnosis with a lack of suppurative infection or sepsis. They were treated with anticoagulants and parenteral antibiotics. Wong et al [9] presented a retrospective case series of 5 patients with OLST, where 3 patients were treated successfully without mastoidectomy and another patient operated on did nor reveal any pus or granulations. The authors concluded that surgery—mastoidectomy—and sinus needle aspiration for final diagnosis should be reserved for patients who are unresponsive or who deteriorate after myringotomy and intravenous antibiotics. Considering our case and review of the literature, if the eradication of the underlining infection can be achieved with antibiotics alone, (as commonly seen in cases of acute mastoiditis with periosteitis) then surgery of OLST may be withheld. This conservative approach for OLST should be contraindicated in cases of acute or chronic infection with evidence of perisinus bone destruction. In chronic otitis media, cholesteatoma or granulation tissue commonly erodes the bone sinus late and acts as a persistent source of infection that warrants surgery. In contrary, in cases of OLST secondary to acute otitis media with no previous antibiotic treatment, where an osteothrombophlebitic process is most probably involved in the pathophysiology, antibiotic treatment could be sufficient. Because the patient we treated was recovering with no signs of sepsis and no evidence of suppurative disease on CT, we decided to withhold the surgery and observe him closely with repeated scans. This approach seemed appropriate in our case because of the good general condition of the child, the good clinical response, and the lack of radiologic progression. In this conservative treatment strategy, it is of the utmost importance to continue long-term antibiotics and aspiration by tympanocentesis or myringotomy of middle ear fluids. In addition, it is crucial to perform serial imaging studies to monitor for thrombus propagation. Further reports on OLST cases managed conservatively would be invaluable for defining the role of this treatment option. 4. Conclusions 1. Otogenic lateral sinus thrombosis is a potentially lethal complication of otitis media and mastoiditis. Whereas
141
some patients present with a fulminate disease, in others the disease may be relatively mild and only detectable with imaging studies. 2. Although a traditional OLST has been treated by mastoidectomy and clot removal from the sinus, in recent years several modifications had become accepted with good outcomes. 3. Conservative treatment of OLST consisting of myringotomy and intravenous antibiotics without surgery is appropriate in highly selected cases secondary to acute otitis media in which prompt response to this treatment is seen. 4. A high index of suspicion must be maintained during the prolonged antibiotic treatment for the possibility of thrombus propagation and the development of concomitant intratemporal and intracranial complications. References [1] Teichgraeber JF, Per-Lee JH, Turner JS. Lateral sinus thrombosis: a modern perspective. Laryngoscope 1982;92:744-51. [2] Bradley DT, Hashikasi GT, Mason JC. Otogenic sigmoid sinus thrombosis: what is the role of anticoagulation? Laryngoscope 2002;112:1726-9. [3] Kaplan DM, Krause M, Puterman M, et al. Otogenic lateral sinus thrombosis in children. Int J Pediatr Otorhinolaryngol 1999;49:177-83. [4] Ooi EH, Hilton M. Management of lateral sinus thrombosis: update and literature review. J Laryngol Otol 2003;117:932-9. [5] Syms MJ, Tsai PD, Holten MR. Management of lateral sinus thrombosis. Laryngoscope 1999;109(10):1616-20. [6] Kutluhan A, Kiris M, Yurttas V, et al. When can lateral sinus thrombosis be treated conservatively? J Otolaryngol 2004;33:107-10. [7] Spandow O, Gothefors L, Fagerlund M, et al. Lateral sinus thrombosis after untreated otitis media. A clinical problem—again? Eur Arch Otorhinolaryngol 2000;257:1-5. [8] Gracia RD, Baker AS, Cunningham MJ, et al. Lateral sinus thrombosis associated with otitis media and mastoiditis in children. Pediatr Infect Dis J 1995;14:617-23. [9] Wong I, Kozak FK, Poskitt K, et al. Pediatric lateral sinus thrombosis: retrospective case series and literature review. J Otolaryngol 2005;34:79-85. [10] Shambaugh GE, Glassock ME. Meningeal complications of otitis media. In: Shambaugh GE, Glassock ME, editors. Surgery of the ear. 3rd ed. Philadelphia, (PA): W.B. Saunders Company; 1980. p. 302-9. [11] Meltzer PE. Treatment of thrombosis of lateral sinus. Arch Otolaryngol 1935;22:131-42. [12] van der Bosch MAAJ, Vos JA, de Letter MACJ, et al. MRI findings in a child with sigmoid sinus thrombosis following mastoiditis. Pediatr Radiol 2003;33:877-9. [13] Singh B. The management of lateral sinus thrombosis. J Laryngol Otol 1993;107:803-8. [14] Agarwal A, Lowry P, Isaacson G. Natural history of sigmoid sinus thrombosis. Ann Otol Rhinol Laryngol 2003;112:191-4.
American Journal of Otolaryngology – Head and Neck Medicine and Surgery 29 (2008) 138 – 141 www.elsevier.com/locate/amjoto
Conservative nonsurgical treatment of a child with otogenic lateral sinus thrombosis Ella Even Tov, MD a , Alberto Leiberman, MD a , Ilan Shelef, MD b , Daniel M. Kaplan, MD a,⁎ a
Department of Otolaryngology—Head & Neck Surgery, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, PO Box 151, Beer-Sheva, Israel b Radiology Institute, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, PO Box 151, Beer-Sheva, Israel Received 20 February 2007
Abstract
We present the case of a 5-year-old boy with otogenic lateral sinus thrombosis that developed after acute mastoiditis, with no prior ear disease. He was treated with myringotomy and antibiotics alone, with no surgical intervention. This approach was followed owing to his good general condition, the prompt response to the antimicrobial treatment, and no evidence of suppurative disease. Sinus recanalization was evident on the follow-up computed tomography 4 months later. We believe that in selected cases of otogenic lateral sinus thrombosis, secondary to an acute ear infection with early response to antibiotic therapy, conservative treatment may be considered and surgical intervention may be withheld. © 2008 Published by Elsevier Inc.
1. Introduction With the advent of antibiotics, intracranial complications of otitis media, including otogenic lateral sinus thrombosis (OLST), are considered rare [1,2]. However, OLST continues to be a life-threatening condition, with mortality reaching 10% [3,4]. Management of OLST in the antibiotic era has traditionally included antibiotic therapy and mastoidectomy with evacuation of the thrombus, with or without anticoagulation medication. In recent years, modifications of this surgical approach have been offered, treating patients with mastoidectomy without evacuation of the clot from lateral sinus [5,6]. Some recent reports propose nonsurgical management of OLST [7-9]. We report a case of a child who developed OLST; however, his prompt response to conservative antibiotic therapy convinced us to pursue this strategy rather than
⁎ Corresponding author. Department of Otolaryngology—Head & Neck Surgery, Soroka University Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel, PO Box 151, Beer-Sheva 84101, Israel. Tel: +972 54 7499234, +972 8 6400635; fax: +972 8 6403037. E-mail addresses: [email protected] (E.E. Tov), [email protected] (A. Leiberman), [email protected] (I. Shelef), [email protected] (D.M. Kaplan). 0196-0709/$ – see front matter © 2008 Published by Elsevier Inc. doi:10.1016/j.amjoto.2007.04.004
intervening surgically. We review the rationale and indications for this nonsurgical approach. 2. Case report A 5-year-old white boy was transferred to a tertiary care otolaryngology department from a community hospital, with the diagnosis of OLST. His present illness started 17 days previously when he complained of right-sided otalgia and was treated with anesthetic eardrops by his general physician. Two weeks later, he presented to the local hospital with right otalgia, a protruded auricle, high fever, and general weakness. The patient and parents denied symptoms of headache and vomiting, as well as any prior ear infections. The rest of his medical history was normal. Erythema of postauricular area on the right was noted, with an edematous tympanic membrane. White blood cell count was 23 700/μL. He was hospitalized with the diagnosis of acute mastoiditis, and parenteral ceftriaxone (1 g daily) was administered. Although fever subsided during the following 3 days, postauricular swelling got worse. A cranial and temporal bone computed tomographic (CT) scan with contrast material was performed. The suspicion of OLST arose after the CT scan, and he was transferred to our medical center for surgical treatment.
E.E. Tov et al. / American Journal of Otolaryngology – Head and Neck Medicine and Surgery 29 (2008) 138–141
139
Fig. 3. Posterior fossa CTV on admission. A filling defect with high attenuation of the sinus walls (delta sign) is demonstrated in the right lateral sinus. On the left side is a normal-appearing sinus enhanced with contrast material.
On arrival, the patient was afebrile, in a good general condition, conscious, with normal neurologic status. The right auricle was protruded with local swelling, erythema, and tenderness in the retroauricular region without fluctuation (Fig. 1). Otomicroscopy revealed a normal external auditory canal and a hyperemic, opaque tympanic membrane. Laboratory test results were as follows: hemoglobin level of 9.6 g/dL; white blood cell count of 8170/μL; electrolyte levels within the reference range. A chest x-ray
was normal. The fundus was examined by an ophthalmologist, and bilateral mild disc edema was noted, with normal sight and visual field. Serous fluid was aspirated by needle from the middle ear, and bacteriological culture failed to demonstrate bacterial growth. A high-resolution temporal bone CT scan showed an opaque middle ear and mastoid air cells, with no bone destruction on the right side (Fig. 2). On postcontrast CT of the posterior fossa in the venous stage (CTV), a highly attenuated right transverse and sigmoid sinus with a filling defect was observed, as well as soft tissue edema of retroauricular tissues without abscess formation (Fig. 3). No other intracranial complications were evident. The antibiotic treatment was changed to intravenous meropenem 1500 mg divided into 3 daily doses.
Fig. 2. An axial high-resolution CT scan of the temporal bone at the level of the mesotympanum performed after admission. The right mastoid air cells are partially opaque without bone erosion.
Fig. 4. Posterior cranial fossa CTV performed 4 months later at a similar level. The right lateral sinus is enhanced normally with contrast material.
Fig. 1. The right auricle is protruded with local swelling and redness in the
140
E.E. Tov et al. / American Journal of Otolaryngology – Head and Neck Medicine and Surgery 29 (2008) 138–141
At this point, the medical staff considered surgical intervention, including mastoidectomy with exploration of the lateral sinus. During the next 24 hours, the child felt better, there was no progression in the otologic findings, and there were no signs of sepsis. After the parents were advised on the options of surgery vs a conservative approach, they opted for close observation, repeated scans, and withholding of surgery. During the next 3 days, there was a complete resolution of symptoms and signs. On a repeat CT on the fourth day of admission, there was no evidence of thrombus propagation. At the end of the first week of hospitalization, the patient underwent duplex of the upper neck, demonstrating a patent internal jugular vein on the right. Repeated ophthalmologic examination showed no change. The patient was discharged after 10 days and continued the same intravenous antibiotic therapy for an additional 2 weeks at home. Four months after hospitalization, a follow-up postcontrast CT scan was performed, demonstrating normal venous flow of the right lateral sinus (Fig. 4). Optic discs were considered normal by the ophthalmologist.
3. Discussion Otogenic lateral sinus thrombosis is a rare complication of acute and chronic otitis media nowadays. It usually develops as an extension of perisinus infection eroding the bone by coalescence, by granulation tissue, or by cholesteatoma. Except for bone erosion, OLST may also be caused by osteothrombophlebitis of emissary mastoid veins, with an intact bony sinus plate at the time of surgical exploration [10]. The first descriptions of OLST report mortality rates of 100%. This figure dropped dramatically to 35% because surgical intervention has been offered [11]. In the antibiotic era, there has been a further decline of mortality [4,8]. In recent years there have been less reports of OLST-related mortality, and these were usually associated with concomitant intracranial complications. This dramatic decline in mortality can be attributed to early diagnosis, including highresolution CT and magnetic resonance imaging (MRI), and intensive care unit postoperative care [3,4]. Clinical symptoms and signs of OLST include headache, fever, and prolonged ear infection—manifestations that overlap with otitis, mastoiditis, and other intracranial complications. The classic “picket-fence fever pattern,” described in the preantibiotic era, reflecting clots with bacteremia, occurs relatively infrequently today. When OLST is suspected, a high-resolution CT scan of the temporal bone and postcontrast CT of the posterior cranial fossa demonstrating venous phase should be performed. The “delta sign,” caused by the enhancement of the lateral sinus wall, is considered diagnostic. This finding is more sensitively demonstrated by MRI with gadolinium; the thrombus has low signal intensity on T2-weighted images,
with an absence of flow on MRI venography [12]. Magnetic resonance imaging is also superior in demonstrating abscess formation within the sinus and for excluding an adjacent subdural empyema, cerebritis, or cerebral abscess. Despite these advantages, MRI is very costly and not readily available in many centers, including our own, at the time the child presented to us. Magnetic resonance imaging is the test of choice for confirming the diagnosis. When CT is performed and fails to demonstrate the thrombus, MRI is mandatory. With the help of modern radiologic techniques that detect the thrombus with high sensitivity and accuracy, there should be no difficulties in establishing the correct diagnosis when OLST is suspected and in following up possible thrombus propagation. In our patient, the diagnosis of OLST was established conclusively by clinical appearance and unilateral delta sign on CTV. Early bilateral papillary edema was noted in the patient, probably implying the development of otitic hydrocephalus, which is commonly referred to today as pseudotumor cerebri. This complication has been reported in 26% of children with OLST [8]. The management of OLST includes antibiotic therapy and prompt mastoid surgery with or without anticoagulation. Internal jugular vein ligation is rarely indicated nowadays and is usually reserved for unresponsive cases with lung thromboemboli or deep neck infection. More conservative approaches to OLST treatment have been suggested in recent years. Intraoperative aspiration of the sinus during mastoidectomy is commonly used to confirm the diagnosis and for deciding whether to surgically open and then to obliterate the sinus. When no free blood flow is recovered, the sinus has traditionally been incised and the clot has been removed. Interestingly, several studies have reported similar favorable outcome when the clot was left untouched [4,5,13]. Kutluhan et al [6] managed 4 cases of OLST with radical mastoidectomy. In 2 of them, no pus was aspirated intraoperatively from the sinus; and accordingly, no further procedure on the sinus was performed, and the patients had full recovery. Bradley et al [2] reported a series of 9 patients with OLST of which only 7 patients underwent mastoidectomy. Intraoperative needle aspiration of the sinus was performed in 4 of them, and incision of the sinus with thrombus evacuation was performed in only 2 of the patients. In their study, most of the patients were treated with anticoagulation therapy, and they reported a good short-term outcome. However, the rationale for choosing the type of intervention was not discussed. Agarwal et al [14] described a case of OLST with concomitant epidural abscess and occipital osteomyelitis that required posterior fossa craniectomy, leaving the thrombus untouched. Surgery left a window in the parietooccipital bone that allowed serial follow-up with ultrasound while the patient was recovering. Normal venous flow within sigmoid sinus was demonstrated at week 5 after surgery. This case strengthens the argument that the natural history of OLST is of resolution as soon as the source of infection is managed.
E.E. Tov et al. / American Journal of Otolaryngology – Head and Neck Medicine and Surgery 29 (2008) 138–141
There have been 2 previous case reports on patients with OLST who did not undergo mastoid surgery at all; one was in a 7-year-old and the other in a 14-year-old [7,8]. In both cases, the patients were transferred from other medical centers after initial antibiotic treatment and were afebrile at diagnosis with a lack of suppurative infection or sepsis. They were treated with anticoagulants and parenteral antibiotics. Wong et al [9] presented a retrospective case series of 5 patients with OLST, where 3 patients were treated successfully without mastoidectomy and another patient operated on did nor reveal any pus or granulations. The authors concluded that surgery—mastoidectomy—and sinus needle aspiration for final diagnosis should be reserved for patients who are unresponsive or who deteriorate after myringotomy and intravenous antibiotics. Considering our case and review of the literature, if the eradication of the underlining infection can be achieved with antibiotics alone, (as commonly seen in cases of acute mastoiditis with periosteitis) then surgery of OLST may be withheld. This conservative approach for OLST should be contraindicated in cases of acute or chronic infection with evidence of perisinus bone destruction. In chronic otitis media, cholesteatoma or granulation tissue commonly erodes the bone sinus late and acts as a persistent source of infection that warrants surgery. In contrary, in cases of OLST secondary to acute otitis media with no previous antibiotic treatment, where an osteothrombophlebitic process is most probably involved in the pathophysiology, antibiotic treatment could be sufficient. Because the patient we treated was recovering with no signs of sepsis and no evidence of suppurative disease on CT, we decided to withhold the surgery and observe him closely with repeated scans. This approach seemed appropriate in our case because of the good general condition of the child, the good clinical response, and the lack of radiologic progression. In this conservative treatment strategy, it is of the utmost importance to continue long-term antibiotics and aspiration by tympanocentesis or myringotomy of middle ear fluids. In addition, it is crucial to perform serial imaging studies to monitor for thrombus propagation. Further reports on OLST cases managed conservatively would be invaluable for defining the role of this treatment option. 4. Conclusions 1. Otogenic lateral sinus thrombosis is a potentially lethal complication of otitis media and mastoiditis. Whereas
141
some patients present with a fulminate disease, in others the disease may be relatively mild and only detectable with imaging studies. 2. Although a traditional OLST has been treated by mastoidectomy and clot removal from the sinus, in recent years several modifications had become accepted with good outcomes. 3. Conservative treatment of OLST consisting of myringotomy and intravenous antibiotics without surgery is appropriate in highly selected cases secondary to acute otitis media in which prompt response to this treatment is seen. 4. A high index of suspicion must be maintained during the prolonged antibiotic treatment for the possibility of thrombus propagation and the development of concomitant intratemporal and intracranial complications. References [1] Teichgraeber JF, Per-Lee JH, Turner JS. Lateral sinus thrombosis: a modern perspective. Laryngoscope 1982;92:744-51. [2] Bradley DT, Hashikasi GT, Mason JC. Otogenic sigmoid sinus thrombosis: what is the role of anticoagulation? Laryngoscope 2002;112:1726-9. [3] Kaplan DM, Krause M, Puterman M, et al. Otogenic lateral sinus thrombosis in children. Int J Pediatr Otorhinolaryngol 1999;49:177-83. [4] Ooi EH, Hilton M. Management of lateral sinus thrombosis: update and literature review. J Laryngol Otol 2003;117:932-9. [5] Syms MJ, Tsai PD, Holten MR. Management of lateral sinus thrombosis. Laryngoscope 1999;109(10):1616-20. [6] Kutluhan A, Kiris M, Yurttas V, et al. When can lateral sinus thrombosis be treated conservatively? J Otolaryngol 2004;33:107-10. [7] Spandow O, Gothefors L, Fagerlund M, et al. Lateral sinus thrombosis after untreated otitis media. A clinical problem—again? Eur Arch Otorhinolaryngol 2000;257:1-5. [8] Gracia RD, Baker AS, Cunningham MJ, et al. Lateral sinus thrombosis associated with otitis media and mastoiditis in children. Pediatr Infect Dis J 1995;14:617-23. [9] Wong I, Kozak FK, Poskitt K, et al. Pediatric lateral sinus thrombosis: retrospective case series and literature review. J Otolaryngol 2005;34:79-85. [10] Shambaugh GE, Glassock ME. Meningeal complications of otitis media. In: Shambaugh GE, Glassock ME, editors. Surgery of the ear. 3rd ed. Philadelphia, (PA): W.B. Saunders Company; 1980. p. 302-9. [11] Meltzer PE. Treatment of thrombosis of lateral sinus. Arch Otolaryngol 1935;22:131-42. [12] van der Bosch MAAJ, Vos JA, de Letter MACJ, et al. MRI findings in a child with sigmoid sinus thrombosis following mastoiditis. Pediatr Radiol 2003;33:877-9. [13] Singh B. The management of lateral sinus thrombosis. J Laryngol Otol 1993;107:803-8. [14] Agarwal A, Lowry P, Isaacson G. Natural history of sigmoid sinus thrombosis. Ann Otol Rhinol Laryngol 2003;112:191-4.