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Otogenic Lateral Sinus Thrombosis

  • Author: B Viswanatha, DO, MBBS, PhD, MS, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Mar 03, 2015
 

Background

Otogenic lateral sinus thrombosis is a well-known intracranial complication of otitis media. It occurs in combination with other intracranial complications. The advent of antibiotics has brought about a decline in this condition. Before the advent of antibiotics, most lateral sinus thrombosis was attributable to acute otitis media; however, in most of the recent published reports, chronic otitis media predominates.

An image depicting otogenic lateral sinus thrombosis can be seen below.

MR venogram that shows nonfilling of the lateral s MR venogram that shows nonfilling of the lateral sinus on the left side.
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History of the Procedure

Lateral sinus thrombosis was first described in 1826. Three decades later, the pathology of lateral sinus thrombosis was first described by Lebert. In 1888, Lane performed the first successful surgery for lateral sinus thrombosis.

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Problem

Lateral sinus thrombosis is a potentially fatal condition in which early diagnosis may be difficult because of previous antibiotic therapy. In the antibiotic era, the presentation of lateral sinus thrombosis has changed from pronounced signs and symptoms to vague and nonspecific symptoms. The decreased incidence and change in presentation requires clinicians to maintain a high index of suspicion to make the diagnosis.

Lateral sinus thrombosis should be suspected in patients who have persistent fever, otorrhea, and headache despite adequate antibiotic treatment.

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Epidemiology

Frequency

Lateral sinus thrombosis accounts for 6% of all intracranial complications in the era of antibiotic treatment of suppurative ear disease.

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Etiology

The proximity of the middle ear and mastoid air cells to the dural venous sinuses predisposes them to thrombosis and thrombophlebitis secondary to infection and inflammation in the middle ear and mastoid.

Lateral sinus thrombosis usually develops as a complication of chronic otitis media caused by the direct dissemination of the infection through the neighboring eroded bone. It has been reported in a patient with an intact sigmoid plate, indicating propagation by the thrombophlebitic spread through the small emissary vein. It may also develop as a complication of acute suppurative otitis media by thrombophlebitic dissemination through the emissary vein in the intact bone. Lateral sinus thrombosis was ranked second to meningitis in the preantibiotic era as the most frequent fatal complication of otitis media and lateral sinus thrombosis occurred largely as a complication of acute otitis media. It is less often a disease of children in association with acute otitis media. More often, it is seen in the adult patient after a long history of chronic ear disease.

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Pathophysiology

Initially, a perisinus abscess is formed, and, as the infection penetrates the dura and approach intima, a mural thrombus develops. Damage to the intima of blood vessels, hypercoagulation, and decreased blood flow are contributory factors in the formation of thrombus within the vessels. Damage to the tunica intima is the predominant factor in septic sinus thrombosis because the inflammatory process initiates fibrin formation and aggregation of blood platelets. The thrombogenic properties of bacteria are supposed to accelerate the process. Unless effective treatment is properly instituted, the mural clot grows and necrotizes, forming an intramural abscess. A mural thrombus then develops within the lumen of the sinus, propagates proximally and distally, and may become infected. The lumen of the vessel is eventually occluded by the propagating thrombus, and infected material may be embolized into the systemic circulation, causing septicemia.

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Presentation

Clinical features vary according to the stage of the disease. Patients present with headache, fever, and otorrhea. The classic case of lateral sinus thrombosis in the preantibiotic era typically produced a picket fence fever curve, due to the periodic release of hemolytic streptococci from the septic sinus thrombus. With the occlusion of the lumen of the sinus, an interruption of the cortical venous circulation results in headache, papilledema, and increased intracranial pressure. Involvement of the torcular and sagittal sinus can result in otitic hydrocephalus.

Tenderness and edema over the mastoid (the Griesinger sign) are highly suggestive of lateral sinus thrombosis and reflex thrombosis of mastoid emissary vein. With the extension of thrombophlebitis into the jugular bulb and internal jugular vein, pain may be present in the neck, particularly on rotation. Internal jugular vein may be palpated in the neck as a tender cord. The 9th, 10th, and 11th cranial nerve may be paralyzed by the presence and pressure of a clot in the jugular bulb (jugular foramen syndrome).

Because the right transverse is usually dominant, the symptoms are more likely to occur when this sinus is involved. Recovery depends on the development of collateral circulation or possibly recanalization of the sinus. Because of this, the presence of anastomotic channel is important for recovery.

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Indications

See Medical therapy.

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Relevant Anatomy

The lateral sinus is formed by the confluence of the superior petrosal sinus and the transverse sinus. The right transverse sinus is usually a continuation of the sagittal sinus, and the left transverse sinus is a continuation of the straight sinus. The lateral, or sigmoid, sinus exits the skull through the jugular foramen to become the internal jugular vein. It is called the lateral sinus because it is encountered laterally in mastoid surgery.

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Contributor Information and Disclosures
Author

B Viswanatha, DO, MBBS, PhD, MS, FACS Professor of Otolaryngology (ENT), Sri Venkateshwara ENT Institute, Victoria Hospital, Bangalore Medical College and Research Institute, India

B Viswanatha, DO, MBBS, PhD, MS, FACS is a member of the following medical societies: Indian Medical Association, Indian Society of Otology, Association of Otolaryngologists of India

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Gerard J Gianoli, MD Clinical Associate Professor, Departments of Otolaryngology-Head and Neck Surgery and Pediatrics, Tulane University School of Medicine; President, The Ear and Balance Institute; Board of Directors, Ponchartrain Surgery Center

Gerard J Gianoli, MD is a member of the following medical societies: American Otological Society, Society of University Otolaryngologists-Head and Neck Surgeons, Triological Society, American Neurotology Society, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Vesticon<br/>Received none from Vesticon, Inc. for board membership.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Jack A Shohet, MD President, Shohet Ear Associates Medical Group, Inc; Associate Clinical Professor, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, School of Medicine

Jack A Shohet, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Neurotology Society, American Medical Association, California Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Envoy Medical <br/>Received consulting fee from Envoy Medical for medical advisory board member. for: Envoy Medical .

Acknowledgements

The author wishes to thank Professor Khaja Naseeruddin - Joint Director of Medical Education, Professor Kishore Chandra Prasad, Professor B.N. Sambamurthy, and Professor P.P. Devan.

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MR venogram that shows nonfilling of the lateral sinus on the left side.
MRI that shows thrombus in the lateral sinus on the left side.
MRI that shows postcontrast enhancement of the sinus wall on the left side.
 
 
 
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