1

Introduction

Otogenic lateral sinus thrombosis (LST) is an uncommon complication of otitis media with potentially significant morbidity and mortality. Despite the widespread use of antibiotics, intracranial complications of otitis media continue to occur. The diagnostic acumen of the modern otolaryngologist has been challenged by infrequent cases and subsequent lack of familiarity with management. Infectious lateral sinus thrombosis (LST) accounts for 2%–20% of all intracranial complications of otitis media . Classic signs and symptoms include high-grade “picket fence” fever, otalgia, purulent otorrhea, and altered mental status. However, the prevalence of some classic symptoms like high spiking “picket fence” fevers as well as intracranial complications of LST has diminished the with the use of antibiotics . Much have been written regarding the management of otogenic intracranial complications; however, controversy still exists regarding the efficacy and necessity of various diagnostic and therapeutic maneuvers including sinus aspiration, thrombectomy, and use of anticoagulation.

2

Case report

A 14 year old male presented with a four day history of right-sided otalgia, otorrhea, fever, and headache followed, in the ensuing days, with vomiting, intermittent episodes of confusion and visual hallucinations, fatigue, blurry vision, imbalanced gait and right buttock pain. He had been started on ciprofloxacin ear drops by his primary care physician two days prior to presentation in the emergency department at our institution. Clinical exam on presentation was consistent with right otitis media, demonstrating purulent discharge draining from an edematous right ear canal and mastoiditis with a positive Griesinger’s sign. Laboratory studies were within normal limits with a white blood cell count of 4900 cells/mm ³ . Findings from a lumbar puncture were also within normal limits. CT scan with contrast demonstrated opacification of the right mastoid air cells without bony trabecula destruction and a filling defect in the right transverse and sigmoid sinuses. Subsequent MRI/MRV confirmed evidence of sinus thrombosis ( Fig. 1 ). The patient was started on vancomycin, metronidazole, and ceftazidime. Due to lack of clinical improvement over the next 12 h following onset of medical therapy and continued altered mental status, the decision was made to proceed with surgical management, which included right myringotomy and tube placement and a simple mastoidectomy. The sigmoid sinus was not aspirated or ligated. Beta hemolytic group A streptococcus was identified from an epidural abscess found intraoperatively. His antibiotic course was then narrowed to ceftriaxone and clindamycin. The patient was not anticoagulated. On postoperative day 5 the patient’s otologic symptoms had resolved. Total hospital stay was 10 days. The patient was followed up in clinic after one week with sustained resolution of his symptoms. Follow up imaging confirmed complete recanalization of the sinuses ( Fig. 2 ).

MR venogram images after the administration of intravenous gadolinium. Coronal MR venogram demonstrating the filling defect in the right transverse sinus (arrow).

Post-operative follow-up coronal MR venogram image demonstrating that the right transverse sinus has returned to normal caliber. Asymmetry of the transverse sinuses represents a normal variant, as opposed to post-thrombotic changes.

2

Case report

A 14 year old male presented with a four day history of right-sided otalgia, otorrhea, fever, and headache followed, in the ensuing days, with vomiting, intermittent episodes of confusion and visual hallucinations, fatigue, blurry vision, imbalanced gait and right buttock pain. He had been started on ciprofloxacin ear drops by his primary care physician two days prior to presentation in the emergency department at our institution. Clinical exam on presentation was consistent with right otitis media, demonstrating purulent discharge draining from an edematous right ear canal and mastoiditis with a positive Griesinger’s sign. Laboratory studies were within normal limits with a white blood cell count of 4900 cells/mm ³ . Findings from a lumbar puncture were also within normal limits. CT scan with contrast demonstrated opacification of the right mastoid air cells without bony trabecula destruction and a filling defect in the right transverse and sigmoid sinuses. Subsequent MRI/MRV confirmed evidence of sinus thrombosis ( Fig. 1 ). The patient was started on vancomycin, metronidazole, and ceftazidime. Due to lack of clinical improvement over the next 12 h following onset of medical therapy and continued altered mental status, the decision was made to proceed with surgical management, which included right myringotomy and tube placement and a simple mastoidectomy. The sigmoid sinus was not aspirated or ligated. Beta hemolytic group A streptococcus was identified from an epidural abscess found intraoperatively. His antibiotic course was then narrowed to ceftriaxone and clindamycin. The patient was not anticoagulated. On postoperative day 5 the patient’s otologic symptoms had resolved. Total hospital stay was 10 days. The patient was followed up in clinic after one week with sustained resolution of his symptoms. Follow up imaging confirmed complete recanalization of the sinuses ( Fig. 2 ).

MR venogram images after the administration of intravenous gadolinium. Coronal MR venogram demonstrating the filling defect in the right transverse sinus (arrow).

Post-operative follow-up coronal MR venogram image demonstrating that the right transverse sinus has returned to normal caliber. Asymmetry of the transverse sinuses represents a normal variant, as opposed to post-thrombotic changes.

3

Materials

A detailed search in the Pubmed database was performed with complete review of all literature published using the key words, “pediatric”, “lateral sinus thrombosis”, and “otitis media.” Papers authored from 1993 to present, including pediatric patients less than or equal to 16 years of age that specified the management of otogenic lateral sinus thrombosis and mortality were included. Full text papers not available under the Yale University licensing were excluded.

4

Results

This review includes 21 individual reports and case series involving 104 pediatric patients. Our review includes 73% males (n = 69) and 27% (n = 26) females. The average age upon presentation was 7.7 years. Of the cases of lateral sinus thrombosis specifically associated with a diagnosis of otitis media, 33% were associated with chronic otitis media (COM), while 67% were associated with acute otitis media (AOM). Lateral sinus thrombosis occurred in the right side 61% of the time. There were no reports of bilateral LST.

The most commonly reported symptoms were fever, headache, vomiting, and otalgia. On exam the most common signs were otorrhea, neck stiffness, papilledema, and abducens nerve palsy ( Table 1 ). The average time between the onset of symptoms and admission to the hospital was 11.0 days.

Table 1

Review of the symptoms, signs and complications in 63 pediatric patients upon diagnosis with lateral sinus thrombosis.

Symptoms	No. of cases	Frequency	Physical exam findings	No. of cases	Frequency	Complications	No. of cases	Frequency
Fever	42	0.67	Otorrhea	28	0.44	Papilledema	16	0.25
Headache	40	0.63	Neck stiffness	16	0.25	Abducens Nerve Palsy	15	0.24
Vomiting	30	0.48	Postauricular tenderness	13	0.21	Otitic Hydrocephalus	14	0.22
Otalgia	24	0.38	Hearing loss	6	0.10	Epidural abscess	7	0.11
Diplopia	19	0.30				Perisinus abscess	4	0.06
Dizziness	10	0.16				Subperiosteal abscess	3	0.05
Photophobia	5	0.08				Septic Arthritis	3	0.05
Altered mental status	3	0.05
Multiple Spiking Fevers	2	0.03

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