Post on 02-Jul-2015
Lateral Sinus Thrombosis
A Complication of CSOM
Overview
• 6% of all Intracranial complications of CSOM
• In CSOM direcrt spread through bone erosion and thrombophlebitic spread through emissary veins
• In ASOM spread is mainly through emissary veins
Anatomy
• Formed by the confluence of the superior petrosal and transverse sinuses
• Becomes internal jugular vein at its exit from foramen jugulare
Spread
• Directly through bone erosion due to granulation and cholesteatoma
• Thrombophlebitis of the mastoid emissary veins– Griesinger’s Sign
– Erythema, edema and tenderness over mastoid area
Pathophysiology• Perisinus abscess penetrates dura reaches
intima mural thrombus forms due to intimal damage, hypercoagulation and blood flow in sinus
• Bacteria & thrombus platelet aggregtion fibrin formation mural clot necrosis of clot intramural abscess
• Clot propagates occlusion of vessel lumen & infected emboli given off in circulation metastatic abscesses septicemia
Presentation
• Varies according to stage
Presentation Contd.
• Despite antibiotics may present as– Fever with periodic chills
– Picket fence due to periodic release of steptococci in blood from septic thrombus
– Headache– Due to raised ICP caused by interrupted cortical venous circulation
Papilledema
– Otorrhoea– Refractory to antibiotic therapy
– Neck Pain– Extension of thrombophlebitis to jugular bulb and internal jugular
vein IJV palpated as a tender cord in neck
Presentation Cont.
– Neck rigidity– Due to meningeal irritation. Torticollis may also be seen due to
guarding of the neck muscles
– Nausea, vomiting– Due to raised ICP and bacteremia
– Altered mental state and focal neurologic signs– If brain abscess
– Vertigo and nystagmus– Involvement of labyrinth
– Seizures– Temporal lobe involvement
– Lethargy
Presentation Cont.• Jugular Foramen Syndrome-Vernet’s Syndrome
- Dysphonia/hoarseness- Soft palate dropping- deviation of the uvula towards the normal side- dysphagia- loss of sensory function from the posterior 1/3 of the
tongue- decrease in the parotid gland secretion- loss of gag reflex- Sternocleidomastoid and trapezius muscles paresis
Presentation Cont.• Jugular Foramen Syndrome-Vernet’s Syndrome– 9th, 10th & 11th and sometimes 12th nerve paralysis due to
pressure of clot in jugular bulb– Symptoms
» pain in or behind ear due to irritation of the auricular branches of the 9th and 10th nerves
» headache due to irritation of the meningeal branch of vagus» hoarseness due to paralysis of the laryngeal nerves» dysphagia (diffiuclty to swallow) due to paralysis of the
pharyngomotor fibres» honers syndrome ( ptosis of upper eyelid, pupillary
constriction) due to interruption of sympathetic internal caortid plexus
» wasting of affected side of tongue and deviation of the protruded tongue to the affected side due to infranuclear paralysis of 12th nerve
Presentation Cont.» deviation of the uvula away form the affected side due to
unopposed action of levator palatini» sensory loss in oroharynx on the affected side» inabllity to adduct the vocal cords to the midline» weakness and wasting of sternocleidomastoid and
treapezius due to involvement of 11th nerve
sympathetic signs may be absent if accessory nerve unaffected
– Recovery depends on collateral circulation and recanalization of the sinus
– Surgical intervention not required usually– Decompression and removal of clot if necessary
Presentation Cont.
• Otitic Hydrocephalus
– Due to interrupted cortical venous circulation obstruction in CSF flow leads to ventricular dilatation
– One or both lateral sinuses may be found thrombosed
– S&S of raised ICP`
Clinical Examination
• Anaemia & emaciation• Griesingers’s sign• Positive Tobey – Ayer’s Test• Positive Crow – Beck’s Test• Tenderness along IJV• Enlarged jugular nodes• Torticollis • Positive Kernig’s Sign • Positive Brudzinski’s Sign
Bacteriology
• Acute– Hemolytic stretpococci– Pneumococci– Staphylococci
• Chronic– Bacillus Proteus– Pseudomonas Pyocyaneus– E.coli– Bacteroides – Staphylococci
Labs
• Polys on CBC• CSF examination ICP only• C/S of ear swab• C/S of pus material from sinus if available
Imaging
• CT with contrast Delta Sign
• Gadolinium enhanced MRI Delta Sign– MRI is the investigation of choice & is done in
combination with CT
• Serial MRV in combination with MRI to see clot propagation and resolution
Treatment
• Medical + Surgical Combo
• Medical– I/V antibiotics– Anti coagulants only if clot in superior sagittal
sinus or ICP persists despite medical management
Treatment Contd.
• Surgical• Mastoidectomy + removal of clot from sinus
– ASOM– Cortical + removal of sinus plate
– CSOM + Cholesteatoma– Radical
– Refractory Septicemia– IJV ligation to stop emboli being thrown into circulation
Follow up
• Post op antibiotics for 2-3 weeks• Post op MRI & MRV
Complications
• Mostly ipsilateral• At times contralateral due to hematogenous
spread
Prognosis
• Mortality has decreased to less than 10% due to availability of effective medical and surgical treatment
Name No. Drains to / Becomes
Inferior Sagittal Sinus 1 Straight sinus
Superior Sagittal Sinus 1 Becomes right transverse sinus or confluence of sinuses
Straight Sinus 1 Becomes left transverse sinus or confluence of sinuses
Occipital Sinus 1 Confluence of sinuses
Confluence Of Sinuses 1 Right and left transverse sinuses
Sphenoparietal Sinuses 2 Cavernous sinuses
Intercavernous Sinuses 2 Cavernous sinuses
Cavernous Sinuses 2 Superior and inferior petrosal sinuses
Superior & Inferior Petrosal Sinuses
2/2 Transverse sinuses
Transverse Sinuses 2 Sigmoid sinusees
Sigmoid Sinuses 2 Jugular bulb IJV