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