Clinical characteristics of otogenic lateral sinus thrombosis in patients under 18 years old compared with that in adult patients.

BACKGROUND: Otogenic lateral sinus thrombosis (OLST) is a rare complication of otitis media. We do not know whether the disease progress between the pediatric and adult OLST patients is consistent. However, pediatric surgical methods always refer to the adults'. AIMS/OBJECTIVES: This study aimed to seek evidence for suitable surgical methods in pediatric patients. MATERIALS AND METHODS: The clinical manifestation, laboratory findings, and findings in operation between children and adult groups were compared. RESULTS: Ten children and 17 adults OLST patients were included. Most pediatric patients had no history of chronic otitis media or cholesteatoma (p<.001). The ratios of otorrhea, tympanic perforation and sclerotic type mastoid in CT scan were significantly lower in the children group (p<.05). The mean air conduction hearing threshold in the children and adolescent group (31.25 ± 21.27 dB) was significantly lower than that of the adult group (77.6 ± 23.66 dB) (p<.001). The diseases in attics (66.7%) and the ossicular chain destruction (33.3%) were not as severe as those in the adult group (p<.05). The eustachian tube closure was found similar in two groups. CONCLUSIONS AND SIGNIFICANCE: Conservative surgery is recommended to pediatric OLST to obliterate the diseases and improve middle ear and mastoid drainage, preserving hearing function.

Headache attributed to cranial venous sinus stenting: A case series and literature review.

BACKGROUND: The diagnostic criteria for headache attributable to cranial venous sinus stenting were first formalized in the recently published third edition of the International Classification of Headache Disorders (ICHD-3). However, the diagnostic criteria for headache caused by cranial venous sinus stenting are based on very few data and the condition is poorly characterized. OBJECTIVES: To validate the diagnostic criteria for cranial venous sinus stenting headache by retrospectively studying the characteristics of headache in patients with isolated pulsatile tinnitus who underwent curative cranial venous sinus stenting and who had not previously complained of headache. PATIENTS AND METHODS: We retrospectively studied clinical, radiological, and manometric data from patients with isolated venous pulsatile tinnitus who had not previously reported headache. All patients underwent lateral sinus stenting in our institution between October 2010 and February 2018. RESULTS: Forty eight patients, 47 females and one male, were enrolled. The mean age at symptom onset was 36.2 ± 8.7 years and the mean body mass index was 24.0 ± 3.2 kg/m2. Lateral sinus stenosis was evident in 47 patients and a sigmoid diverticulum in one. Fourteen patients experienced headaches after recovering from general anesthesia. All were female, with a mean age of 35.5 ± 9.6 years. Headache persisted for less than 3 days in six patients (42.8%); for 3 days to 3 months in four (28.6%); and for longer than 3 months in four (28.6%). The headaches were located on the same sides as the cranial venous sinus stents in 13 patients (92.9%) and were principally occipital, being oppressive in nine patients (64.3%) and of moderate intensity in seven (50%). Age at onset of pulsatile tinnitus and body mass index were significantly associated with headache (p < 0.05; t-test). CONCLUSION: To the best of our knowledge, this is the first study to describe cranial venous sinus stenting headache in detail. We found that de novo headache developed after cranial venous sinus stenting, and was usually mild to moderate, unilateral, but oppressive; almost one-third of such headaches persisted for more than 3 months. Researchers and clinicians must become familiar with this headache spectrum; further prospective studies are required.

Stenting of symptomatic lateral sinus thrombosis refractory to mechanical thrombectomy.

OBJECTIVE: Endovascular mechanical thrombectomy for the treatment of cerebral venous sinus thrombosis is not always successful. We present our experience of using self-expanding stents to facilitate effective recanalization of persistent lateral sinus thrombosis refractory to endovascular mechanical thrombectomy. METHODS: Data from patients who underwent endovascular mechanical thrombectomy for the treatment of acute symptomatic cerebral venous sinus thrombosis between August 2015 and July 2018 were evaluated. Patient demographics, procedural techniques, devices used and follow-up outcomes were assessed. RESULTS: A total of 14 patients underwent endovascular mechanical thrombectomy during the study period. Of these, stenting of the occluded sinus was performed in five patients with extensive sinus thrombosis after conventional endovascular mechanical thrombectomy. Three of the five patients had a variable degree of venous infarction and/or hemorrhage before treatment. The target lesion was located in the right lateral sinus in all five patients. Due to the length of the involved sinus, two stents were required in one patient and three stents in two patients. The only procedure-related complication was an asymptomatic tearing of the sinus wall in one patient. Stent patency could not be maintained in two patients due to stent buckling within the jugular foramen segment and an inability to maintain antiplatelet medication. Modified Rankin Scale scores at 2-16 months were zero in two patients, one in two patients, and five in one patient. CONCLUSIONS: Stenting for the thrombotic occlusion of the lateral sinus is a feasible rescue method to overcome unsuccessful endovascular mechanical thrombectomy. However, currently available stenting systems may be unsuitable for use in the intracranial dural sinus system.

Surgical Thrombectomy Combined with Bilateral Decompressive Craniectomy in a Life-Threatening Case of Coma from Cerebral Venous Sinus Thrombosis: Case Report and Literature Review.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke. Medical and neurointerventional strategies, such as in situ thrombolysis, are standard therapies. These techniques are insufficient when clinical deterioration arises from mass-associated effects and transtentorial herniation; in such cases, decompressive hemicraniectomy may be indicated. To the best of our knowledge, the association of open surgical thrombectomy with bilateral decompressive craniectomy has not been reported to date. CASE DESCRIPTION: A 45-year-old woman presented with extensive cerebral venous sinus thrombosis that was resistant to anticoagulation and endovascular therapies. Her clinical condition deteriorated until she became comatose, and bilateral hemicraniectomy combined with open surgical thrombectomy through the superior sagittal sinus was indicated. Computed tomography angiography confirmed postoperative maintenance of sinus permeability. The patient's clinical status improved dramatically, and she had a favorable outcome, including recovery of her functional independence to perform all activities of daily living (modified Rankin Scale score = 0). The follow-up period was 5 years. CONCLUSIONS: Open surgical thrombectomy combined with decompressive craniectomy is a lifesaving procedure that can lead to favorable outcome and should be considered for treatment of refractory malignant cerebral venous sinus thrombosis.

Otogenic Lateral Sinus Thrombosis: A Review of Fifteen Patients and Changing Trends in the Management

Abstract Introduction Otogenic lateral sinus thrombosis is a rare intracranial complication of otitis media in the modern age of antibiotic treatment, but it is potentially a dangerous complication. Objectives The aim of this study is to focus on the various clinical presentations, management options and sequelae in a series of fifteen patients with otogenic lateral sinus thrombosis. Methods Retrospective chart review of inpatients treated for otogenic lateral sinus thrombosis at our tertiary care institution between 2010 and 2015. Results A total of 15 patients (11 males and 4 females) with ages ranging from 9 to 60 years were diagnosed with otogenic lateral sinus thrombosis. The most commonly reported symptoms were headache, ear discharge and hard of hearing, which were experienced by all 15 (100%) patients. In contrast to previous studies found in the literature, 7 (47%) patients in our series presented with neck pain and neck abscess. Imaging studies and microbiological cultures were performed for all patients, who also underwent a mastoidectomy procedure. Internal jugular vein ligation was performed on 5 (33%) patients. Incision and drainage of the neck abscess was performed on 7 (47%) patients. All patients had a satisfactory resolution of their symptoms, and the mortality rate was of 0%. Conclusions Otogenic lateral sinus thrombosis, though a rare complication, can still occur; therefore, keeping a high level of suspicion is important, especially in developing countries. We also describe the patients with neck abscess associated with this rare condition. Combining parenteral antibiotics with surgical intervention is the treatment of choice.

[Diagnosis and treatment of the complications of otitis media in adults. Case series and literature review]. / Abordaje diagnóstico y terapéutico de las complicaciones de la otitis media en el adulto. Serie de casos y revisión de la literatura.

BACKGROUND: The complications of otitis media (intra-cranial and extra-cranial) used to have a high morbidity and mortality in the pre-antibiotic era, but these are now relatively rare, mainly due to the use of antibiotics and the use of ventilation tubes, reducing the incidence of such complications significantly. Currently, an early suspicion of these complications is a major challenge for diagnosis and management. CLINICAL CASES: The cases of 5 patients (all male) are presented, who were diagnosed with complicated otitis media, 80% (4) with a mean age of 34.6 years (17-52). There was major comorbidity in 60% (3), with one patient with diabetes mellitus type 2, and two with chronic renal failure. There were 3 (60%) intra-cranial complications: one patient with thrombosis of the sigmoid sinus and a cerebellar abscess; another with a retroauricular and brain abscess, and a third with meningitis. Of the 2 (40%) extra-cranial complications: one patient had a Bezold abscess, and the other with a soft tissue abscess and petrositis. All patients were managed with surgery and antibiotic therapy, with 100% survival (5), and with no neurological sequelae. The clinical course of otitis media is usually short, limiting the infection process in the majority of patients due to the immune response and sensitivity of the microbe to the antibiotic used. However, a small number of patients (1-5%) may develop complications. CONCLUSION: Otitis media is a common disease in our country, complications are rare, but should be suspected when the picture is of torpid evolution with clinical worsening and manifestation of neurological signs.

[Lateral Sinus Thrombosis--A Rare Complication of an Acute Mastoiditis or Infected Cholesteatoma]. / Die Sinusvenenthrombose--eine seltene Komplikation der akuten Mastoiditis und des Cholesteatoms.

BACKGROUND: Lateral sinus thrombosis (LST) is a rare but threatening complication of an acute mastoiditis or infected cholesteatoma. Currently only very few papers are available in the literature dealing with the systematic investigation of patients with suspected LST. The purpose of the present study was to evaluate the clinical, intraoperative and therapeutic findings of patients with particular disease. PATIENTS AND METHODS: For this retrospective study the clinical records of 7 patients which were admitted for a suspected LST were evaluated. All patients underwent mastoidectomy with exposition of the lateral sinus and investigating of its blood flow. RESULTS: A LST was confirmed in 4 patients, 3 patients had a phlebitis. Patients with a LST presented additional symptoms beside otalgia, i. e., dizziness, cephalgia, meningism, deafness of the affected ear, and facial nerve paresis. Postoperative MRI scans revealed a recanalization of the sinus in all cases. Although immediate surgery, 2 patients developed a 2-staged brain abscess in the cerebellum. CONCLUSION: Clinical symptoms of the SVT are unspecific. In cases of an acute mastoiditis, neurological signs might be pathognomonic and can direct to a LST. Therapeutic concepts comprise intravenous antibiotics and operative elimination of disease. The exposition of the lateral sinus should be performed in any mastoidectomy for a LST in order to scrutinize its blood flow. In case of a thrombosis additional anticoagulative therapy might be indicated. To exclude a 2-staged brain abscess control MRI scans 7 through 14 days postoperatively are recommended.

Dural enhancement and thickening in acute mastoiditis.

Dural enhancement and thickening in imaging studies observed in acute mastoiditis patients is an uncommon phenomenon. It is infrequently seen in dural sinus thrombosis, and may be caused by infiltration of inflammatory cells and an increased number of thin-walled blood vessels. We present a three-year-old boy who presented with acute mastoiditis, complicated by subperiosteal abscess. Computerized tomography (CT) demonstrated subperiosteal abscess, and the child underwent mastoidectomy. Despite adequate treatment, symptoms worsened and neurological sequelae were suspected. CT and magnetic resonance imaging (MRI) studies demonstrated an atypical dural enhancement at the sigmoid perisinus and suboccipital abscess. The child underwent revision mastoidectomy and drainage of the abscess. Following the second procedure, resolution of symptoms was noted. Follow-up MRI did not demonstrate any dural pathologies.

Venous sinus stenting is a valuable treatment for fulminant idiopathic intracranial hypertension.

Over the past 10 years, transverse sinus stenting has grown in popularity as a treatment for idiopathic intracranial hypertension. Although promising results have been demonstrated in several reported series, the vast majority of patients in these series have been treated on an elective basis rather than in the setting of fulminant disease with acute visual deterioration. We identified four patients who presented with severe acute vision loss between 2008 and 2012 who were treated with urgent transverse sinus stenting with temporary cerebrospinal fluid (CSF) diversion with lumbar puncture or lumbar drain as a bridge to therapy. All patients presented with headache, and this was stable or had improved at last follow-up. Three patients had improvement in some or all visual parameters following stenting, whereas one patient who presented with severe acute vision loss and optic disc pallor progressed to blindness despite successful stenting. We hypothesize that she presented too late in the course of the disease for improvement to occur. Although the management of fulminant idiopathic intracranial hypertension remains challenging, we believe that transverse sinus stenting, in conjunction with temporary CSF diversion, represents a viable treatment option in the acute and appropriate setting.

Management of otogenic lateral sinus thrombosis.

OBJECTIVE: To evaluate the changing clinical course and trends in management of otogenic lateral sinus thrombosis (OLST), in view of the rarity of the said lesion and antibiotic abuse. METHODS: A retrospective case study was done in 6 patients referred to our tertiary care centre with OLST over a period of three years from May 2007 to May 2010: Department of Otorhinolaryngology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - a tertiary care university teaching hospital under central government of India. Medical records of all the patients were scrutinized and data pertaining to patient profile, type of chronic suppurative otitis media (CSOM), clinical course with any other complication and management were tabulated. The said data was scientifically analyzed w.r.t. current medical literature on the subject. RESULTS: Clinically, it was observed that all patients had protracted CSOM - attico antral type, with history of rampant misuse of antibiotics. The attack of OLST in each case was triggered off by an acute attack of suppurative otitis media. Moreover, in all the cases OLST was masquerading as an intra-cranial complication, with no specific clinical features thereby causing missed diagnosis initially. All these patients were diagnosed by CT scan, and underwent modified radical mastoidectomy (MRM) with needle aspiration of sinus under antibiotic cover. The said treatment protocol resulted in excellent prognosis with no morbidity or mortality whatsoever. Pathologically, cholesteatoma was detected in 5 of the six cases with one case having only granulations. CONCLUSIONS: In this era of antibiotic abuse, the clinical presentation of OLST has altered substantially, and mimics other intra-cranial complication with vague signs and symptoms. There are conflicting views in contemporary medical literature regarding management of OLST. In our experience, MRM with needle aspiration under antibiotic cover is the treatment of choice for all cases of OLST associated with CSOM attico antral disease/cholesteatoma disease.

Current trends in the management of the complications of chronic otitis media with cholesteatoma.

PURPOSE OF REVIEW: Complications of cholesteatoma can be of a different nature from those of other otitis media. This review aims to undertake an analysis of current literature regarding management of the complications of cholesteatoma. RECENT FINDINGS: Despite a significant decline in the incidence of complications secondary to cholesteatoma in developed countries it is still a considerable problem in the developing countries. Among intratemporal complications, facial nerve paralysis and labrynthine fistula and among intracranial complications, meningitis, brain abscess and lateral sinus thrombosis are most common. In cases of facial nerve paralysis, decompression with complete disease eradication is considered to be the mainstay of treatment and usefulness of an epineural incision and the range of the decompression are still debatable. Labyrinthine fistula is commonly managed by a single staged matrix removal, followed by closure of the fistula. Partial labrynthectomy in difficult cases is gaining favor among surgeons today. Meningitis and brain abscesses are treated with antibiotics and steroid therapy followed by surgery when the patient is neurologically stable. In lateral sinus thrombosis, mastoidectomy and removal of infected tissue is the primary treatment. Sinus incision and thrombectomy does not seem to improve recanalization and anticoagulation is usually not necessary. Treatment of meningoencephalic herniations is based mainly on the diameter of the herniation. SUMMARY: There is considerable debate in the management of almost every complication of cholesteatoma. Multicentric studies to compare the efficacies of various treatment modalities are the need of the hour to come to definitive conclusions regarding the best treatment options.

Successful treatment of cerebral venous sinus thrombosis with the Solitaire FR thrombectomy device.

A young woman with factor V Leiden thrombophilia presented with headache due to thrombosis of the right transverse sinus (TS) and superior sagittal sinus. Despite appropriate anticoagulation, she experienced worsening headache, progressive neurologic deficits and spontaneous subarachnoid hemorrhage. Endovascular therapy was therefore undertaken. A 6 mm Solitaire FR device was deployed in the TS and withdrawn in a stepwise fashion, resulting in complete recanalization of the sinus. Her headache improved and her neurologic deficits resolved. Endovascular therapy for cerebral venous sinus thrombosis is currently recommended only for those patients with deterioration despite appropriate anticoagulation. The thrombus burden is usually high in this subset of patients, and recanalization can be challenging with currently available endovascular techniques. This is the first report of cerebral venous sinus thrombectomy with the Solitaire FR device, which may offer another option for those patients requiring endovascular treatment.

[Some clinical and imaging aspects of lateral sinus thrombophlebitis]. / Aspecte particulare clinico-imagistice întâlnite în tromboflebita sinusului lateral.

AIM: This article focuses on the lateral sinus thrombophlebitis, which is a serious complication of the supurated otopathies. MATERIAL AND METHODS: It is based on a study of a significant number of both exo- and endocranial complications treated in the the "Sf Spiridon" Hospital- ORL department and at the "Prof. dr. N. Oblu"- Neurosurgery department (57 out of 251 cases admitted in the past 5 years). RESULTS: Among the 57 cases, there were 8 lateral sinus thrombophlebitis, as well as 6 cases where meningitis coexisted with other endocranial complications, such as lateral sinus thrombophlebitis or brain abscess. The article contains details about some cases with special problems of diagnostic and treatment. CONCLUSIONS: The symptoms of the presented cases are completely different from the common symptomatology. However, the diagnostic of such cases is possible due to the modern imaging methods as well. The lateral sinus thrombophlebitis is usually determined by different causes, one of them being the misuse of the antibiotics (class and daily/total dose). When endocranial complications occur the symptoms of the meningitis are masking the symptoms of other complications. Even if the CT scan or MRI exams performed right on the patient's admission show no other complications, the patient should be followed for a period of 15 up to 30 days after the treatment of the meningitis, by repeating imaging tests to identify a possible complication.

Lateral sinus thrombosis in children: a review.

A retrospective study was undertaken to review the clinical presentation, evaluation, management, and outcome of otogenic lateral sinus thrombosis (LST) in children. All pediatric patients with LST seen in our department between 1999 and 2007 were included; there were 9 cases involving 6 boys and 3 girls whose ages ranged from 8 to 12 years. They had all been treated with antibiotics elsewhere prior to admission, and the duration of symptoms before admission ranged from 5 to 18 days. The most common presenting symptoms were ear discharge, headache, otalgia, and fever. Radiologic evaluation included computed tomography and magnetic resonance imaging. All patients underwent radical mastoidectomy with incision of the lateral sinus and removal of its content. There were no deaths. Pseudomonas and Proteus spp were the most commonly identified organisms. Otogenic LST still poses a serious threat that warrants immediate attention and care. It is often associated with other intracranial complications, such as cerebellar abscess. Computed tomography and magnetic resonance imaging play an important role in the management of this disease. Early and aggressive surgical intervention of this otogenic complication can potentially minimize mortality.

Severe visual loss after ear surgery.

Sigmoid sinus thrombosis was once one of the most common intracranial complications of otitis media, but this has become less common since the advent of antibiotics. The frequency of sigmoid sinus hypoplasia reported in the literature is about 17%. Considering the possibility of postoperative intracranial hypertension, sigmoid sinus and jugular bulb surgeries were contraindicated in this case.We present a case with sigmoid sinus thrombosis of the sinus due to compression flowing surgical injury. This is a unique case, which presents with contralateral sigmoid sinus hypoplasia. Eventually, the patient presented to us with otitic hydrocephalus, increased intracranial pressure, papilledema, oculomotor and abducens nerve palsy, and severe right-side visual loss are prominent features.

Lateral sinus thrombosis in the pediatric population: multiple presentations for a potentially lethal disease.

Lateral sinus thrombosis complicating head and neck infections is a rare but potentially life-threatening condition.We report 4 pediatric cases of lateral sinus thrombosis occurring in different settings (2 patients with acute otitis media, 1 patient with chronic otitis media, and another with acute tonsillitis) to emphasize the nonspecific clinical presentation of this complication. In all our cases, early diagnosis was missed.Keeping a high index of suspicion when dealing with these infections is a reasonable approach.

Managements for lateral sinus thrombosis: does it need the ligation of internal jugular vein or anticoagulants?

The purposes of this study were to review the clinical characteristics and treatment outcomes of patients with lateral sinus thrombosis (LST) and to discuss the need of internal jugular vein (IJV) ligation or anticoagulants. We retrospectively reviewed the charts of five patients (1 male and 4 female) with LST. The chief complaints were otalgia, fever, mastoid tenderness, and neck pain. All patients were confirmatively diagnosed with MRI-Venography or Angio-CT scans. The patients were treated with appropriate antibiotics and operations including mastoidectomies with/without thrombectomy according to their suspected disease course. The authors did not perform IJV ligation and use anticoagulants in all cases, but there were no mortalities or morbidities. IJV ligation and use of anticoagulants do not seem to be essential procedures for the management of LST, and it should be considered carefully according to the extents of disease and the state of patients.

Presentation, treatment, and clinical course of otogenic lateral sinus thrombosis.

CONCLUSIONS: Otogenic lateral sinus thrombosis (OLST) is almost always associated with other complications of chronic otitis media (COM) and did not present a distinct clinical expression. In our experience, OLST exhibits a benign course if the underlying disease is controlled. Mastoidectomy in combination with broad-spectrum antibiotics provided effective treatment. Anticoagulation therapy is no longer used routinely. Recanalization is rare and is independent of the use of anticoagulants. OBJECTIVES: This study aimed to contribute to the understanding of the clinical aspects and evolution of OLST. PATIENTS AND METHODS: The study investigated a retrospective case series in a tertiary teaching hospital. From 1993 to 2007, eight cases of OLST were treated. The clinical and imaging data, treatments, and outcomes were analyzed. The follow-up period ranged from a minimum of 6 months to 5 years. RESULTS: In all eight patients, the lateral sinus thrombosis was detected by imaging studies performed to evaluate complications and symptoms related to COM. Fever, headache, and cranial nerve paralysis were the main clinical manifestations associated with coexisting mastoiditis, meningitis, and cerebellar and epidural abscess. We could not identify features specific to lateral sinus thrombosis in any case. All patients underwent mastoidectomy and were given broad-spectrum antibiotics for 2 months. Four cases were anticoagulated and all eight cases experienced complete clinical recovery without sequelae.