Lateral sinus thrombophlebitis

Lateral sinus throbophlebitis and otitic hydrocephalous

1. Lateral sinus thrombophlebitis Presentor Kamal Ghimire

2. Lateral sinus thrombophlebitis Inflammation of inner wall of lateral venous sinus (sigmoid sinus and transverse sinus) with the formation of intrasinus thrombus

3. Etiology Occurs as a complication of acute coalescent mastoiditis masked mastoiditis or chronic suppuration of middle ear and cholesteatoma Bacteria: In acute: hemolytic streptococcus, pneumococcus or staphylococcus In chronic: bacillus proteus,pseudomonas pyocyaneus,E.coli and staphylococci

4. Pathogenesis Formation of perisinus abscess (either by bony erosion of bony dural plate overlying sinus or by thrombosis of emissary vein) Endophlebitis mural thrombus formation Occlusion of sinus lumen intrasinus abscess Extension of infected thrombus

5. Extension of thrombus Proximal: confluence of sinus, superior sagittal sinus, cavernous sinus Distal : mastoid emissary vein to jugular bulb and jugular vein

6. Clinical features Hectic picket fence fever with rigors: high fever, irregular, one or more spikes per day Each spike is due to release of fresh septic embolus Fever accompained by chills and rigors Temperature subsides with sweating Headache Anemia and emaciation

7. Clinical features……. Griesinger’s sign: edema over posterior part of mastoid due to thrombosis of mastoid emissary vein Papilloedema : blurring of disc margins, retinal hemorrhages or dilated veins in fundoscopy Tenderness along jugular vein

8. Some tests Tobey-Ayer test: compression of I.J.V.  rapid rise of C.S.F. pressure (50 – 100 mm water  rapid fall on release of compression. In thrombosed side no rise. Crowe - Beck test: pressure on I.J.V. on normal side  engorgement of retinal veins + papilloedema seen in fundoscopy due to lateral sinus thrombosis on opposite side.

9. Investigations Blood smear: to rule out malaria Blood culture CSF analysis: normal except for rise in pressure Imaging Contrast enhanced CT scan Contrast enhanced MRI MR venography Culture and sensitivity of ear swab Delta sign

10. Delta sign(red arrow): traingular area with rim enhancement and central low density area

11. Complications Septicemia and abscess in lung,bone,joints , or subcutaneous tissue Meningitis and subdural abscess Cerebellar abscess Thrombosis of jugular bulb and jugular vein with associated cranial nerves involvement Cavernous sinus thrombosis: proptosis,fixation of eyeball, and papilloedema Otitic hydrocephalous

12. Treatment Urgent complete cortical or modified radical mastoidectomy : Sinus wall incised. Infected clots removed & abscess drained Antibiotics: broad spectrum antibiotics. Can be changed once culture and sensitivity report is available. Should be continued at least for a week after operation Anticoagulants: in cavernous sinus thrombosis

13. 4. Internal jugular vein ligation: for embolism not responding to antibiotics & surgery 5. Blood transfusion: for anaemia

14. Otitic hydrocephalous Increase in CSF pressure in the presence of acute or chronic otitis media not secondary to brain abscess or meningitis, almost exclusively associated with sigmoid sinus thrombosis.

15. Etiology :1. Associated lateral sinus thrombosis  obstruction of cerebral venous return. 2. Superior sagittal sinus thrombosis   ed C.S.F. absorption Both of these factors result in raised ICP

16. Clinical features Symptoms Severe headache,nausea and vomiting Diplopia involving VI cranial nerve Blurring of vision Signs Papilloedema with hemorrhages Nystagmus CSF pressure rises(>300 mm H2O)

17. TREATMENT Treating L.S.T reducing CSF pressure: I.V. Dexamethasone 4mg Q6H I.V . 20% Mannitol 0.5 gm /kg Repeated lumbar puncture / lumbar drain Ventriculo -peritoneal shunt

18. References: Dhingra ENT and head and neck surgery Ballenger’s otorhinolaryngology17 head and neck surgery