Sigmoid sinus thrombosis in otolaryngology

Thrombosis of the sigmoid sinus is a condition where a blood clot forms in the sigmoid sinus, a large vein located in the brain. It can lead to symptoms such as headache, dizziness, visual disturbances, and in severe cases, neurological deficits. Causes include trauma, infections, dehydration, and clotting disorders. Treatment typically involves anticoagulation therapy and addressing the underlying cause. In some cases, surgery may be necessary to remove the clot or improve blood flow. Early diagnosis and treatment are crucial to prevent complications such as stroke or brain damage.

1. SIGMOID SINUS
THROMBOSIS
SHRUTI GUSAIN
GROUP 5

2. What is Sigmoid Sinus Thrombosis ?
uLateral sinus thrombosis ,also known as
sigmoid sinus thrombosis forms when infection
from the adjacent mastoid contacts and
penetrates the venous wall and forms a
thrombus.
uSST Is a rare but serious medical condition
that occurs when a blood clot forms in the
sigmoid sinus, a large vein located at the
base of the brain that drains blood from the
brain.
uThe clot can block blood flow and lead to a
buildup of press In brain and cause relative
symptoms .
uEmbolisation of the thrombus can cause
distal disease

3. Etiology?
uGenetic prothromboticconditions:
-Antithrombin deficiency, Protein C and protein S deficiency,Factor V Leiden mutation,
Prothrombin mutation (the substitution of A for G at position20210),homocysteinemiacausedby
gene mutations in methylenetetrahydro-folate reductase.
uAcquired prothromboticstates: Nephrotic syndrome, Antiphospholipidantibodies,
Homocysteinemia,
Pregnancy, Puerperium.
uInfections:Otitis, mastoiditis, sinusitis,Meningitis,Systemic infectious disease.
uInflammatory disease: Systemic lupus erythematosus,Wegener's granulomatosis,Sarcoidosis
Inflammatory bowel diseases,Behçet'ssyndrome
uHematologicconditions:Polycythemia, primary and secondary ThrombocythemiaLeukemia ,
anemia, including paroxysmal nocturnal hemoglobinuria .
uDrugs:Oral contraceptives ,Asparaginase
uMechanical causes, trauma
uMiscellaneous:Dehydration, especially in children , Cancer.

4. Anatomy & Spread ?
uFormed by the confluence of the
superior petrosal and transverse
sinuses .
uBecomes internal jugular vein at its
exit from foramen jugulare.
uDirectly through bone erosion due
to granulation and
cholesteatoma.
uThrombophlebitis of the mastoid
emissary veins.
•Griesinger’sSign –erythema ,
edema and tenderness over
mastoid area.

6. Epidemiology
uAge –ADULTS OR OLDER CHILDREN
u6-10 % of all Intracranial complication of chronic otitis media.
uTypes of ear infections associated-most common with
cholesteatoma.
ØMay occur from other forms of chronic mastoiditis.
ØAcute otitis media in rare cases –caused by
osteothromophlebitis.
§Otherassociated intracranial complications-meningitis,
epidural abscess, subdural empyema , cerebellar abscess.

12. Clinical features:
uIn the era of antibiotics, may be present without symptoms
•Classical presentation is very rare-components were:
1.There was severe febrile illness with rigorsin patient with
middleeardisease.
2.Rise of temperature to 39-40 c and rapid fall of temperature
with sweating( picket fence fever patterndue to periodic
release of streptococci in blood from septic thrombus.
3.Shivering used to be so severe so as to shake the bed.
4.Headache and neck pain( due to incr. ICP —>papilledema
).
5.Anaemia with emaciation was also seen in classical cases.

13. Clinical features:
oFeeling of being ill.
oPersistent fever ( but without violent swings and rigors
as seen in pre antibiotic era) .
oHeadache, vomiting( due to raise ICP and bacteremia
).
oOtalgiawithmastoidtenderness .
oNeckpain, Neck torticollisalong with tenderness along
jugular vein.
oWhen thrombosis extend to subclavian vein -engorged
collateral veins over shoulder maybe seen.
odevelopment of hydrocephalus
oChemosisor proptosis of one eye
odrowsiness, lethargy, coma

14. Examination Findings?
uOtoscopic findings suggestive of middle ear
infections.
uTenderness over mastoid process and
sternomastoid .
uFundusexamination-Papilloedema.
uGriesingerssign -pitting edema over the occipital
region well behind the mastoid process caused
by clotting within large mastoid emissary vein.
uAnemiaand emaciation
uPositive Tobey-Ayer’s Test.
uPositive Crow-Beck’s Test.
uKernig’sand Brudzinski’sSign.

16. Bacteriology & Labs
uACUTE
oHemolyticstreptococcus
oPneumococci
oStaphylococci
uCHRONIC
oBacillus Proteus
oPseudomonas pyocyaneus
oE.coli
oBacteroides
oStaphylococci
uIncrease Polyp on CBC.
uCSF exam show increased
ICP.
uLumbarpuncture should
be performed if
papilloedemadoes not
suggest that raised intra
cranial pressure may lead
to coming.
uCSF analysis done in cases
of suspected meningitis.

21. Treatment?
uMedical + Surgery —àcombination therapy
uMedicine:
•I/Vantibiotics
•Anticoagulant only if clot in superior sagittal sinus
or increased ICP persists despite medical
management.

22. uSurgical:
oMastoidectomy+removalofclotfromsinus.
oASOM -Cortical + removal of sinus plate.
oCSOM + Cholesteatoma:radical
oRefractory Septicaemia: UV litigation to stop emboli
being thrown into circulation.
üFollowup: -
oPost op antibiotic for 2-3 weeks
oPostopMRI&MRV.

23. Complications?
ØComplications of sigmoid sinus thrombosis may include:
üIncreased pressure in the brain: Sigmoid sinus thrombosis can cause an
increase in intracranial pressure, which can lead to headaches,
nausea, vomiting, and changes in vision.
üNeurological deficits:Depending on the location and extent of the clot,
sigmoid sinus thrombosis can cause neurological deficits, such as
weakness, numbness, or paralysis on one side of the body.
üHearing loss: Sigmoid sinus thrombosis can affect the inner ear and
cause hearing loss or ringing in the ears.
üSeizures: In some cases, sigmoid sinus thrombosis can lead to seizures,
which can cause sudden, uncontrolled movements and loss of
consciousness.
üMeningitis: Sigmoid sinus thrombosis can lead to the development of
meningitis, which is a serious infection that can cause inflammation of
the brain and spinal cord.
üPulmonary embolism:In rare cases, a blood clot from the sigmoid sinus
can break off and travel to the lungs, causing a pulmonary embolism.

24. Case study
uA 35-year-old woman presented to the emergency department with a severe headache that
had been ongoing for the past two days. She had no significant medical history and was not
taking any medications. On examination, she had a fever of 38.5°C and was sensitive to light.
She also had tenderness over the left ear.
uA CT scan of the head showed no abnormalities, but a subsequent MRI with contrast revealed
a thrombus in the left sigmoid sinus. The patient was diagnosed with sigmoid sinus thrombosis
and was started on intravenous antibiotics and anticoagulation therapy.
uOver the next few days, the patient's symptoms gradually improved, and she was discharged
from the hospital on oral anticoagulation therapy. A follow-up MRI after six months showed
resolution of the thrombus.
uAlthough the exact cause of the thrombus was not determined, the patient reported having a
recent upper respiratory tract infection, which may have contributed to the development of
the clot. The patient was advised to seek medical attention immediately if she experienced
any recurrent symptoms.

25. Links to additional videos
uhttps://youtu.be/Ip4xT4DQ0U4
uhttps://youtu.be/v7wiFiHzaEU
uhttps://youtu.be/qMpXDbcLX9o
uhttps://youtu.be/SZKTnrHmS4I