Otogenic Lateral Sinus Thrombosis Treatment & Management

Updated: Mar 21, 2019
  • Author: B Viswanatha, DO, MBBS, PhD, MS, FACS, FRCS(Glasg); Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

Medical Therapy

Treatment of lateral sinus thrombosis is universally agreed to be with a combination of antibiotics and surgery. In selected cases of lateral sinus thrombosis, medical therapy alone with intravenous antibiotics may be successful.

A literature review by Au et al of 104 pediatric patients with lateral sinus thrombosis (using case reports from 1993-2011) found the prevalence of various management strategies to be as follows [3] :

  • Broad-spectrum antibiotics (100%)

  • Mastoidectomy (94%)

  • Anticoagulation (57%)

  • Manipulation of the thrombosed sinus (50%)

Most authors agree that anticoagulants have no place in the management of lateral sinus thrombosis. Anticoagulants have been advocated to prevent extension of the thrombus to the distal sinuses. However, they are rarely used now, because most infections can be controlled with antibiotics and surgery, and this tends to prevent the thrombus from propagating. The risks of anticoagulation include releasing septic emboli from clot breakdown and uncontrollable hemorrhage at the bleeding site. Anticoagulants arrest the spread of thrombosis but may increase the risk of venous infarctions and are therefore no longer used.

Systemic anticoagulation is not necessary unless the clot is shown to involve the sagittal sinus, or signs of increased intracranial pressure persist despite medical management.

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Surgical Therapy

The management of lateral sinus thrombosis includes the combination therapy of appropriate antibiotics and surgeries. A mastoidectomy with the removal of the infected clot and thrombus in the lateral sinus is considered the standard surgical care.

Cortical mastoidectomy is sufficient for non cholesteatomatous ear disease. It allows the drainage of the initiating infection and confirms the diagnosis of lateral sinus thrombosis. Perisinus disease can be found despite a normal-appearing sinus plate. Current recommendations state that the removal of the sinus plate that overlays the sinus should always be performed.

Most cases are due to attico antral type of ear disease. Cholesteatoma is a persistent source of infection and is unresponsive to antibiotics. The early removal of this source of infection reduces the possibility of further intracranial extension, shortens the duration of illness, and provides definitive treatment. Canal wall down mastoidectomy has been used successfully in the treatment of cholesteatomatous ears with lateral sinus thrombosis.

Although an appropriate management of the thrombus in the sinus is not certain, most authors propose needling of the lateral sinus before incision in order to confirm the diagnosis. No further intervention is required, if free blood is aspirated. If blood is not returned, the diagnosis can be confirmed with incision on the sinus and evacuation of the clot, and obtaining free bleeding from the sinus is unnecessary.

Recent reports have shown that if the surrounding granulation tissue and inflammation are removed through a mastoidectomy, the sinus will recannalize without clot evacuation. Jun et al are of the opinion that the organized thrombus is an initial step for spontaneous resolution, finally inducing recanalization of a sinus.

Recent authors are of the opinion that with modern antibiotic therapy internal jugular vein ligation is not required. [4, 5, 6] Internal jugular vein ligation may possibly isolate the cause of infection and prevent embolization, thus increasing the cure rates of lateral sinus thrombosis. But internal jugular vein ligation may not eliminate septic complications because of collateral veins and may predispose the patient to retrograde-intracranial septic complications and add surgical risks of additional cervical dissections.

Internal jugular vein ligation should be reserved for those cases in which septicemia and embolization do not respond to initial surgery and antibiotic treatment. Recently, several studies showed the possibility of conservative managements with limited indications for the internal jugular vein ligation.

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Intraoperative Details

Intraoperative needle aspiration of the sinus provides information on sinus patency or obstruction of blood flow. Absence of the blood return and aspiration of pus or thrombus are indications for opening the sinus. With the removal of the sinus plate, a longitudinal incision is made on the sinus and the thrombus is removed. Free bleeding from both ends is desirable. If no bleeding is found, evacuating as much of the clot as possible should suffice. Before the introduction of antibiotics, obtaining free bleeding from each end of the incised sinus was considered desirable, but now following the clot centrally to obtain free bleeding is not thought to be necessary and removing organized thrombus is also not thought to be necessary.

However, recent reports have challenged this dictum and demonstrate that if the surrounding granulation tissue and inflammation are removed through a mastoidectomy, the sinus recanalizes without clot evacuation.

A study by Ryan et al of seven pediatric patients with otogenic lateral sinus thrombosis indicated that the condition can be successfully treated with aggressive management of the mastoid cavity, with no thrombectomy required. All of the study’s patients achieved good recovery without major sequelae after undergoing treatment with intravenous antibiotics and mastoidectomy, with the sigmoid sinus unroofed and a tympanostomy tube placed. None of the children underwent sinus exploration with thrombectomy. Five of the patients were treated with perioperative anticoagulation without complication. [7]

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Postoperative Details

After the thrombus has been evacuated, the patient should be maintained on antibiotics for 2-3 weeks and a repeat MRI and MR venogram should be performed to rule out the development of secondary intracranial complication such as brain abscess, or propagation of thrombus in to the superior sagittal sinus.

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Follow-up

Follow-up MRI of the brain should be obtained to detect late embolic abscess or other delayed intracranial complications.

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Complications

The presence of lateral sinus thrombosis mandates further investigation for additional intracranial complication. Before the antibiotic era, lateral sinus thrombosis had associated complications in 80% of the patients. The development of antibiotics has led to a decrease in the incidence of complications, which is now 20%.

Usually associated complications are seen on the same side as the diseased ear. Viswanatha et al have reported a case of attico antral disease with ipsilateral lateral sinus thrombosis and contralateral occipital lobe abscess. [8] The development of abscess in one hemisphere following infection in the contralateral mastoid can presumably occur from hematogenous spread of organisms.

Otitic hydrocephalus is known to complicate a significant number of lateral sinus thrombosis cases.

The aforementioned literature review by Au et al of 104 pediatric patients treated for lateral sinus thrombosis found the mortality rate to be 0.96% (one patient in 104). Contributing to the 10% morbidity rate were conditions such as cranial nerve palsy, sensorineural hearing loss, stroke, and septic hip joint. [3]

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Outcome and Prognosis

The first successful surgery for lateral sinus thrombosis was performed by Lane in 1888. Until then, the mortality for this complication was 100%. Operative intervention reduced the mortality to 50%. Between 1932 and 1940, when antibiotics were introduced, a combination of antibiotics and surgical management reduced the mortality rate to 25%.

In the era of antibiotics, mortality averaged up to 10% of surgically treated cases and close to 100% for untreated cases.

In studies by Samuel et al (1987), Amirmajdi (1988), O'Connell (1990), Syms et al (1999), Bardley et al (2003), Ooi et al (2003), and Viswanatha (2007), no mortalities were found. [9, 10, 11, 12, 5, 13, 14]

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Future and Controversies

Before the advent of antibiotics, ligation of the internal jugular vein was performed almost routinely in order to avoid dissemination of thrombophlebitic process and septic emboli. Internal jugular vein ligation is controversial.

In 1939, Cody summarized the argument for internal jugular vein ligation as follows [15] :

  • This procedure isolates the source of infection from the general circulation.

  • This procedure protects against the possibility of the mural thrombus embolizing.

  • This procedure does not alter the favorable course of the disease or add undue burden to the patient.

In 1935, Lyman summarized the argument against internal jugular vein ligation as follows [16] :

  • Numerous cases of symptomless lateral sinus thrombosis were found during mastoid surgery.

  • Septic complication often followed internal jugular vein ligation because the ligation above the entrance of the facial vein does not block off collateral circulation.

  • In the presence of collateral circulation, ligation may cause retrograde thrombosis and interruption of the venous return from the head, resulting in intracranial infection.

  • Operative interventions on the internal jugular vein exposed the patient to damage to the vagus, accessory, and hypoglossal nerves.

Today internal jugular vein ligation is indicated for the following specific reasons:

  • When the clots extends beyond the mastoid area.

  • When septicemia and pulmonary complications persist despite initial treatment with surgery and antibiotics.

  • When infection or thrombosis of the internal jugular vein is found.

In 2011, Ropposch et al published a retrospective study report on the management of lateral sinus thrombosis. [17] They are of the opinion that anticoagulant therapy is a safe treatment option to prevent extension of the thrombosis and development of other intracranial complications.

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