Auris Nasus Larynx 41 (2014) 143–147

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Management of otogenic lateral sinus thrombosis Gautam Bir Singh a,b,*, Anil K. Rai a, Sarvejeet Singh a, Radhamadhab Sahu a, Rubeena Arora a a b

Department of Otorhinolaryngology & Head-Neck Surgery, Lady Hardinge Medical College & Associated Hospitals, New Delhi 110001, India VMMC & Safdarjung Hospital, New Delhi, India

A R T I C L E I N F O

A B S T R A C T

Article history: Received 8 March 2013 Accepted 3 October 2013 Available online 20 November 2013

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. ß 2013 Elsevier Ireland Ltd. All rights reserved.

Keywords: Otogenic lateral sinus thrombosis Chronic suppurative otitis media

1. Introduction Otogenic lateral sinus thrombosis (OLST) is a rare intracranial complication of suppurative otitis media [1–3]. The treatment of suppurative otitis media with highly potent antibiotics in the modern era has led to the dramatic decrease in the incidence of the said complication [1–4]. Thus, a marked paucity of literature exists on the cited subject in modern otology. However, the clinical course of this dreaded complication has also been altered by these antibiotics leading to a more subtle presentation of OLST. In addition, it is still associated with a mortality and morbidity of 10% and 30% respectively [2,3]. With this background, we present our

modest experience in a series of 6 patients who successfully underwent treatment for OLST. This study highlights the paradigm shift in the clinical course and management of OLST. 2. Materials and method The clinical records of 6 patients of OLST, which were referred to our institution Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi: a tertiary care university teaching hospital over a period of three years i.e. may 2007 to may 2010 were analyzed in this retrospective study design. 3. Results

* Corresponding author at: House No: 1433/Sector: 15, Faridabad 121007 (National Capital Region), Haryana, India. Tel.: +91 0129 4012368/4007550; mobile: +91 9818836242. E-mail addresses: [email protected], [email protected] (G.B. Singh). 0385-8146/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.anl.2013.10.005

All the 6 cases that reported to us were young and less than 25 years of age [mean age: 19 years], 2 were in paediatric age group, i.e. less than 12 years of age, rest were all adults. There were 2 females and 4 males in the study group.

G.B. Singh et al. / Auris Nasus Larynx 41 (2014) 143–147

144 Table 1 Otogenic lateral sinus thrombosis [clinical course]. Patient profile [age/sex]

Social background

Ear diagnosis

Case I 15 M

Rural

Case II 12 M Case III 25F Case IV 20 M Case V 22 F

Rural

Case VI 10 M

Rural

CSOM-B/E R/E-AA L/E-TT CSOM-R/E AA CSOM-L/E AA CSOM-L/E AA CSOM-B/E L/E-AA R/E-TT CSOM-B/E R/E-AA L/E-TT

Rural Rural Rural

H/O antibiotic intake

S/S of intracranial complication

Referral period (days)

6

Yes

Present

10

3

Yes

Present

12

3

Yes

Present

14

10

Yes

Present

23

8

Yes

Present

10

5

Yes

Present

16

Duration of CSOM (yrs)

M: male; F: female; CSOM: chronic suppurative otitis media; B/E: both ear; L/E: left ear; R/E: right ear; AA: attico antral; TT: tubotympanic; yrs: years. Table 2 Laboratory investigations [meninigitis]. Case profile

Case I 15 M Case II 12 M Case III 25 F Case IV 20 M Case V 22 F Case VI 10 M

CSF Gross examination

Proteins (normal: 15–45 mg/dl)

Glucose (normal: 40–70 mg/dl)

Leucocyte counts (normal: 0–5 cu mm) neutrophil

Turbid

60

18

Turbid

80

20

Turbid

76

16

Turbid

60

18

Turbid

73

14

Turbid

62

12

650 N92 550 N92 1010 N84 650 N88 750 N93 2000 N90

hs-CRP (high sensitivity C-reactive proteins) (normal: 0.00–0.30 mg/dl)

30 24 Not available Not available 20 28

Note: All the case had pyogenic meningitis: CSF had an increase in proteins and decrease in glucose with leucocytosis [predominantly nuetrophills]

All these cases had protracted chronic suppurative otitis media (CSOM) with a history of intermittent discharge for years [for a minimum 3 years and maximum of 10 years, mean being: 5 years and 10 months]. All the patients gave the history of use of antibiotics during their protracted course of disease to stop the discharge. Unfortunately, the details of this antibiotic treatment were not available: as most of our patients belong to a rural background, and had no medical record of their treatment. It was an attack of acute suppurative otitis media in each case that finally led to the aetiopathogenesis of lateral sinus thrombosis. Initially all the patients had symptoms of headache, nausea and vomiting with dizziness or vertigo along with ear discharge which prompted them to seek medical advice (Table 1). All of our cases had fever at some point of time during the course of their illness, but none had the characteristic picket fence fever mentioned in the medical text. As we could only examine the medical records of the patients, only two cases had a positive history of neck rigidity, and only in one case brudzinskis sign was documented to be positive. Initially all cases were diagnosed as meningitis and started on I/V antibiotics. Table 2 documents the CSF findings and hs-CRF, i.e. high sensitivity C reactive proteins values. The evaluation of the table delineates the severity of the infection in these cases However, later on as the condition of the patient deteriorated and CT scan revealed a thrombus in the sinus; these cases were referred to our ENT department. In two cases the patients had multiple referrals, i.e. the patient had visited two or more than two hospitals before being referred to a tertiary care institute. The time from the start of aforesaid symptoms of intracranial involvement to the transfer to our tertiary care hospital varied from a minimum of 10

days to a maximum of 23 days, mean: 14 days (Table 1). Two cases were also referred from the departments of our institution, one from neurosurgery and the other from general medicine. On examination, three cases had bilateral CSOM; other three had unilateral ear disease. In all the patients, the ear on the side of lateral sinus thrombosis was having attico antral perforation. The other ear in bilateral CSOM patients was harbouring mucosal disease only (Table 1). One female patient had a neck swelling with cord sign positive (Fig. 1). Cord sign is defined as an induration corresponding to the

Fig. 1. Patient’s photograph showing swelling [abscess] in neck.

G.B. Singh et al. / Auris Nasus Larynx 41 (2014) 143–147

145

Table 3 Otogenic lateral sinus thrombosis [management]. Case profile

Diagnosis OLST

Hypercoagubility

Pus culture

Any other complication

Treatment

Case I 15 M Case II 12 M Case III 25 F

CT scan

Absent

Sterile

Meningitis

MRM + Needle aspiration of sinus + Tympanoplasty type III + antibiotics

CT scan

Absent

Sterile

MRM + Needle aspiration of sinus + Tympanoplasty type III + antibiotics

CT scan

Absent

Sterile

Case IV 20 M Case V 22 F Case VI 10 M

CT scan

Absent

Sterile

Meningitis + IJV thrombosis Meningitis + IJV thrombosis + carotid space abscess Meningitis

CT scan

Absent

Sterile

Meningitis

MRM + Needle aspiration of sinus + Tympanoplasty type III + antibiotics

CT scan

Absent

Sterile

Meningitis

MRM + Needle aspiration of sinus + Tympanoplasty type III + antibiotics

MRM + Needle aspiration of sinus + Tympanoplasty type III + antibiotics

MRM + Needle aspiration of sinus + Tympanoplasty type III+ antibiotics

M: male; F: female; OLST: otogenic lateral sinus thrombosis; IJV: internal jugular venous thrombosis; MRM: modified radical mastoidectomy.

course of internal jugular vein beneath the anterior border of sternocleidomastoid [5]. This patient was diagnosed to have an associated carotid abscess with IJV thrombosis (Fig. 2). One paediatric patient also had an IJV thrombosis (Table 3). All the patients in our medical institution underwent CT scan (Table 3) on the basis of which the final diagnosis of OLST was made (Fig. 3). In accordance with our treatment protocol, all the patients underwent: modified radical mastoidectomy with delineation of the sinus and needle aspiration [till frank blood is aspirated] under intravenous antibiotics (amoxycillin + clavulinic acid, along with metrogyl) for 14 days, followed by systemic antibiotics for another 3 weeks. No anti-coagulent treatment was given in any patient. The erosion of sinus plate was seen only in three cases and all these cases had perisinus abscess. Pathologically, of the six patients 5 patients had cholesteatoma disease, one patient had frank granulations and one patient had granulations along with cholesteatoma. A brief synopsis of the surgical management is given in Table 4. All the patients had an excellent outcome with no morbidity related to OLST. They were subsequently discharged after 3 weeks on oral antibiotics and were kept on a regular follow-up for 3 months in the ENT OPD, with no untoward incident to report.

probably attributed to the ignorance about the seriousness of persistent ear discharge in our rural population. From this case study it is clear that OLST has no distinct clinical expression; a fact widely accepted in medical literature and attributed to the early use of potent antibiotics for treatment of suppurative otitis media [3,9–11]. All the cases in this series were diagnosed by accident during the investigative image study. However, all our patients prior to having LST had meningitis with clear clinical features of intra cranial complication. It is thus prudent to re-evaluate all cases of intracranial complication with CSOM not responding to medical treatment. From the above account it is clear that cases of OLST may not be always seen

4. Discussion The study and analysis of the aforesaid data brings forth some interesting facts regarding the complication OLST. All the CSOM patients who were referred to us with lateral sinus thrombosis were young patients (age