303

TOVI AND HIRSCH

J Oral Maxiliofac 49:303-305.

Surg

1991

Posttrauma tic Septic Superior Sagittal Sinus Thrombosis: Report of a Case FERIT TOVI, MD,* AND MENACHEM

Serious intracranial lesions may be associated with trauma to the facial skeleton.’ In their series, Noyek et al’ reported associated intracranial pathology in one third of the patients with facial trauma, and vascular occlusion from thrombosis among the late sequelae. Septic cerebral venous thrombosis is known to occur only in the presence of an acute infectious process.3 We report an unusual case of septic superior sagittal sinus thrombosis (SSST) presenting as an early complication of a complex facial trauma. Report of a Case A 2%year-old man was admitted to the emergency department of the Soroka Medical Center after having sustained a smashing blow to his face. On admission, he was conscious and vital signs were within normal limits. Positive physical findings were confined to the facial region and included multiple, deep lacerations in the nose and the cheeks, abnormal motion and pain on manipulation of the mandible and the palatal segment of the maxilla, and fracture of the upper and low incisor teeth. There was no evidence of cerebral, cervical, or other injury. The routine laboratory data showed no abnormality and the chest radiograph was normal. Radiographs of the facial bones showed fractures involving both maxillary sinuses and the left zygomatic arch, and a left paramedian fracture of the mandible. Computed tomography (CT) confirmed the above findings, but no intracranial abnormality was detected. At surgery, the longitudinal split of the hard palate and the comminuted fracture in the anterior and inferior as-

HIRSCH, MDT

pects of both maxillary sinuses were reduced by wiring of the bone fragments and supporting them by transnasally introduced sinus balloons. The mandibular fracture was plated and maxillomandibular fixation was performed. The multiple lacerations in the face were sutured, tracheotomy was done, and intravenous crystalline penicillin, 12 million units daily was started. By the second postoperative day, focal seizures, spiking fever, and deterioration in consciousness occurred. Fundoscopic results were normal. Neurologic examination showed a left hemiparesis. Anticonvulsive treatment with hydantoin, 100 mg twice daily, was initiated. At this stage, the blood count showed hemoglobin 8.0 g/dL and leukocytosis of 27,000/mm3. Enterococcus grew on blood cultures and, based on the antibiotic sensitivity tests performed, the treatment was changed to intravenous gentamicin, 80 mg, Cefuroxime, 750 mg, and chloramphenicol, 1.0 g three times daily. Resolution of the spiking fever and return of mental status occurred by the third postoperative week, but the patient remained hemiplegic. A repeated CT scan of the brain did not show any intracranial abnormality. In view of the persisting neurological deficit, cerebral angiography was performed. A partially recanalized SSST was found in the venous phase of both carotid angiograms

Received from Soroka Medical Center, and Faculty of Health Sciences, rael. * Head t Head Address

Ben Gurion University of the Negev, Beer Sheva, Is-

and Professor, Department of Otolaryngology. and Professor, Department of Radiology. correspondence and reprint requests to Dr Tovi: Department of Otolaryngology, Soroka Medical Center. Beer Sheva 84101, Israel. 0 1991 American Association of Oral and Maxillofacial Surgeons 0278-2391/91/4903-0017$3.00/0

FIGURE 1. Right lateral carotid angiogram, late venous phase, 2 weeks after injury. Note partial recanalization of the occluded superior sagittal sinus (arrows).

304

SAGI’ITAL SINUS THROMBOSIS

(Fig 1). At the end of the third postoperative

week, the maxillomandibular fixation was removed and the trachea was decanulated. Satisfactory reduction of the complex facial fractures was confirmed radiographically. Because the patient remained hemiplegic, he was referred to a rehabilitation center.

Discussion The cases of SSST fall into two groups, aseptic and septic. Aseptic thrombosis develops in conditions associated with dehydration or in people with increased propensity to spontaneous intravascular thrombosis.3 Fractures across this sinus, and sometimes head trauma without penetrating injury or fracture, may also give rise to superior sagittal sinus thrombosis.4 In this condition, rupture of small sinusoids may provoke disintegration of the endothelial lining of the sinus and precipitate thrombosis. The sagittal sinus is less commonly involved by a septic process than are the lateral and cavernous sinuses. Southwick et al3 found only 23 reported cases of SSSST since the advent of the antibiotics. Septic occlusion of the sagittal sinus occurs frequently during the course of bacterial meningitis. Subdural empyema, brain abscess, osteomyelitis of the skull, paranasal sinus infection, and expansile septic thrombosis from other sinuses or from cortical veins may also give rise to SSSST.3 Septic emboli from a distant focus of infection have also been reported in the etiopathogenesis.5-8 The scarcity of specific signs and symptoms of SSSST makes this diagnosis difficult. Headaches associated with nausea, vomiting, and confusion rapidly progressing to coma are the main symptoms of this disease. These clinical manifestations depend on the rapidity of development, location, and extension of the thrombus within the sagittal sinus. Papilledema may occur as a result of decreased cerebrospinal fluid resorption. However, this sign is not so common because patients do not survive long enough for it to develop.3 High fever is suggestive of a septic process in the development of the dural venous sinus occlusion. Frequently, in SSSST, hemiparesis occurs secondary to cortical vein thrombosis, which may also give rise to focal or generalized seizures. Less frequently, sensory hemiparesis, hemianopia and dysphasia may occur.6 In the present case, septic embolization from the contaminated multiple open wounds of the midface seems to be the causative factor in the development of the SSSST. Most probably, the septic emboli involved the sinus via the emissay vein of the foramen

cecum, which contributes a pathway for intracranial extention of nasal and paranasal infections. The diagnosis of SSSST has been facilitated by neuroimaging techniques. A dynamic radionuclide brain scan may prove useful in demonstrating the nonfilling of the sinus.3 The most specific CT lindings of superior sagittal sinus thrombosis are seen in contrast enhanced scans and include the “empty delta sign,” gyral enhancement and focal cerebral edema.9~‘0 The “empty delta sign” represents the intravascular filling defect of the clot observed only at the level of the torcular herophili. Cerebral angiography, and particularly its late venous phase, is the method of choice to confirm this diagnosis.3 In our case, the CT examination proved to be nondiagnostic, while cerebral angiography demonstrated the partial occlusion of the superior sagittal sinus. The treatment of SSSST includes massive administration of appropriate intravenous antibiotics, anticonvulsive drugs, and mannitol to reduce cerebral edema. The use of anticoagulants is contraindicated because they may aggravate hemorrhagic infarcts commonly associated with this condition. In cases associated with paranasal sinus infection, the involved sinus cavities must be drained to avoid further spread of the infection. Acute, complete occlusion of the superior sagittal sinus is usually rapidly fatal because of the ensuing venous hypertension resulting in cerebral edema and infarction. Patients with partial thrombosis of the sagittal sinus may have a more favorable course of the disease and may recover with minimal sequelae. Despite the early development of the clinical manifestations of the thrombosis in our case, the prompt administration of antibiotics apparently prevented its propagation toward a lethal outcome; however, the initial neurological deficit remained unaltered. To the best of our knowledge, this is the first documented case of SSSST following a maxillofacial fracture. Therefore, oral and maxillofacial surgeons treating facial injuries should consider SSSST in the presence of septic fever and neurologic deficit in patients with no obvious central nervous system abnormalities on CT. References 1. Leopard P: Complications, in Rowe NL, William JL (eds): Maxillofacial Injuries, ~012. Edinburgh, Churchill Livingstone, 1985, pp 749-762 2. Noyek AM, Kassel EE, Wrotzman G, et al: Contemporary radiologic evaluation in maxillofacial trauma. Otolaryngol Clin North Am 16:473, 1983 3. Southwick FS, Richardson EP Jr, Swartz MN: Septic thrombosis of the dural venous sinuses. Medicine 67:82, 1986

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4. Carrie AW, Jaffe FA: Thrombosis of superior sagittal sinus caused by trauma without penetrating injury. J Neurosurg ll:l73, 1954 5. Askenazy HM. Kosary IZ, Braham J: Thrombosis of the longitudinal sinus. Neurology 12:288, 1962 6. Krayenbuhl H: Cerebral venous thrombosis. Clin Neurosurg 14:l. 1967 7. Polter AA, Jones AW: Intracranial venous thrombosis in Uganda. East Afr Med J 50534, 1973

J Oral Maxillofac

8. Strauss SI, Stem NS, Mendelov H, et al: Septic superior sagittal sinus thrombosis after oral surgery. J Oral Surg 31:560. 1973 9. Buonanno FS, Moody DM, Ball MR, et al: Computed cranial tomographic findings in cerebral sinovenous occlusion. J Comput Assist Tomogr 2:281, 1978 IO. Rao CVG, Knipp HC, Wagner EJ: Computed tomographic findings in cerebral sinus and venous thrombosis. Radiology 140:391. 1981

Surg

49~305307. 1991

Materal Synovial Cysts of the Temporomancfibular Joint ANTHONY

FAROLE, DMD,* AND MARK W. JOHNSON,

The temporomandibular joint (TMJ) synovial (ganglion) cyst is a rare condition, with only nine cases previously reported in the literature; all of these cases were unilateral.‘-’ Our case is unique in that it represents the first report of bilateral TMJ ganglion cysts. It includes computed tomography (CT), CT-arthrography, and magnetic resonance imaging as part of the diagnostic workup.

DMDt

results were normal and he had a class I dentoskeletal relationship. A panoramic radiograph taken in closedand open-mouth positions showed no abnormalities except for a possible ectopic calcification adjacent to or within the right TMJ. Magnetic resonance imaging (MRI) showed bilateral cystic structures just anterior and lateral to the condyles, the right larger than the left (Figs 1 and 2). A CT scan of the temporal bones with contrast (Isovue; Squibb Diagnostics, Princeton, NJ) injected into the right lesion under CT-assisted needle guidance revealed opacification of a

Report of a Case A 22-year-aid

man complained of right temporomandibular joint pain for several months. The pain was most pronounced during wide opening of the mouth. He was

referred by his internist to the senior author (A.F.) for evaluation. Physical examination revealed a 2-cm fluctuant mass in the right preauricular region. The mass was nontender and became enlarged during a Valsalva maneuver or when he would bend down. It was not evident or palpable in the upright position. Pain was elicited in the right TMJ area during mouth opening. However, the mandibular range of motion was normal in all directions. The remainder of the head and neck examination revealed no evidence of adenopathy or bruit, and there was no evidence of paresthesia or motor nerve deficit. Oral examination

Received from Thomas Jefferson University Hospital, Philadelphia, PA. * Assistant Director, Oral and Maxillofacial Surgery Residency Program. t Formerly Chief Resident. Oral and Maxillofacial Surgery: currently, in private practice, Newburn, NC. Address correspondence and reprint requests to Dr Farole: Thomas Jefferson University Hospital, Suite 100, 130 S 9th St, Philadelphia, PA 19107-5233. 0 1991 American geons

Association

0278-2391/91/4903-0018$3.00/O

of Oral and Maxillofacial

SurFIGURE I. Axial magnetic resonance image showing bilateral cystic structures (arrows) anterior to mandibular condyles.

Posttraumatic septic superior sagittal sinus thrombosis: report of a case.

303 TOVI AND HIRSCH J Oral Maxiliofac 49:303-305. Surg 1991 Posttrauma tic Septic Superior Sagittal Sinus Thrombosis: Report of a Case FERIT TOVI...
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