Accepted Manuscript Title: Visual and neurologic deterioration in otogenic lateral sinus thrombosis: 15 year experience Author: Be´ata Rosdy Zsuzsanna Cs´ak´anyi Katalin Koll´ar ´ Kov´acs Judit M´oser M´onika Mell´ar Andrea Kulcs´ar Eva Gy¨orgy V´arallyay G´abor Katona PII: DOI: Reference:

S0165-5876(14)00269-9 http://dx.doi.org/doi:10.1016/j.ijporl.2014.05.001 PEDOT 7120

To appear in:

International Journal of Pediatric Otorhinolaryngology

Received date: Revised date: Accepted date:

7-3-2014 27-4-2014 3-5-2014

Please cite this article as: Be´ata Rosdy, Zsuzsanna Cs´ak´anyi, Katalin Koll´ar, ´ Judit M´oser, M´onika Mell´ar, Andrea Kulcs´ar, Eva Kov´acs, Gy¨orgy V´arallyay, G´abor Katona, Visual and neurologic deterioration in otogenic lateral sinus thrombosis: 15 year experience, International Journal of Pediatric Otorhinolaryngology http://dx.doi.org/10.1016/j.ijporl.2014.05.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Visual and neurologic deterioration in otogenic lateral sinus thrombosis: 15 year experience

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Beáta Rosdy *, Zsuzsanna Csákányi **, Katalin Kollár *, Judit Móser *, Mónika Mellár *, Andrea Kulcsár***, Éva Kovács ****, György Várallyay *****, Gábor Katona**

Department of Neurology, Heim Pál Children’s Hospital, Budapest, Hungary

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Department of ENT & Bronchology, Heim Pál Children’s Hospital, Budapest,

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Hungary

Department of Paediatric Infectology, United St István and St László Hospital ,

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Budapest, Hungary

**** Department of Radiology, Heim Pál Children’s Hospital, Budapest, Hungary

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Authors:

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***** Semmelweis Medical School MR Research Center

Beáta Rosdy M.D.

Deputy Head of Department; Department of Neurology, Heim Pál Children’s Hospital Ulloi u.86. 1089 Budapest, Hungary e- mail: [email protected]

Zsuzsanna Csákányi M.D.

Deputy Head of Department; Department of Otorhinolaryngology and Bronchology, Heim Pál Children’s Hospital Ulloi u.86. 1089 Budapest, Hungary e-mail: [email protected]

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Katalin Kollár M.D. Head of Department; Department of Neurology, Heim Pál Children’s Hospital Ulloi u.86. 1089 Budapest, Hungary e-mail: [email protected]

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Judit Móser M.D. Department of Neurology, Heim Pál Children’s Hospital

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Ulloi u.86. 1089 Budapest, Hungary

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e-mail: [email protected]

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Andrea Kulcsár M.D.

Department of Paediatric Infectology, United St István and St László Hospital ,

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Éva Kovács M.D.

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e-mail:[email protected]

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Gyáli u. 5-7. 1097 Budapest, Hungary

Department of Radiology, Heim Pál Children’s Hospital, Budapest, Hungary Ulloi u.86. 1089 Budapest, Hungary e-mail:[email protected]

György Várallyay M.D.

Semmelweiss Medical School MR Research Center Balassa u.6.1083 Budapest, Hungary e-mail:[email protected]

Gábor Katona M.D.Ph.D. (corresponding author )

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Head of Department; Department of Otorhinolaryngology and Bronchology, Heim Pál Children’s Hospital Ulloi u. 86. 1089 Budapest, Hungary

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e-mail: [email protected]

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Beáta Rosdy *, Zsuzsanna Csákányi **, Katalin Kollár *, Judit Móser *, Mónika Mellár *, Andrea Kulcsár***, Éva Kovács ****, György Várallyay *****, Gábor Katona** Department of Neurology, Heim Pál Children’s Hospital, Budapest, Hungary Department of ENT & Bronchology, Heim Pál Children’s Hospital, Budapest, Hungary *** Department of Pediatric Infectious Diseases, United St István and St László Hospital, Budapest, Hungary **** Department of Radiology, Heim Pál Children’s Hospital, Budapest, Hungary ***** Semmelweis University MR Research Center ABSTRACT

Objective: Otogenic lateral sinus thrombosis is a rare complication of acute otitis media whose clinical presentation has changed with the early use of antibiotics. The aim of this study was to analyze the changing clinical signs, vaccination status, therapeutic management and outcome of these patients. Method: Retrospective chart review of 10 children treated with otogenic lateral sinus thrombosis in a tertiary level teaching hospital in Budapest, Hungary, from January 1998 till August 2013.

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Results: Patients were divided into Early and Late presenting groups. In the Early presenting group, sepsis developed within one week after the onset of acute otitis media. At admission otological symptoms were predominant. The Late presenting group experienced acute otitis media several weeks prior to presentation and in this group neurologic symptoms dominated the clinical picture at admission. All patients received antibiotics. Eight of them were also treated with low molecular weight heparin. All children underwent cortical mastoidectomy. After surgery, the clinical signs of elevated intracranial pressure transiently worsened. This manifested as progression of papilledema in seven children, causing severe visual disturbance in two cases. After medical treatment and serial lumbar punctures all patients except one recovered. This child has permanent visual acuity failure of 0.5 D unilaterally. At one year follow up complete and partial recanalization were noted in five and two patients, respectively.

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Conclusion: After mastoidectomy the signs of elevated intracranial pressure can transiently worsen, papilledema can progress. Daily bedside monitoring of visual acuity and regular ophthalmoscopy with neurologic examination is recommended during hospitalization. Close follow up is advised up to one year. When the dominant sinus is occluded, the clinical scenario is more protracted and severe.

Keywords: Lateral sinus thrombosis, acute otitis media, intracranial pressure, papilledema, mastoidectomy, anticoagulation, sigmoid sinus thrombosis

1. Introduction

The frequency of complications of acute otitis media (AOM), including lateral sinus thrombosis (LST), brain abscess, and epi- and subdural abscesses has decreased dramatically with the use of appropriate antibiotics [1]. This number is further decreased by the use of vaccination against Haemophilus influenzae type b and Streptococcus pneumoniae [2, 3]. However, LST still occurs even in developed countries. Because of its rarity and changing clinical picture due to the use of antibiotics [4, 5] diagnosis still remains a challenge. The extension of inflammation in AOM to the mastoid bone can result in inflammation of the bony wall of the sigmoid sinus (SS), which can lead to its thrombosis [6, 7]. As cerebral sinuses lack valves, the thrombi can propagate to other sinuses and to the internal jugular vein (IJV). Even unilateral occlusion of symmetrically developed cerebral venous sinuses results in reduced resorption of cerebrospinal fluid (CSF) causing elevation in intracranial pressure 4 Page 4 of 15

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(ICP). The venous drainage is frequently asymmetrical. In 41% of the population the right sided sinuses are the dominant ones [8]. In thrombosis it is a determinant factor which side is occluded. If the dominant sinus is occluded, the clinical signs of elevated ICP are more severe and protracted [9]. The most dangerous complication of LST is persistently elevated ICP (also referred to as otitic hydrocephalus or pseudotumor cerebri), which may lead to retinal hemorrhages and visual disturbance. Furthermore, it can progress to blindness, which might go undiagnosed by caregivers of small children. If papilledema is present, administering acetazolamide, or in case of further progression, steroids and/or performing serial lumbar punctures are mandatory. In rare cases ventriculo-peritoneal shunt must be implanted. The recommended treatment for LST is surgery with subsequent conservative therapy [4,7,10, 11]. The introduction of anticoagulants decreased the risk of death and serious neurologic consequences and reduced the recurrence of thrombosis within 6 months [7, 12, 13, 14,]. However its routine use is still a matter of debate [5, 15, 16, 17, 18]. 2. Method

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We performed a retrospective chart review of patients, under 18 years of age, treated with otogenic LST in Heim Pál Teaching Children’s Hospital in Budapest from January 1998 till August 2013. Information concerning age, gender, thrombotic events in the family, past medical history, vaccination status, preceding infections and their treatment, clinical signs, laboratory parameters, thrombophilic screening, microbiologic results, otoscopic picture, as well as imaging results were collected at admission. Surgical and conservative therapy were analyzed. Length of hospital stay, antibiotic and anticoagulation therapy, complications and their treatments were recorded, as well as data from clinical and imaging follow up.

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Approval of the ethics committee of the hospital was obtained.

3. Results

Otogenic LST was diagnosed in ten patients (6 boys, 4 girls). Mean age of the patients was 5. 6 years (age range 4-8 years). All patients were from the capital (Budapest), where 100% of the pediatric population is treated by pediatricians, and oto-rhino-laryngological consultation is readily available. Clinical signs at admission are depicted in Table 1. Based on the clinical picture at admission, patients could be divided in two groups, which we defined as Early and Late presenting groups. One presenting early (within one week) and the other late (after 2-6 weeks) following AOM. Patients in the Early presenting group at the time of diagnoses had not yet been treated with antibiotics, while patients in the Late presenting group had. Control otoscopy at 7 days revealed healing of the acute process. Chronic otitis media was not diagnosed in any of these patients. The presence of chronic illness was not revealed in any of our patients. Neither thrombophilia nor familial recurrent thrombosis was reported. All patients suffered from headache, were lethargic and had nausea. All but one vomited. All patients complained about neck pain and parents reported excessive sleepiness in all. 5 Page 5 of 15

Torticollis was present in five children, nuchal rigidity in an additional three, and these occurred in both groups. 7/10 children reported otalgia. Patients in the Early presenting group experienced high spiking fever, otoscopy revealed red, inflamed tympanic membrane and otorrhea was present in 3/5. Among patients in the Late presenting group two experienced diplopia (due to abducens nerve palsy), ataxia was observed in three and facial palsy was found in one. Otoscopy revealed only slight retraction of the tympanic membrane. After surgery an additional three patients reported transient diplopia and one experienced ataxia.

Results of investigations are presented in Table 2.

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Ophthalmoscopy at admission revealed papilledema in all but one of the cases. Visual disturbance was not present. Progression of papilledema with new retinal hemorrhages appeared in seven children two to three days following surgery. One patient transiently lost his vision, while another patient had severe visual disturbance. Only one patient experienced permanent visual acuity failure of 0.5 D on one eye. Clinical signs of elevated ICP worsened transiently after surgery in half of the subjects.

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C-reactive protein (CRP) and leukocyte count were elevated in all patients in the Early presenting group, but in none of the cases in the Late presenting group. In two children clinical progression occurred despite of a significant decrease in the level of inflammatory markers after one day of antibiotic treatment. Three subjects underwent diagnostic lumbar puncture. One of these had elevated CSF leukocyte and protein count due to an epidural abscess. Bacteriological cultures of the middle ear were sterile in all patients. Blood cultures or CSF cultures and/or mastoid cultures taken intraoperatively proved positive for Streptococcus pneumoniae in 4/5 of the Early presenting cases, but in none of the Late presenting cases. Two children had been vaccinated against pneumococcus. They had received heptavalent vaccine twice in the first year of life and a booster with 13 valent vaccine (containing strain 19 A) after the second year. One of them was infected with strain (19 A) against which she had only received one vaccination. In the other patient serotyping was not successful. Immunologic screening in these two children revealed no immunodeficiency. Laboratory screening for hypercoagulability was carried out in four subjects. We did not find any positive results. At follow up no recurrent thrombotic events were reported. Imaging was performed in all patients. In two children MRI and MR venography (MRV) was performed immediately upon admission. The majority of patients underwent emergency CT with contrast, which detected an opacification of the mastoid cells and SS thrombosis in all of them. In five cases the thrombosis extended into the lateral sinus, while internal jugular vein involvement occurred in three children. CT revealed perisinous abscess in four patients, which was verified intraoperatively in three of them. In two cases only perisinous granulation tissue was found. Imaging revealed congenital hypoplasia of the left outflow tract based on the significant asymmetry of the jugular foramina. Dehiscence of the bony wall of the sinus was diagnosed with CT in two patients, and in two other cases it was found intraoperatively. One epidural occipital and one cerebellar abscess were recognized on CT scans, both confirmed by MRI. Where LST with complications was revealed on the emergency CT scan, 6 Page 6 of 15

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an acute MRI/MRV was also performed before surgery to refine the diagnosis. The study provided additional information in only one patient, in whom temporal cerebritis or venous infarction was suspected. At follow up the presence of hemorrhagic venous infarct was verified. In six patients the first MRI and MRV were performed within a week after surgery and these did not detect any additional complication not already described on the original CT scan.

Therapy

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Surgical therapy

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Each patient underwent mastoidectomy with exploration of the sigmoid sinus wall. Prior to the availability of low molecular weight heparin (LMWH), needle puncture, incision and thrombectomy were performed in two cases. The internal jugular vein was also ligated in one of them. Perisinous abscesses were eliminated in three patients, while in an additional two only perisinous granulation tissue could be removed. In these five children decompression of the sinus wall was performed as well. One epidural abscess was incised and drained with neurosurgical help. No surgical complications occurred. There was no need for reoperation.

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Conservative therapy

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Each child was treated with intravenous (i.v.) antibiotics. Amoxicillin and clavulanic acid or ceftriaxone were administered for 14 days. Bacterial culture results did not lead to a change in the mode of antibiotic treatment. The patient with cerebellar abscess received i.v. ceftriaxone therapy for 14 days, which was followed by i.v. meropenem treatment for an additional four weeks. Follow up MRI before the cessation of antibiotic treatment revealed disappearance of the brain abscess. LMWH has been available for children in Hungary since 2002. In our practice it was administered to eight patients in therapeutic doses. Effectivity was monitored by anti Xa activity measurements. All but one patient received LMWH for six months. The single patient who received LMWH only for three months was the one showing a complete recanalization on MRV at the three months follow up. In the first cases we administered LMWH in therapeutic dosage until the three months follow up MRI. When incipient recanalization was visualized, we reduced the doses of the medication to preventive dosage for the next three months. Based on more recent guidelines (12), for the prevention of recurrence of thrombosis, LMWH was administered in therapeutic dosage for six months in the last four subjects, independently from the results of MRV at three months. After six months, anticoagulation was discontinued independently of the degree of recanalization. Neither bleeding complications, nor thrombocytopenia occurred. Patients displaying clinical or ophthalmologic signs of elevated ICP received oral acetazolamide for one to four months. The clinical picture was protracted and more severe in those cases, where the dominant sinus was occluded. Tapering of medication was gradually performed with close ophthalmoscopic and neurologic follow up. If the visual acuity of the 7 Page 7 of 15

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patient deteriorated following surgery and the papillary prominence increased and new hemorrhages appeared while on acetazolamide, oral steroids were started in a dose of 1 mg/kg/day under close supervision. After improvement this was gradually tapered. One patient lost his vision on both eyes; he got intravenous pulse steroid therapy 30mg/kg/day for 3 days, followed by 1mg/kg/day till visual and ophthalmoscopic improvement. In patients with further deterioration while being on oral steroids, pulse therapy was administered. Serial therapeutic lumbar punctures were performed in two patients, in whose cases the pulse steroid therapy did not help. There was no need to implant a ventriculo-peritoneal shunt in any of the ten patients.

Follow up

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Length of hospital stay ranged from 2-4 weeks. As children under six years of age do not complain of visual disturbance due to elevated ICP, regular tests are necessary. That is the reason why we taught parents to perform postoperative daily bedside visual acuity testing using bright, attention grabbing toys. Children had to take the test with the naked eye. One adult would hold the child on their lap, alternately covering each eye, while the parents standing opposite would keep moving the toys, at the same time closely observing the fixation and ocular motility of the child. During hospitalization fundoscopy with complete neurological examination was also performed every other day to detect any other possible signs of elevated ICP.

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Psychologists screened the children and helped them to regain their former level of physical activity. If attention deficits or behavior changes were noted, regular consultations were added, until the problems resolved. At the one year follow up visit these complaints were no longer present. During the hospital stay physiotherapy was performed daily. Ataxia ceased by the date of discharge. Nuchal pain, rigidity and permanent torticollis diminished after surgery, but episodic head tilting could be observed for months. On average the signs of elevated ICP such as headache, abducens palsy, double vision, retinal hemorrhages and visual disturbance persisted for two months (range 1-5 months) after surgery. After discharge patients were followed up at expanding intervals: weekly in the first month, every second week in the second and third months, and then monthly up to the sixth month, with a last visit at one year. The most serious clinical cases were checked yearly after that. At the follow up visit a complete pediatric, neurologic and otologic examination was performed, as well ophthalmoscopy and visual acuity tests. Formal audiologic evaluation was carried out at three months after discharge. Normal hearing was verified in all patients. Imaging follow up was performed in all cases by MRI. In cases where LST was accompanied by intracranial complications, MRI and MRV were repeated at three weeks, six weeks, three months and at one year. In cases without intracranial complications, imaging was performed at three months and one year. In the child who underwent ligation of the internal jugular 8 Page 8 of 15

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vein, a follow up MRI and MRV were carried out ten years later, showing good emissarial collateral circulation on the affected side, and an increase in the caliber of the previously hypoplastic contralateral venous outflow. At three months only partial recanalization was present in the majority of patients, while at one year complete recanalization could be detected in five and partial in two subjects. In one subject with no recanalization the length of the occlusion decreased with restoration of flow at the IJV and in transverse sinus, while the SS remained occluded.

4. Discussion

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We performed a retrospective chart review of children under 18 years of age with otogenic LST. Our patients could be divided in two groups of equal size, Early and Late presenting groups. In the Early presenting group we found acute clinical setting, with earache, otorrhea, high spiking fever, similar to what had been reported in preantibiotic era studies, or from third world countries [19]. In the Late presenting group neurologic symptoms (such as abducens nerve palsy, diplopia, ataxia, and facial palsy) dominated the clinical picture, which is in agreement with other studies from countries with good access to health care [4,6,10]. We emphasize the importance of detailed history taking. When focal neurological signs are present, questions addressing otitis media should be asked. It may be the only way to reveal otogenic etiology. General symptoms that are clinically difficult to differentiate from signs of elevated intracranial pressure, occurred at the same frequency in both groups. However, the otoscopic picture differed between the two groups. In the Early presenting group red, inflamed tympanic membrane, with or without otorrhea could be visualized, while in the Late presenting group a slight retraction of the tympanic membrane was observed. We suggest that in a child previously treated for AOM with antibiotics and presenting with focal neurological signs and a slight tympanic membrane retraction, ophthalmoscopy and imaging should be performed. The same protocol is suggested in septic patients treated with antibiotics for AOM, but clinically not improving after 24-48 hours of treatment. We agree with Penido [20] that cases of LST may occur more frequently than is clinically diagnosed. All patients were vaccinated against Haemophilus influenza type B, with the last two patients also against Pneumococcus. In thrombus formation the thrombotic activity of streptococci is suspected as an etiological factor [21]. Neuraminidase released from Streptococcus pneumoniae damages endothelial cells. This results in the induction of procoagulant activity by tissue factor, which leads to the activation of the whole procoagulant pathway with subsequent fibrin formation and deposition [22].In the Early presenting group the etiological role of Pneumococci could be observed in the same proportion (4/5) as reported by others [4,7,16,23]. Two patients from the Early presenting group had been properly immunized against Pneumococcus. In one of them the etiological role of Streptococcus 19 A was confirmed, a serotype present only in the 13 valent vaccine. To achieve effective immunization against the six additional serotypes, a second booster vaccination with PCV 13 schedule is presumed under five years of age.

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Fundoscopic examination at admission revealed developing papilledema in all cases but one, but visual disturbance was not noted. Our findings are in contrast with the results of Vieira et al [24] and Sitton et al [25], who both reported papilledema in 28% of patients. Our findings also contrast with Novoa et al [14], who put it at 44 %. However, there is one series close to our results, reported by Koitschev et al [26], where 80% of patients had papilledema and focal neurological signs.

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Imaging revealed opacified mastoid cells and LST in all patients, with hypoplasia of the left venous outflow tract in three. According to the literature, CT with contrast could detect only 60% of LST cases [27,28]. The gold standard MRI/MRV [24, 27, 28] with no radiation exposure not just visualizes circulation in sinuses, but detects other intracranial complications with high sensitivity. This influences both the duration of antibiotic administration and the type of surgery. However, access to an emergency MRI is frequently problematic, like in the majority of our cases [9].

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Treatment of otogenic LST consists of administering antibiotics. Operative management is questioned by some new publications [29], but the majority of authors recommend early mastoidectomy [4,7,10,30]. All of our patients, besides getting antibiotics, underwent cortical mastoidectomy. Perisinous abscesses and granulation tissues were eliminated in five. Since the administration of broad spectrum antibiotics [7, 10, 25, 30] a more conservative approach is suggested in handling the thrombosis. Prior to the availability of LMWH, i.e. before 2002, needle puncture, incision and thrombectomy were performed in two patients. One of them underwent IJV ligation as well. The role of anticoagulation in patient management remains controversial. Child neurologists and pediatric hematologists recommend it [12, 14, 25, 31, 32, 33], while its use is still being debated among oto-laryngologists [15,16,17]. Neilan et al [17] report spontaneous recanalization after pure mastoidectomy and antibiotics in 52.9% of cases. In patients in whom additional anticoagulation was used, the percentage of recanalization was 66.7%, which was not significantly higher. Some authors [11,23] recommend anticoagulation only in cases of extended thrombosis. We have been administering LMWH for all patients with LST without any complication ever-since it became available in Hungary for children,

The most interesting finding in the course of the past 15 years in our series has been that the signs of elevated ICP transiently worsen after mastoidectomy. This had not been reported previously. Although the general clinical condition of our patients improved after surgery, the signs of elevated intracranial pressure newly appeared or worsened in 70% of cases and persisted for an average of two months. A more protracted course was seen in those patients where the dominant venous outflow was occluded [9]. The only persisting complication was permanent unilateral visual deficit of 0.5D in one patient. There are no evidence based clinical data for the reason of transiently elevated ICP after mastoidectomy. As a hypothesis, we think that cortical mastoidectomy transiently alters emissarial collateral circulation due to the direct closing of veins by the surgery itself or by perivasal and periosteal edema.

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We followed up our patients for one year. This was the usual time mentioned by others, but the regularity of follow up was not reported in any series. After discharge our patients were followed up at expanding intervals (see p.5). At the follow up visits complete pediatric, neurologic and otologic examinations were performed, ophthalmoscopy and visual acuity testing were done as well. Formal audiologic evaluation was performed three months after discharge. Imaging follow up was always recorded by MRI. If intracranial complications occurred, MRI and MRV were done at 3 weeks, 6 weeks, 3 months and at one year. In cases without intracranial complications follow up examinations were performed at 3 months and one year. At the three months follow up partial recanalization was visualized in the majority of patients. At one year complete recanalization was seen in 50% of cases and partial in 20%. These data are the same as reported in the literature [17, 23].

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5. Conclusion

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Otogenic LST still remains present even in developed countries. Both acute and late presenting forms can be found. The two groups show different symptoms. The diagnosis must be considered in a child with acute AOM, who after 24-48 hours of appropriate antibiotic administration does not clinically improve and shows signs of elevated ICP. On the other hand for children with focal neurological signs at the time of admission, detailed questioning must be carried out to reveal previous ear infections. In acute presenting cases otoscopy shows red, inflamed tympanic membrane, while in late presenting cases slight tympanic membrane retraction can be visualized. Ophthalmoscopy is a useful screening tool, but imaging is mandatory in verifying LST. Administering broad spectrum antibiotics and performing mastoidectomy, if necessary with decompression of the SS, seems to be essential, while thrombectomy and ligation of IJV are not. Our series confirms that anticoagulation with LMWH is safe. It is advised to prevent the extension of thrombosis and to lower the incidence of other serious neurologic complications. Signs of elevated ICP can transiently worsen after surgery; therefore we recommend daily bedside monitoring of visual acuity and regular ophthalmoscopy with neurologic examination during hospital stay. After discharge close follow up is advised up to one year.

Acknowledgements

We gratefully acknowledge the support given to us by Professor Zoltán Harkányi, head of Department of Radiology, Heim Pál Children’s Hospital; Gábor Rudas PhD, director, Peter Barsi PhD consultant radiologists of MR Research Center, Budapest.

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[26] A. Koitschev, C.Simon, H. Löweinheim, M.Kumpf, D.Besch & U. Ernemann, Delayed otogenic hydrocephalus after acute otitis media in pediatric patients: the changing presentation of a serious otologic complication, Acta Oto-Laryngologica, 125 (2005) 12301235

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[27] R. M. Irving, F.R.C.S., N. S. Jones, F.R.C.S., M. A. Hall-Craggs, F.R.C.R., B. Kendall, F.R.C.R., CT and MR imaging in lateral sinus thrombosis, Journal of Laryngology and Otology 105 (1991) 693-695

Ac ce pt e

[28] N. Dlamini, L. Billinghursta, and F. J. Kirkham, Cerebral Venous Sinus (Sinovenous) Thrombosis in Children, Neurosurg Clin N Am. 21(3-5) (2010) 511–527. [29] E. E. Tov, A. Leiberman, I. Shelef, D.M. Kaplan, Conservative nonsurgical treatment of a child with otogenic lateral sinus thrombosis, American Journal of Otolaryngology – Head and Neck Medicine and Surgery 29 (2008) 138–141 [30] J.H. Lee, S. J. Choi, K. Park, Y.H. Choung, Managements for lateral sinus thrombosis, Eur Arch Otorhinolaryngol. 266 (2009) 51–58 [31] E. Chalmers, V. Ganesen, R. Liesner, S. Maroo, T. Nokes, D. Saunders and M. Williams, Guideline on the investigation, management and prevention of venous thrombosis in children, British Journal of Haematology, 154 (2011) 196–207 [32] M.D. Moharir, M. Shroff, D. Stephens, A.M. Pontigon, A. Chan, D. Mac Gregor, D. Mikulis, M. Adams, G. deVeber, Anticoagulants in pediatric cerebral sinovenous thrombosis: a safety and outcome study, Ann Neurol. 67(5) (2010) 590-9 [33] G. Saposnik, F. Barinagarrementeria, R. D. Brown, C. D. Bushnell, B. Cucchiara, M. Cushman, G. deVeber, J. M. Ferro, F.Y. Tsai, Diagnosis and Management of Cerebral Venous Thrombosis, Stroke 42(2011) 1158-1192

13 Page 13 of 15

Table 1 Clinical signs at admission

us

+ + + + + + +

cr

General Fever sympto ms Headache Lethargy Nausea Vomiting Neck pain Sleepiness Otologic Otalgia sympto ms Otorrhea

Late onset cases N:5 -

d

M

Neurolo Nuchal rigidity gical signs Torticollis Diplopia, abducens palsy Ataxia Facial palsy Visual disturbance

3/5

-

+

-

an

Retroauricular pain

+ + + 4/5 + + 2/5

ip t

Early onset cases N:5 +

2/5

1/5

2/5 -

3/5 2/5 3/5 1/5 -

Ac ce pt e

+ , in all patients; - , in none of the patients

Table 2 Results

Early onset cases N:5 Yes

Late onset cas No

Leukocytosis Elevated CRP

Yes

Elevated CRP

No

Streptococcus pneumoniae 4/5

Blood/CSF or mastoid cultures

negativ

Red,inflamed edematous tympanic membrane 5/5

Otoscopy

Papilledema 5/5

Ophthalmoscopy

Slight retractio

Papilledema 14 Page 14 of 15

CT+C or MR/MRV

Verified the dia

Ac ce pt e

d

M

an

us

cr

ip t

Verified the diagnosis

15 Page 15 of 15

Visual and neurologic deterioration in otogenic lateral sinus thrombosis: 15 year experience.

Otogenic lateral sinus thrombosis is a rare complication of acute otitis media whose clinical presentation has changed with the early use of antibioti...
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