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Matthew SittonMedical College of WisconsinEmail: msitton@mcw.eduPhone: (414) 805-5609Website: www.mcw.edu; www.chw.org

Objectives: 1. Discuss the presentation, work up, and treatment of a series pediatric patients presenting with acute otogenic lateral sinus thrombosis (OLST)2. Review the literature in discussing surgical treatment and the role of anticoagulation for sinus thrombosis from complicated otomastoiditis

Methods: Retrospective case series of seven patients with otomastoidits and lateral sinus thrombosis were included in the study. Type of anticoagulation used and both clinical and radiographic outcomes were compared. Pediatric literature review was conducted using Pubmedsearch terms “thrombosis and otitis media and anticoagulation” limited to english.

Results: Seven patients presented with acute otomastoiditis with sigmoid sinus thrombosis. Six patients were treated with anticoagulation for 1.5 –12 months. Six patients underwent myringotomywith tube and 4 patients underwent cortical mastoidectomy without thrombectomy. Six patients had resolution of thrombosis by imaging in less than 6 months. Literature review of 19 pts with OLST showed that 95% had mastoidectomy and 84% had myrigotomy with tube. All 19 patients received anticoagulation. Sixteen patients had complete clinical recovery with recanalization or resoluation of clot in 3 patients.

Conclusions: The treatment of OLST is controversial. Most (23/26) patients had complete clinical recovery despite clot resolution in 9 of the 26 patients. Four patients had bleeding complication with anticoagulation. This series and literature review highlights the controversy of surgical and use of anticoagulation in the treatment of OLST and the need for further investigation.

Pediatric Otogenic Lateral Sinus Thrombosis: Role of Anticoagulation & SurgeryCase Series and Literature Review

Matthew Sitton, MD; Robert Chun, MDMedical College of Wisconsin

Presenting signs and symptoms were fever (n=6), otorrhea (n=3),vomiting (n=4), diplopia (n=4), otalgia (n=3), headache (n=3), mastoid tenderness (n=2), neck stiffness (n=1), dizziness (n=1). All patients had been diagnosed and treated with oral antibiotics within the last month of presenting to the hospital for an episode of acute otitis media.

One patient had a history of recurrent acute otitis media and one patient had a history of 4-5 ear infections in the past 5 years. All other patients had a history of less than 2 episodes of acute otitis media in their lifetime.Five patients initially underwent contrast enhanced computed tomography (CT)

of head. Thrombus was diagnosed in 3 of the 5 patients by CT. The other 2 patients with negative CT had subsequent MRI scans, which revealed sigmoid sinus thrombus. Six of the 7 patients underwent MRI and MRV (Figure 1A). The patient who did not undergo MRI and MRV, was diagnosed with sigmoid sinus thrombosis by CT scan alone.

Four patients had an lumbar puncture(LP) at admission. Two patients had elevated opening pressures, they were treated with acetazolamide and one patient required multiple readmissions for increased intracranial pressure treated with repeat LPs and drainage of cerebrospinal fluid.

All patients underwent surgery. No patients had complications noted during surgery. None of the patients were treated with ligation of sinus or internal jugular vein, incision or thrombectomy of sigmoid sinus, or ventriculoperitoneal (VP) shunt.

All but one patient was treated with anticoagulation for an average of 6 months (Table 1). All patients had a negative hypercoagulability workup. The only complication from anticoagulation use was an episode of epistaxis lasting less than 10 minutes that resolved with pressure at home.

Six patients underwent MRI and MRV (Figure 1B) and 1 patient underwent CT for follow up imaging. Follow up imaging was obtained on average 3 months after diagnosis (range: 4 days to 7 months).

All presenting signs and symptoms resolved including diplopia (Figure 2). Five patients had resolution of their symptoms and signs at discharge. One patient was

The role of anticoagulation in the literature is unclear. Prevention of thrombus progression or embolization, and resolution of thrombus are proponents for the use of anticoagulation. However potential complications of anticoagulation include bleeding, drug interactions, thrombocytopenia, osteoporosis, and hemorrhagic skin necrosis. In addition most anticoagulation requires either twice daily injections or weekly lab draw visits. In our series of 7 patients there was 1 minor complication of self-resolving epistaxis. In the literature review, 4 hematologic complications, with at least 2 requiring either further surgery or transfusion of blood products. Criteria suggested by one author is to use anticoagulation on cases with evidence of thrombus progression, thrombus extending to other sites on initial exam ( jugular vein, transverse sinus, cavernous sinus), neurologic changes, persistent fevers, or embolic events9. Five of the six patients treated with anticoagulation in our series met those criteria.

The most common surgical procedures put forth in the literature are internal jugular vein ligation, thrombectomy, decompression of sigmoid sinus, aspiration of sigmoid sinus, cortical mastoidectomy, or myringotomywith tube placement. Most authors, more recently, perform mastoidectomywith or without myringotomy tubes 9,10,11,12. None of our 7 patients required thrombectomy or ligation of the jugular vein.

Imaging has become the diagnostic method of choice due to its low morbidity and accuracy. Contrast enhanced CT may suggest thrombosis by showing an empty triangle surrounded by dural enhancement, the so called “empty delta sign”13. MRI has been shown to be more sensitive then contrast CT in the detection of OLST14, 15. Two of five contrasted CT scans in our series did not reveal thrombosis. These cases of OLST were confirmed with MRI. Our results confirm the increased sensitivity of MRI.

Following IRB approval, the medical charts of all patients hospitalized at Children’s Hospital of Wisconsin between January 1, 1999 to February 14, 2011 were searched for cases corresponding with a diagnosis of otitis media or mastoiditis (ICD9 381.00-381.06, 382.00-382.02, 382.9, 383.00-383.1) and diagnosis of lateral sinus thrombosis or sigmoid sinus thrombosis (ICD9 325, 437.6). Eighteen patients were identified with these codes. Inclusion criteria were 1) otogenic sinus thrombosis 2) pre and post treatment CT or MRI. Exclusion criteria was chronic otitis media with cholesteatoma. After charts were reviewed, 7 patients were included.A PubMed literature search was performed using “thrombosis” AND “otitis media” AND “anticoagulation.” The search was limited to articles available in English. From this data we cannot draw conclusions in the terms of appropriate

surgical treatment and medical management of the sigmoid sinus thrombosis. However, in the combined literature search and our series, of the twenty six patients, twenty two had mastoidectomy and only four patients had complications secondary to anticoagulation. Most (23/26) patients had complete clinical recovery despite clot resolution in 9 of the 26 patients.

Otogenic lateral sinus thrombosis (OLST) is a rare complication of acute otomastoiditis. Classically, symptoms included “picket-fence” fevers, headache, erythema and edema and tenderness over the posterior portion of the mastoid (Griesinger sign). Now with widespread use of antibiotics to treat acute otitis media, signs and symptoms of OLST have become less ominous. Suspicion of OLST should be had in patients with a recent history of acute otitis media and with headache, nausea and vomiting, or abducens nerve palsy. Lateral sinus thrombosis may lead to otic hydrocephalus, papilledema, seizures and coma1. The thrombus may propagate resulting in cavernous sinus thrombosis or internal jugular vein thrombus. Prior to surgical or antibiotic therapy lateral sinus thrombosis was considered universally fatal. More recently with newer antibiotics the mortality for pediatric otogenic lateral sinus thrombosis has been reported to be 5%2.

INTRODUCTION

METHODS AND MATERIALS

CONCLUSIONS

DISCUSSIONRESULTS

REFERENCES

Table 1: Treatment and OutcomesFigure 1. Initial MRV (A) and Post treatment MRV (B) of Patient 2

ABSTRACT

CONTACT

-discharged after 14 days complaining of diplopia despite resolution of abducens nerve palsy. They had resolution of all complaints by 1 month post op visit. One patient required 2 readmission, after being hospitalized for 9 days, for emesis diplopia and raised intracranial pressure. They were treated with multiple LPs for drainage of CSF. This patient’s diplopia and vomiting episodes resolved at around 2 months after diagnosis.

The PubMed search resulted in 20 articles. Nineteen articles were available for review. Articles were excluded because no follow up imaging (n=6), chronic otitis media with cholesteatoma (n=2), lack of distinction of patients receiving anticoagulation (n=1), non otogenic (n=1), adult (n=1), no involvement of sigmoid sinus(n=2). Leaving 5 articles3,4,5,6,7,8 and 19 patients for further data extraction and inclusion with our data. (See Figure 3)

Clinically symptoms resolved in all but 3 of the 19 patients. Two patients had persistent but improved diplopia at 3 months and 25 months post op and 1 patient had persistent decreased visual acuity at 3 months post op. Follow up MRI/MRV revealed resolution of clot in 3 patients (1 at 6 months), partial recanalization in 9 patients (1 patient at 6 months and 3 patients at 3 months), and persistent occlusion in 7 patients(1 patient at 5 months and 3 patients at 3 months). Of the 3 patients whose clinical symptoms did not improve, 2 patients had partial resolution of thrombus at 6 months and 3 months and 1 patient had persistent occlusion at 3 months on follow up imaging.

Four patients had aspiration of the sinus. All 19 patients were treated with anticoagulation. Seventeen patients received enoxaparin. Duration was given for 5 patients, which was between 3 weeks to 6 months (average 17.8 weeks). One patient received enoxaparin for 1 month and then converted to warfarin for 5 months. One patient received an anticoagulant with the name nor duration reported.

Complications recorded were four patients suffering from a post-op bleed or hematoma, one requiring operative drainage of a post-auricular hematoma and another requiring packed red blood cells and fresh frozen plasma. Management of the other 2 postop bleed or hematoma was not reported.

RESULTS

Figure 3: Literature ReviewFigure 2: CHW series

A B