LATERAL SINUS THROMBOSIS IN CHRONIC OTITIS MEDIA

Abstract

To the Editor: We read with great interest the article "Management of lateral sinus thrombosis in chronic otitis media" by Mete Iseri et al. (Otol Neurotol 2006; 27:1098-1103) (1). Authors presented five patients with lateral sinus thrombosis (LST) as a complication of chronic otitis media (COM). The sigmoid sinuses in presented patients were not resected, the clots were not evacuated, and internal jugular vein was not ligated in any of the patients. Only four of five patients with LST received anticoagulation therapy. Because these are different to our experience in the managing of LST, we have several comments regarding their diagnosis and treatment. Now very rare, LST is one of the most frequent complications of COM. The natural history of otitis media has changed since the introduction of antibiotics, reducing associated intratemporal and intracranial complications. Incidence of LST is mainly related to anatomical abnormalities of the temporal bone, virulence of pathogens, and coexistence of acquired or congenital coagulation disorders (2-4). Computed tomography, T1- and T2-weighted magnetic resonance (MR) imaging, and MR venography in diagnostics enabled the early diagnosis of LST. Contrast-enhanced computed tomographic scan shows the empty δ sign consisting of a darkened area of the thrombus, surrounded by the contrast-enhanced sigmoid sinus wall. On MR imaging, the thrombus in LST seems isointense on T1- and hypointense on T2-weighted images. Magnetic resonance venography may evaluate the presence of blood and the blood flow within the sinus lumen (1,3). These assessments should be used in each case of suspected intracranial complication patients with COM and coagulation disorders. Anatomical variations of sinus and cerebral veins must be taken into account to avoid false-positive diagnosis of sinus thrombosis (3). In cases of aplasia of one lateral sinus or thrombophlebitis of cerebral veins, jugular vein ligation is contraindicated because it may affect the cerebral blood circulation. The generally accepted treatment of LST in COM is canal wall dawn mastoidectomy and decompression of the sigmoid sinus (2,5). If septic fever, presence of perisinual abscess, granulation tissue around the sinus, and no blood flow in sinus by puncture is observed, lateral sinus should be incised and the clot removed. In acute mastoiditis with LST and without perisinus abscess, the accepted surgical procedure is mastoidectomy with decompression of the sigmoid sinus and treatment with antibiotics and anticoagulants (5). Follow-up MR venography will be helpful in assessing the recanalization process of lateral sinus. Other useful parameters for follow up in these patients are sedimentation rate, C-reactive protein, white blood cell count, and coagulation system. The authors of the article did not perform jugular vein ligation; thus, they would expect distant metastases with infected emboli. In our opinion, the patients' safety requires jugular vein ligation if the symptoms of sepsis in LST are present. Our experience consists of eight cases of LST with COM (27.6% of all intracranial complications of COM) treated at the ENT Department from 1990 to 2004. Management of our LST cases comprised canal wall down mastoidectomy with sigmoid sinus decompression, removal of the clot, jugular vein ligation, and anticoagulants and antibiotics treatment, which gave good final treatment result. Appearance of LST septic symptoms in COM is an indication for particular diagnostics of coagulation system and for treatment with intravenous antibiotics and anticoagulants. On the other hand, the role of anticoagulants is controversial in the treatment of nonseptic case of LST. Jerzy Kuczkowski, M.D., Ph.D. Waldemar Narozny, M.D., Ph.D. Boguslaw Mikaszewski, M.D., Ph.D. Department of Otolaryngology Medical University of Gdańsk Gdańsk, Poland