Minnesota academy of ophthalmology and oto‐laryngology

Abstract

AbstractThrombosis of the lateral sinus as a complication of middle ear and mastoid suppuration never fails to produce mental aggravation whenever one is confronted with it. There is still a great deal of dispute relative to its management.The profession apparently has divided itself into three groups; namely, those who always ligate the internal jugular, following the original dictates of Zaufal, Lane and Ballance; those who never ligate the jugular, as Mygind, Rott, Dixon and others; and those who classify each case individually. They attempt, by the use of their best surgical and medical judgment, to decide which cases should be ligated and which should be treated expectantly.During the past two years we have had a series of 10 cases of lateral sinus involvement; this is in addition to a report of 14 cases recently presented by the writer.The symptomatology of lateral sinus thrombosis may be divided into two groups: general and local. The general symptoms are temperature, chills, convulsions, proportionate pulse rate, mental picture, hematology, spinal fluid changes and metastasis to various parts of the body. The local signs and symptoms are centered about the external surface of the mastoid and the mastoid cavity, and vary with the type of mastoid, the condition of the lateral sinus and the internal jugular vein. Knowledge of the condition of these structures is elicited by inspection, palpation, ophthalmologic observations and various diagnostic tests.The problem of the internal jugular vein: In the early part of this paper the author stated that there were three schools of thought relative to the surgical procedure of lateral sinus thrombosis. Although the surgical principle is simple and theoretically perfect, nevertheless ligation of the jugular vein has fallen short in many instances. Therefore, the efficacy of such a routine treatment is not entirely satisfactory and, from a therapeutic standpoint, ligation does not always solve the problem.In sinus thrombosis, one is confronted with the following elements which must be overcome; namely, infection, septicemia, thrombosis (which may be the source of a local and focal infection), embolism and metastasis.In combating the above, both medical and surgical therapeutic measures are utilized. The medical treatment consists of tonics, hematonics, repeated blood transfusions, chemotherapy, autogenous and stock vaccines, specific and nonspecific sera.The orthodox surgical treatment consists of the following: 1. Evacuation of the thrombus from the lateral sinus, if present, and the obliteration of the sinus by packing; 2. in phlebitis, the lateral sinus is merely incised and then obliterated; and 3. the third surgical principle deals with the ligation of the internal jugular vein.The rationale for ligating the internal jugular vein is to obliterate the channel carrying the infection and thus check septicemia, bacteremia and, particularly, emboli and metastasis. One of the important factors overlooked was the collateral circulation through which infection still continues to enter the general circulation.To substantiate this contention, the writer offers as proof the fact that 33 per cent of metastasis occurred after ligation and even higher percentages have been reported by other observers. In addition, the hospitalization period is not shortened and the mortality rate is often higher.At the present time we practice phlebotomy of the internal jugular vein and lateral sinus. We do not disturb the clots cither distally or proximally, as we believe that the thrombus is the result of the infection and is Nature's method of controlling it.