Lateral Sinus Thrombosis Research Articles

A Rare Case of Tentorial Sinus Thrombosis in a Patient with Sickle Cell Disease

Background: The reported incidence of venous thromboembolism in sickle cell disease patients is approximately 12% before the age of 40, accompanied by an additional 5-10% incidence of cerebral venous sinus thrombosis. Tentorial sinuses are venous structures in the posterior cranial fossa, draining the occipital and temporal lobes and the superior part of the cerebellum. Here, we describe a rare case of lateral tentorial sinus thrombosis in a patient with sickle cell disease. Methods: Case report and review of the available literature Results: A 26-year-old woman with sickle cell disease presented with a 2-day history of headache, nausea, and vomiting. Neurological exam was normal. CT brain revealed hyperdensity in the right occipital region and subtle area of hypodensity in the right medial occipital lobe. MRI/MRV brain showed right lateral tentorial sinus and occipitobasal vein thrombosis in addition to right medial occipital lobe venous infarct. The patient was started on therapeutic heparin initially, then transitioned to apixaban. Hemoglobin electrophoresis revealed a HbS fraction of 80.6% and HbF 16.6%. The patient received an exchange transfusion and was discharged home in stable condition. Conclusions: In patients with symptoms concerning for cerebral venous thrombosis, attention is usually directed to the traditional dural venous sinuses and cortical veins, while other venous structures can be overlooked. Although, in this particular case, it was clear on imaging, tentorial sinus thrombosis can easily be missed if not associated with brain edema or venous infarct.

Lateral Sinus Thrombosis as a Sequela of Chronic Mastoiditis

Lateral sinus thrombosis (LST) is a known but rare complication of chronic otitis media and mastoiditis in the antibiotic era. The classic symptoms of picket fence fever and other unspecific symptoms could be masked by the usage of the antibiotics contributed to the late presentation and delay in treatment. Thus, clinicians should be vigilant and detect this complication early to prevent mortality and morbidity. Administration of broad-spectrum antibiotics and surgical mastoidectomy to eradicate the perisinus infection are the main treatment modalities. Here, we report a case of partially treated chronic otitis media complicated with LST after a 6 months gap of defaulted follow-up.

Cerebral Venous Thrombosis in Patients With Traumatic Brain Injury: Epidemiology and Outcome.

The natural history and epidemiological aspects of traumatic cerebral venous thrombosis (CVT) are not fully understood. Due to the concomitant occurrence with intracranial hemorrhages, guidelines for medical treatment have been highly controversial.In this study, our objective was to carry out an analysis description of the population and to conduct a literature review. A prospectively gathered radiology registry data of patients hospitalized at the tertiary hospital of Centro Hospitalar Universitário do São João, Porto, Portugal, between 2016 and 2021 was carried out. All patients with traumatic brain injury (TBI) and concomitant CVT were identified. CVT was confirmed by CT venogram. Demographic, clinical, and radiological data and their medical management were reported. In-hospital complications and treatment outcomes were compared between patients measured by the Glasgow Outcome Score Extended (GOSE) at discharge and GOSE at three months. There were 41 patients with traumatic CVT admitted to this study. The majority (45.2%) had a hyperdense signal near the lateral sinus at admission, and only 26.2% presented with skull fractures. Of this cohort, 95% had experienced lateral sinus thrombosis. Twenty-five patients (60%) had occlusive venous thrombosis. Venous infarct was the main complication following CVT.Thirty-two patients (78%) were anticoagulated after CVT and four developed complications. At the three-month follow-up after discharge, 28.2% had good recovery (GOSE > 6). This study revealed a higher incidence of CVT in severe TBI and a mild association with skull fractures. There is a higher incidence of CVT in the lateral sinus. Management was inconsistent, with no difference in outcome without or with anticoagulation. Larger, prospective cohort studies are required to better comprehend this condition and determine evidence-based guidelines.

Intracranial Spread of Infections Among the Patients of Chronic Suppurative Otitis Media

Objective: To determine the frequency of intracranial spread of infections among the patients of chronic suppurative otitis media presenting at a tertiary care hospital in Karachi.Study Design: Cross-Sectional Study.Place and Duration of Study: The study was carried out at the Department of ENT, Head and Neck Surgery, Dow Medical College, Dr. K.M Ruth Pfau Civil Hospital, Karachi, Pakistan, from January 2021 to January 2022.Methods: Out of 87 patients with Chronic Suppurative Otitis Media were included using a non-probability sampling technique. Possible routes of spread of infections were identified based on per operative findings. The Descriptive statistics were applied to all parameters. On inferential statistics, Chi-square test was used for stratification, considering p-value ≤0.05 as significant.Results: 75 (86.2%) were male and 12 (13.8%) were female. 21 (24.1%) patients were found with meningitis, 11 (12.6%) with lateral sinus thrombosis, and 2 (2.3%) with otitis hydrocephalus. As far as signs and symptoms are concerned, 87 (100%) patients had a headache, 74 (85.1%) had nausea and vomiting, 44 (50.6%) patients had vertigo, 43 (49.4%) had a fever, 18 (20.7%) had diplopia, and 73 (83.9%) had altered consciousness. 69 (79.3%) of patients' route of infection in the patients of chronic suppurative otitis media had bone erosion, 12 (13.8%) had thrombophlebitis, and 6 (6.9%) had anatomical pathways. Among different sites of spread of infection, the most common site was sinodural angle 45 (51.72%).Conclusion: Bone erosion, with 79.3%, was the most prevalent route of intracranial spread, followed by thrombophlebitis and anatomical pathways.
 How to cite this: Malik MI, Naqvi AF, Naqvi SU, Khan N, Ali A, Abbas N. Routes and Sites of Intracranial Spread of Infections Among the Patients of Chronic Suppurative Otitis Media. Life and Science.2023; 4(4): 476-482. doi: http://doi.org/10.37185/LnS.1.1.476

Profile and Outcome of Prospective Non-Septic Lateral Sinus Thrombosis Patients from a Stroke Unit of a Developing Country.

Due to effective treatment of middle ear infections there is a change in etiologies causing lateral sinus thrombosis (LST) and outcome. There is a paucity of literature describing homogenous group of patients with nonseptic LST (NS-LST). To describe the clinical profile, risk factors, outcome of patients of NS-LST seen at a single center from South India. Prospective, observational study of 100 patients of NS-LST patients, diagnosed by magnetic resonance imaging (MRI) seen at the stroke unit. During 2 years, 100 patients of NS-LST (isolated: combined: 27:73) (male: female: 44:56), mean age: 31.45 ± 11.13 years, were seen. Subacute presentation (74%) with headache, seizures, focal deficits, and features of raised intracranial pressure were presenting features. Hyperhomocysteinemia (61%), anemia (57%), postpartum state (41%), OCP use (37%), and low VitB12 (32%) were commonly seen risk factors. Imaging with MRI compared withcomputerized tomography (CT) had better diagnostic sensitivity (100% vs. 67%), detection of parenchymal (81% vs. 67%)/hemorrhagic (79% vs. 74%) lesions, and cortical vein thrombosis (31% vs. 15.46%). Treatment with anticoagulation and supportive therapy resulted in good outcome (mRS (0-2)) at 3 months in 81%.There were four deaths, all during admission (one - isolated, three - combined) and 11 patients underwent decompressive surgery. Patients with low GCS level of sensoriumat admission, hemiparesis, combined LST, cerebellar involvement, and decompressive craniectomy had a poor outcome. This single-center large cohort study of NS-LST patients brings out the clinical features, risk factors (peculiar to developing countries), and the superiority of MRI in the diagnosis. Majority of patients have good outcome, with low mortality with 10% requiring decompressive surgery.

A Case of Giant Petrous Apex Cholesteatoma With Pseudomonas Aeruginosa Infection.

Petrous apex cholesteatoma is a relatively rare and chronic aggressive disease that occurs in the petrous part of the temporal bone and can be classified as congenital or acquired. Due to the tendency of petrous cholesteatomas to cause bone destruction and invade important structures such as the facial nerve, cochlea, and semicircular canal, patients present mainly with severe hearing loss, progressive peripheral facial palsy, vertigo, etc. When the lesion invades the intracranial region or is infected, intracranial symptoms such as meningitis, lateral sinus thrombosis, and brain abscess may be present. We report a case of giant petrous cholesteatoma with Pseudomonas aeruginosa infection, with the aim of exploring the corresponding clinical treatment and surgical modalities to provide a reference for the clinical management of this type of disease.

Otogenic Sinus Thrombosis and Hemophilia: A Clinical Case

Background. Patients with hemophilia are protected from thrombosis by a deficiency of one of coagulation factors, therefore thrombotic complications are rare in them. Currently, few descriptions of spontaneous venous thrombosis in adult hemophiliacs can be found in the literature. Even fewer data of thromboembolic complications are reported in pediatric practice. At present, no clear recommendations are given for the management of thrombotic complications in children with hemophilia, which requires further study of this issue to develop prevention and treatment regimens, including otogenic sinus thrombosis in this category of patients.Case description. A 7-year-old boy was transferred from the Somatic Hospital to the Intensive Care Unit of Regional Clinical Hospital No. 2 in Tyumen (Russia) with an Otorhinolaryngology Unit. He was diagnosed with non-perforative form of acute right-sided suppurative otitis media, acute right-sided mastoiditis, thrombosis of the right sigmoid sinus. The anamnesis shows that the child is diagnosed with hemophilia A, of moderate severity (factor VIII level — 5%), for which he has been receiving factor VIII replacement therapy for the last year. Upon admission, a general blood test revealed no abnormalities, with a slight increase in acute-phase parameters: C-reactive protein, fibrinogen, signs of hypocoagulation. Due to negative dynamics, the child underwent anthromastoidotomy against the background of intensive replacement therapy. Surgery revealed the presence of granulation tissue with hemorrhagic thrombi in the antrum and aditus. In the postoperative period, replacement therapy was accompanied with antibacterial and anticoagulant therapy.Conclusion. The management of patients with otogenic sinus thrombosis against the background of hereditary factor VIII deficiency is a difficult task. On the one hand, it requires surgical intervention and anticoagulant therapy in order to prevent further thrombosis, on the other hand — intensive replacement therapy in order to reduce the risks of hemorrhagic complications. The described case demonstrates the need for an interdisciplinary approach to the diagnosis and treatment of a patient with otogenic thrombosis of lateral sinus against the background of hemophilia A. The approach is to minimize the risks of intraoperative complications and insure a favorable outcome.

Otogenic lateral sinus thrombosis

Otogenic lateral sinus thrombosis (LST) occurs as an in­tra­cra­nial complication of otitis media. In the pre­anti­bio­tic era, the mortality was almost 100%. Today, thanks to antibiotics, the rate of mortality dropped at 10%. In the context of chronic otitis media, the infection migrates through bone dehiscence or erosions and causes initially an abs­cess around the lateral sinus, with thrombophlebitis of the venules that surround the external wall of the sinus in the proximity to dura mater, and these will lead to necrosis of the sinus wall, determining the adhesion of fibrin and pla­telets and, finally, forming a mural thrombus, which evolves towards superinfection and sinus occlusion. Parts of the infected thrombus will break off and enter the blood stream, with all the general symptoms and the possible com­pli­ca­tions from it. We present and discuss a case of la­te­ral sinus thrombosis following chronic otitis media in the pandemic context. The particularity of the case is given by the COVID-19 restrictions. In the absence of the antibiotic the­ra­py, due to the pandemic circumstances, the child de­ve­loped a typical form of LST. Knowledge of the clinical ma­ni­fes­ta­tions of “classic” lateral sinus thrombosis facilitated the diagnostic pro­cess. Fortunately, today our patient was able to benefit from powerful broad-spectrum antibiotics which, combined with the surgical treatment, saved his life.

Fatal Otitic Hydrocephalus Due to Sinus Thrombosis: A Case Report

Objective: To report a case of chronic suppurative otitis media with complications of lateral sinus thrombosis and otitic hydrocephalus and to discuss its clinical manifestations, clinical course, ancillary procedures and management. Methods: Study Design: Case Report Setting: Tertiary Government Training Hospital Patient: One Results: A 35-year-old man was admitted due to intermittent right otorrhea for 20 years and headache for a month. The Glasgow Coma Scale (GCS) score was 12, and mastoidectomy performed on the second hospital day showed cholesteatoma with erosion of the bony covering of the sigmoid sinus with scanty purulent discharge. The GCS improved to 15 few hours post- operatively, however, 24 hours post-operatively, GCS decreased from 15 to 10 and a CT scan showed dilatation of cerebral ventricles and lateral sinus thrombosis which persisted on subsequent imaging studies. His condition deteriorated irreversibly despite a ventriculostomy, and he eventually expired after 3 weeks in the ward. Conclusion: Otitic hydrocephalus due to lateral sinus thrombosis is a serious complication of chronic suppurative otitis media seldom encountered nowadays. In this case, otitic hydrocephalus developed and progressed despite broad spectrum antibiotics, mastoidectomy and a ventricular shunt. This case report underscores the importance of early recognition of warning signs of intracranial complications to institute prompt management.

Management of Acute Complicated Mastoiditis: A Systematic Review and Meta-analysis.

The objective of our study was to evaluate the efficacy of treatment options for the most frequently reported complications of acute mastoiditis in the English literature. PubMed, EMBASE, and The Cochrane Library were searched from database inception through March 29, 2019. Two independent reviewers (M.R.K., K.S.) evaluated search results for study inclusion. References cited in publications meeting inclusion criteria were reviewed. Twenty-three included studies were published from 1998 through 2018. Treatment efficacy was determined by comparing the change in number of complication subtypes in each treatment subgroup (medical, conservative, or surgical) from admission to discharge (range: 5-30 days) or postdischarge follow-up (range: 1-27.5 months) with a random effects model. Among 733 identified articles, 23 met inclusion criteria. Of the 883 included patients, 203 were managed medically (23%), 300 conservatively (34%) and 380 surgically (43%). Conservative patients had more extracranial complications (ECC, P = 0.04) and intratemporal complications (IT, P = 0.04) at follow-up compared with medical patients. Medical patients had more total number of complications (TNC, P = 0.03), ECC (P = 0.02), and IT (P = 0.01) at discharge compared with surgical patients. Conservative patients had more of all complications except intracranial/extracranial abscess and "other" at discharge and follow-up compared with surgical patients. There were larger reductions in TNC, ECC, and IT at discharge and follow-up among surgical patients compared with medical and conservative patients. There were greater reductions in TNC, ECC, IT, intracranial complications, subperiosteal abscess and lateral sinus thrombosis at discharge and follow-up among surgical patients compared with conservative patients.

Incomplete Gradenigo Syndrome in a Patient With Mastoiditis and Lateral Sinus Thrombosis.

Incomplete Gradenigo Syndrome in a Patient With Mastoiditis and Lateral Sinus Thrombosis.

P051 Juvenile Behcet's disease

Abstract Background Behçet's disease is a rare systemic vasculitis in children. The most frequent manifestations are orogenitalaphthosis and uveitis. Neurological, digestive, vascular, joint, and skin involvement are possible. We aimed to describe the clinical, diagnostic criteria, and therapeutic features of pediatric-onset Behcet's disease Methods Study carried out based on files collected over 12 years (2007–2018) concerning patients under the age of 15 hospitalized in the pediatric department of CHU de Blida for Behcet disease Results For 12 years (2007–2018), we hospitalized five children for various reasons and whose diagnosis of Behcet's disease was retained. These are 03 boys (2 of the theme are brothers) and 02 girls. The average age at admission was 13.5 years (12–15 years), and the average duration of follow-up is 4.2 years (15 months-8 years). The mean age of onset of first symptoms was 11 years, and the meantime to diagnosis was 2 years (12 months-3 years) The main diagnostic criteria were: mouth ulcers in five patients (100%), genital ulcers in three patients (60%), ophthalmic manifestations in two patients (40%): one had bilateral uveitis, and the other had papillitis, the pathergy test was positive in 3 patients (60%). The other manifestations were as follows: polyarthralgia in 3 patients (60%), family history in one patient (20%). Neurological manifestations were present in 3 patients (60%): one child presented two episodes of aseptic meningitis and thrombosis deep cerebral venous; one child with diffuse cerebral demyelination lesions, and the third with HIC syndrome and massive lateral sinus thrombosis. Three children have a vascular involvement (60%): pulmonary embolism with thrombosis of the superior vena cava (20%), bilateral thrombosis of the jugular veins (20%), and thrombosis of the right ventricle complicated by pulmonary embolism (20%) Initial symptoms included recurrent aphthous stomatitis (100%), arthralgia (60%), prolonged fever (20%), behavioral disturbances and dysarthria (20%), weight loss (40%), and headache (60 %). The histocompatibility antigen (HLAB 51) was found in 2 children (40%). The treatment included corticosteroids for all patients (3 boluses of 1 g/m2/day of methylprednisolone then relayed by prednisone 1 mg/kg/day), azathioprine 2.5 mg/kg/day in 5 children (100%), and colchicine for 2 patients only one patient had received anticoagulant therapy (LMWH followed by VKA) Relapses were observed in a single patient (20%) and mortality in one patient (20%.) Conclusion Behcet's disease is a rare disease whose diagnosis remains difficult in children. However, early diagnosis and aggressive treatment are mandatory to avoid complications and functional sequelae.

Clinical characteristics of otogenic lateral sinus thrombosis in patients under 18 years old compared with that in adult patients

Background Otogenic lateral sinus thrombosis (OLST) is a rare complication of otitis media. We do not know whether the disease progress between the pediatric and adult OLST patients is consistent. However, pediatric surgical methods always refer to the adults'. Aims/objectives This study aimed to seek evidence for suitable surgical methods in pediatric patients. Materials and methods The clinical manifestation, laboratory findings, and findings in operation between children and adult groups were compared. Results Ten children and 17 adults OLST patients were included. Most pediatric patients had no history of chronic otitis media or cholesteatoma (p<.001). The ratios of otorrhea, tympanic perforation and sclerotic type mastoid in CT scan were significantly lower in the children group (p<.05). The mean air conduction hearing threshold in the children and adolescent group (31.25 ± 21.27 dB) was significantly lower than that of the adult group (77.6 ± 23.66 dB) (p<.001). The diseases in attics (66.7%) and the ossicular chain destruction (33.3%) were not as severe as those in the adult group (p<.05). The eustachian tube closure was found similar in two groups. Conclusions and significance Conservative surgery is recommended to pediatric OLST to obliterate the diseases and improve middle ear and mastoid drainage, preserving hearing function.

Antibacterial effect of Karna Dhoopana Yoga against Staphylococcus aureus in the management of Puti Karna (CSOM)

Pūti Karna is a Chronic Disease caused by vitiated Kapha and Pitta dosha with its characteristic features of profuse thick Pūti (foul odor), pūya (pus) discharge from the ear with or without pain. This entity can be correlated with the disease specified in modern ENT (ear, nose and throat) known as Chronic Suppurative Otitis Media (CSOM). This disease entity in turn leads to severe complications as facial paralysis, lateral sinus thrombosis, labyrinthitis, meningitis and brain abscess. According to the Ayurveda system of medicine Pūti Karna can be effectively managed by a very effective local modality known as a Karna Dhoopana. This study was carried out at the central laboratory of Gampaha Wickramarachchi University of Indigenous Medicine, Sri Lanka, using specially prepared fumigation instrument. This Karna Dhoopna Churna has mentioned in “Hasthasara Aushada Yoga Samgraha“. According to the observation, results of the study confirmed the fumigation for 30 minutes has a bactericidal effect on Staphylococcus aureus in vitro. This could be due to the bactericidal components present in the fumes of dhupana yoga. Further, this study confirmed that duration of Karna Dhoopana is an important factor. Its clinical effectiveness was confirmed without any reported complications after Karna Dhoopana treatment. Further, the study proved that the temperature of the fumes does not produce any side effects in the ear. Therefore, this study endeavored to validate the clinical data scientifically.

A study of aerobic bacteriological profile of chronic suppurative otitis media in a tertiary care hospital, South India

Introduction: In the Otolaryngology Out Patient Department (OPD), Chronic Suppurative Otitis Media (CSOM) is the most common encountered otological disease. Staphylococcus aureus and Pseudomonas species are the most commonly encountered etiological agents. Untreated CSOM leads to complications such as facial nerve paralysis, lateral sinus thrombosis, labyrinthitis, meningitis and brain abscess. Materials and Methods: Patients with CSOM having unilateral or bilateral ear discharge for more than 3 months, attending Otolaryngology OPD or admitted in the wards were included in the study. Two swabs were collected from each patient with sterile precautions and submitted to the Microbiology Department. The samples were subjected to Gram’s stain and culture according to standard operative procedure. Antibiotic susceptibility testing was performed by Kirby-Bauer’s disc diffusion method as per CLSI guidelines. Results: A total of 520 samples were collected, out of which 474 samples showed growth. Staphylococcus aureus was the predominant isolate followed by Pseudomonas species. Staphylococcus isolates were highly sensitive to vancomycin and linezolid. Conclusion: Several studies have showed the predominance of different etiological agents in different geographical regions with different antibiotic sensitivity pattern. So, the knowledge of local etiological agent and its susceptibility pattern helps clinicians in treating the patients and to prevent its complications and drug resistance. Keywords: CSOM, Staphylococcus aureus, Pseudomonas aeruginosa, Antibiotic susceptibility pattern, Aerobic bacteria.

Otitis Media Complicated by Lateral Sinus Thrombosis and Citelli's Abscess.

Catalano, Dominic J.∗; Puccinelli, Cassandra L.∗; Lane, John I.†; Carlson, Matthew L.∗,‡ Author Information

Case Report: Otogenic Lateral Sinus Thrombosis

The availability of effective antibiotic therapy has tremendously reduced the incidence of otogenic lateral sinus thrombosis (OLST) and changed its clinical presentation to a subtle one. The nature of predisposing otogenic disease has also changed from acute otitis media to chronic suppurative otitis media (CSOM). The prevalence of CSOM is still high in low-income economies. With such a high prevalence of CSOM, a good clinical acumen is required to identify and manage OLST. We present a case of chronic suppurative otitis media (CSOM) complicated by OLST.

Ten years incidence of intracranial complications of chronic suppurative otitis media

Background: complications of chronic Suppurative Otitis Media have mortality and morbidity risks which are caused by Reluctance in its management with late presentation. The aim of this study was to investigate, the frequency, mortality and morbidity of intracranial complications of chronic suppurative otitis media admitted at our tertiary University Hospital in ten years from 2006 -2016. Result: The total number of patients reported with intracranial complication due to chronic suppurative otitis media was 64 patients. Brain abscess and Meningitis were present in 24 (37.5%) and 22 cases (34.4%). In 14 cases (21.8%) extradural abscess was found while 4 (6.3%) had lateral sinus thrombosis. Conclusion: Brain abscess is the most common and dangerous complication in chronic suppurative otitis media in our region.

Fusobacterium necrophorum, a major provider of sinus thrombosis in acute mastoiditis: A retrospective multicentre paediatric study.

To evaluate in children the clinical severity and evolution of otogenic lateral sinus thrombosis (OLST) due to Fusobacterium necrophorum compared with other bacterial otogenic thrombosis and propose a specific management flowchart for Fusobacterium OLST. A retrospective multicentre cohort study. Four French ENT paediatric departments. A total of 260 under 18years old admitted for acute mastoiditis were included. Initial imaging was reviewed to focus on complicated mastoiditis and 52 OLST were identified. Children were then divided into two groups according to bacteriological results: 28 in the "OLST Fusobacterium group" and 24 in the "OLST other bacteria group". There was a significant association between Fnecrophorum and OLST (P<.001). When compared to the OLST other bacteria group, children in the OLST Fusobacterium group were significantly younger (61months vs 23months, P<.01) and had a more severe clinical presentation: higher CRP (113mg/L vs175.7mg/L, P=.02) and larger subperiosteal abscess (14mm vs 21mm, P<.01). Medical management was also more intensive in the OLST Fusobacterium group than in the OLST other bacteria group: increased number of conservative surgeries (66.7% vs 92.9%, P=.03) and longer hospital stay (13.7days vs 19.8days, P=.02). At the end of follow-up, the clinical course was good in both groups without any neurological sequelae. Thrombotic complications are very frequent in case of Fusobacterium mastoiditis and clinicians should be aware of the initial severity of the clinical presentation. Under appropriate management, the clinical course of Fusobacterium OLST is as good as that of other bacterial otogenic thrombosis.

Lateral Sinus Thrombosis as a Complication of Acute Otitis Media, Clinical Case Report in Bogotá, Colombia

Vascular surgery was consulted who recommended removal of the extruding filament within the nasopharynx using an endoscopic approach to reduce the potential communication with the internal vasculature. Open removal of the foreign body was reserved as a last resort given the potential significant morbidity associated with such surgery. The patient was taken to the OR. Under general anesthesia he was prepared for sinonasal surgery. Under direct visualization with a nasal endoscope, endoscopic scissors were used to amputate the filament at the mucosal junction. Post operatively, the patient recovered without complications. Post-operative CT and angiography was ordered but never completed. On follow up examinations up to 9 months, there had been no further recurrence of symptoms, extrusion, or complications.