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Lateral sinus thrombosis


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Lateral sinus thrombosis

  1. 1. Lateral Sinus Thrombosis A Complication of CSOM
  2. 2. Overview • 6% of all Intracranial complications of CSOM • In CSOM direcrt spread through bone erosion and thrombophlebitic spread through emissary veins • In ASOM spread is mainly through emissary veins
  3. 3. Anatomy • Formed by the confluence of the superior petrosal and transverse sinuses • Becomes internal jugular vein at its exit from foramen jugulare
  4. 4. Spread • Directly through bone erosion due to granulation and cholesteatoma • Thrombophlebitis of the mastoid emissary veins – Griesinger’s Sign – Erythema, edema and tenderness over mastoid area
  5. 5. Pathophysiology • Perisinus abscess  penetrates dura  reaches intima  mural thrombus forms due to intimal damage, hypercoagulation and blood flow in sinus • Bacteria & thrombus  platelet aggregtion  fibrin formation  mural clot  necrosis of clot  intramural abscess • Clot propagates  occlusion of vessel lumen & infected emboli given off in circulation  metastatic abscesses  septicemia
  6. 6. Presentation • Varies according to stage
  7. 7. Presentation Contd. • Despite antibiotics may present as – Fever with periodic chills – Picket fence due to periodic release of steptococci in blood from septic thrombus – Headache – Due to raised ICP caused by interrupted cortical venous circulation  Papilledema – Otorrhoea – Refractory to antibiotic therapy – Neck Pain – Extension of thrombophlebitis to jugular bulb and internal jugular vein  IJV palpated as a tender cord in neck
  8. 8. Presentation Cont. – Neck rigidity – Due to meningeal irritation. Torticollis may also be seen due to guarding of the neck muscles – Nausea, vomiting – Due to raised ICP and bacteremia – Altered mental state and focal neurologic signs – If brain abscess – Vertigo and nystagmus – Involvement of labyrinth – Seizures – Temporal lobe involvement – Lethargy
  9. 9. Presentation Cont. • Jugular Foramen Syndrome-Vernet’s Syndrome - Dysphonia/hoarseness - Soft palate dropping - deviation of the uvula towards the normal side - dysphagia - loss of sensory function from the posterior 1/3 of the tongue - decrease in the parotid gland secretion - loss of gag reflex - Sternocleidomastoid and trapezius muscles paresis
  10. 10. Presentation Cont. • Jugular Foramen Syndrome-Vernet’s Syndrome – 9th , 10th & 11th and sometimes 12th nerve paralysis due to pressure of clot in jugular bulb – Symptoms » pain in or behind ear due to irritation of the auricular branches of the 9th and 10th nerves » headache due to irritation of the meningeal branch of vagus » hoarseness due to paralysis of the laryngeal nerves » dysphagia (diffiuclty to swallow) due to paralysis of the pharyngomotor fibres » honers syndrome ( ptosis of upper eyelid, pupillary constriction) due to interruption of sympathetic internal caortid plexus » wasting of affected side of tongue and deviation of the protruded tongue to the affected side due to infranuclear paralysis of 12th nerve
  11. 11. Presentation Cont. » deviation of the uvula away form the affected side due to unopposed action of levator palatini » sensory loss in oroharynx on the affected side » inabllity to adduct the vocal cords to the midline » weakness and wasting of sternocleidomastoid and treapezius due to involvement of 11th nerve sympathetic signs may be absent if accessory nerve unaffected – Recovery depends on collateral circulation and recanalization of the sinus – Surgical intervention not required usually – Decompression and removal of clot if necessary
  12. 12. Presentation Cont. • Otitic Hydrocephalus – Due to interrupted cortical venous circulation obstruction in CSF flow leads to ventricular dilatation – One or both lateral sinuses may be found thrombosed – S&S of raised ICP`
  13. 13. Clinical Examination • Anaemia & emaciation • Griesingers’s sign • Positive Tobey – Ayer’s Test • Positive Crow – Beck’s Test • Tenderness along IJV • Enlarged jugular nodes • Torticollis • Positive Kernig’s Sign • Positive Brudzinski’s Sign
  14. 14. Bacteriology • Acute – Hemolytic stretpococci – Pneumococci – Staphylococci • Chronic – Bacillus Proteus – Pseudomonas Pyocyaneus – E.coli – Bacteroides – Staphylococci
  15. 15. Labs • Polys on CBC • CSF examination ICP only • C/S of ear swab • C/S of pus material from sinus if available
  16. 16. Imaging • CT with contrast  Delta Sign • Gadolinium enhanced MRI  Delta Sign – MRI is the investigation of choice & is done in combination with CT • Serial MRV in combination with MRI to see clot propagation and resolution
  17. 17. Treatment • Medical + Surgical  Combo • Medical – I/V antibiotics – Anti coagulants only if clot in superior sagittal sinus or ICP persists despite medical management
  18. 18. Treatment Contd. • Surgical • Mastoidectomy + removal of clot from sinus – ASOM – Cortical + removal of sinus plate – CSOM + Cholesteatoma – Radical – Refractory Septicemia – IJV ligation to stop emboli being thrown into circulation
  19. 19. Follow up • Post op antibiotics for 2-3 weeks • Post op MRI & MRV
  20. 20. Complications • Mostly ipsilateral • At times contralateral due to hematogenous spread
  21. 21. Prognosis • Mortality has decreased to less than 10% due to availability of effective medical and surgical treatment
  22. 22. Name No. Drains to / Becomes Inferior Sagittal Sinus 1 Straight sinus Superior Sagittal Sinus 1 Becomes right transverse sinus or confluence of sinuses Straight Sinus 1 Becomes left transverse sinus or confluence of sinuses Occipital Sinus 1 Confluence of sinuses Confluence Of Sinuses 1 Right and left transverse sinuses Sphenoparietal Sinuses 2 Cavernous sinuses Intercavernous Sinuses 2 Cavernous sinuses Cavernous Sinuses 2 Superior and inferior petrosal sinuses Superior & Inferior Petrosal Sinuses 2/2 Transverse sinuses Transverse Sinuses 2 Sigmoid sinusees Sigmoid Sinuses 2 Jugular bulb  IJV