Managements for lateral sinus thrombosis: does it need the ligation of internal jugular vein or...

Eur Arch Otorhinolaryngol (2009) 266:51–58
DOI 10.1007/s00405-008-0724-7
OTOLOGY

Managements for lateral sinus thrombosis: does it need the ligation of internal jugular vein or anticoagulants?

Jun Ho Lee · Seong Jun Choi · Keehyun Park · Yun-Hoon Choung

Received: 10 March 2008 / Accepted: 21 May 2008 / Published online: 6 June 2008© Springer-Verlag 2008

Abstract The purposes of this study were to review theclinical characteristics and treatment outcomes of patientswith lateral sinus thrombosis (LST) and to discuss the needof internal jugular vein (IJV) ligation or anticoagulants. Weretrospectively reviewed the charts of Wve patients (1 maleand 4 female) with LST. The chief complaints were otalgia,fever, mastoid tenderness, and neck pain. All patients wereconWrmatively diagnosed with MRI-Venography or Angio-CTscans. The patients were treated with appropriate antibioticsand operations including mastoidectomies with/withoutthrombectomy according to their suspected disease course.The authors did not perform IJV ligation and use anticoagu-lants in all cases, but there were no mortalities or morbidities.IJV ligation and use of anticoagulants do not seem to beessential procedures for the management of LST, and itshould be considered carefully according to the extents ofdisease and the state of patients.

Keywords Lateral sinus thrombosis · Internal jugular vein · Anticoagulants · Management · Otitis media · Cholesteatoma

Introduction

Intracranial complications of suppurative ear diseasesare rarely seen today [1, 2]. Lateral sinus thrombosis(LST) is a well-known otogenic complication with seri-ous consequences if left untreated [1]. LST was consid-ered as a frequent complication of middle ear infectionat the start of the twentieth century and mortalityreached 100% in untreated cases [3]. The incidence ofLST has sharply declined since the advent of antibiotics;nevertheless, the mortality still reaches to more than10% [4].

Although it is obvious that LST requires prompt mas-toid surgeries with antibiotics for deWnitive manage-ment, the ligation of internal jugular vein (IJV) is still acontroversial issue in the management of LST [5–7]. IJVligation may possibly isolate the cause of infection andprevent embolization, thus increasing the cure rates ofLST [6]. However, IJV ligation may not eliminate septiccomplications due to collateral veins, and maypredispose to retrograde-intracranial septic complica-tions and add surgical risks of additional cervical dissec-tions [3, 4]. Recently, several studies showed thepossibility of conservative managements with limitedindications for the IJV ligation [4, 5, 7, 8]. The use ofanticoagulants is another controversial issue for LST [6,7, 9]. Anticoagulants have been used for the lysis andprevention of thromi in LST, but recently some doctorsinsist that anticoagulants could make the conditionworsen because of systemic spreading of septic emboli[5, 6]. The purpose of this study was to review the clini-cal characteristics and treatment outcomes of patientswith LST and discuss the need of IJV ligation and anti-coagulants.

J. H. LeeDepartment of Otorhinolaryngology, Head and Neck Surgery, College of Medicine, Hallym University, Chunchon, South Korea

S. J. Choi · K. Park · Y.-H. Choung (&)Department of Otolaryngology, Ajou University School of Medicine, San 5, Wonchon-dong, Yeongtong-gu, Suwon 443-721, Republic of Koreae-mail: [email protected]

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52 Eur Arch Otorhinolaryngol (2009) 266:51–58

Materials and methods

The medical records of all cases with a discharge diagnosisof LST at Ajou University Hospital and Chunchon SacredHeart Hospital from September 2003 to December 2005were reviewed retrospectively. All Wve cases were surgicallyand radiologically proven as LST. The data collected fromthe case notes included the demographic details, of patient’spresenting symptoms and signs, radiologic Wndings, bacte-riologic results, treatments, complications, duration ofpre-admission illness, and outcomes. The Institutional ReviewBoards of the Ajou University School of Medicine (Suwon,Korea) approved the study.

Results

Clinical features of patients with LST (Table 1)

One of the patients was male and four were female. The ageof the patients ranged from 8 to 65 years with a mean of37 years. The chief complaints were otalgia, fever, mastoiderythema and tenderness, neck pain during cervical rota-tion, and torticolis. Three patients had histories of chronicotitis media (COM) with purulent discharge, and allpatients had received antibiotic treatments at primary careclinics. The average duration of the pre-admission illnesswas about 1 month.

All patients presented with otalgia, hearing impairment,dizziness, headache, and physically palpable cords of IJV. Inmyringoscopic Wndings, one patient had a bulging drum(case 1), two patients (case 2 and 4) had severe keratin debris(Fig. 1a) packed in their involved external auditory canals(EACs), suggesting cholesteatomas, and one patient (case 3)had an aural polyp bulging (Fig. 2a) from the posterior wallof EAC. In case 5, the patient had a retraction pocket on theposterosuperior quadrant of the drum without perforations.Three patients (case 1, 2, and 3) showed typical picket-fencepatterned fever and two patients (case 4 and 5) had past feverhistories, but without presenting fever. Three patients (case 2,3, and 5) complained pain on the neck in the involved sides.Tenderness on the mastoid areas in the involved sides wasdetected in three patients (case 1, 2, and 3). In cases 2 and 3,patients presented positive Wndings for Toby–Ayer–Quec-kenstedt test and Greisinger’s sign. Especially, the patient ofcase 3 also showed papilledema in the involved side. Theauthors got the impression that LST originated fromcholesteatomas in four patients (case 2, 3, 4, and 5) andacute otitis media in one patient (case 1). Table 1 shows theclinical characteristics of these Wve patients.

Radiologic Wndings of the patients with LST (Table 2)

Computerized tomography (CT) scans of the temporalbone and magnetic resonance image (MRI) of the brainwere performed and showed pathologic Wndings in

Table 1 Clinical characteristics of Wve patients with lateral sinus thrombosis

Case 1 Case 2 Case 3 Case 4 Case 5

Age (years) 8 35 37 65 49

Sex Female Male Female Female Female

Chief complaints Tender mastoid Otalgia Fever Tender mastoid Painful neck

Sites Left Left Left Right Left

Duration of symptoms 1 day 3 weeks 4 weeks 6 weeks 5 weeks

Otalgia ++ ++ + + +

Otorrhea – + + + –

Hearing impairment (PTA) (25/15)a (60/50)a (deaf) (60/40)a (80/60)a

Headache + + + + +

Dizziness + + + + +

Fever + + ++ (+)1 (+)1

Painful neck – + + – ++

Tender mastoid ++ + – ++ –

Palpable cord of IJV – + + + +

Toby–Ayer–Queckenstedt test – + + – –

Papilledema – – + – –

Greisinger’s sign – + + – –

Cranial nerve palsy – – – – –

COM history – + + + –

Cholesteatoma – + + + +

PTA pure tone average, aair conduction threshold/air-bone gap), (+)1 did not present fever at the present time, but had past fever history, IJV internal jugular vein, COM chronic otitis media

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Eur Arch Otorhinolaryngol (2009) 266:51–58 53

Fig. 1 Imaging and operative Wndings in case 2. a The left auditary canal was packed with cholesteatoma debris (arrow). b Infected thrombi were almost removed until organized thrombi (arrow) were seen in the opera-tion. c Temporal bone CT shows the huge eroded lesion (arrow) including a sinus wall. d T1 weighted enhanced MR shows a thrombus (arrow) with rim enhancement in left lateral sinus. e Coronal view of MR venography shows Wlling defects (arrow) in left lateral sinus and internal jugular vein due to thrombosis

Fig. 2 Imaging and operative Wndings in case 3. a Aural polyps(arrow) were detected in the posterior wall of external auditory canal.b Evacuation of thrombi was not done because organized thrombi(arrow) were detected in the sinus. c Temporal bone CT shows a

mastoid lesion with low density. d T1 weighted enhanced MR shows athrombus with rim enhancement in left lateral sinus. e Angio-CT scanshows Wlling defects (arrow) in left lateral sinus due to thrombosis

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mastoid cavities and temporal bones of all patients’(Table 2). Thromboses were diagnosed by rim enhance-ment and Wlling defect of the involved lateral sinus in allT1 weighted enhanced brain MRI scans (Figs. 1d, 2d,3b, d). Angio-CT scan was performed in case 3 (Fig. 2e)and MR-venographies were in other four patients, andall patients presented occlusion signs of involved lateralsinuses (Figs. 1e, 3c, f).

Concomitant complications with LST

All Wve patients did not suVer concomitant complicationssuch as intracranial infections or septic systemic thrombo-sis. A lumber puncture was performed on only one patient(case 3) with meningeal signs and papilledema, butrevealed no evidence of bacterial meningitis. Case 2 patientcontinuously presented the spiking fever even after open

Table 2 Radiologic Wndings of Wve patients with lateral sinus thrombosis

EAC external auditory canal, LS lateral sinus, Lt left, Rt right, IJV internal jugular vein


Tempral bone CT Mastoiditis Partially automastoidectomy

Mastoiditis EAC swelling

Partially automastoidectomy

Mastoiditis

Brain MRI Thrombosis in Lt LS Thrombosis in Lt LS Thrombosis in Lt LS Thrombosis in Rt LS Thrombosis in Lt LS

MR-venography Occlusion of Lt LS Occlusion of Lt LS, IJV – Occlusion of Rt LS Occlusion of Lt LS

Angio-CT – – Occlusion of Lt LS – –

Fig. 3 Radiologic Wndings in case 4 (a, b, c) and 5 (d, e, f). Temporalbone CTs show destructive change and automastoidectomy status inright mastoid cavity in case 4 (a) but a relatively less destructive lesionin case 5 (d). T1 weighted enhanced MRs show enhanced thrombi

(arrows in b and e) in lateral sinuses. Coronal view of MR-venographiesshow Wlling defects (arrows in c and f) in lateral sinuses and internaljugular veins due to thrombosis

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cavitiy mastoidectomy and the removal of septic thrombiand postoperative chest X-ray which showed doubtablemild septic pneumonia. However, all the symptoms disap-peared within 5 days with broad antibiotics.

Bacteriology of LST (Table 3)

Cultures were taken from the middle ear of all patients andthere was growth of Staphylococcus in three cases, but notin other two cases. In cases 2 and 3, Proteus mirabilis andmethycillin-resistant coagulase-negative Staphylococcus(MR-CNS) were detected from otorrhea. In case 4, methy-cillin-resistant coagulase-negative Staphylococcus aureus(MRSA) as well as MR-CNS were detected (Table 3).

Treatments for LST (Table 3)

All patients received combination therapies of antibioticsand surgeries. Four patients received the same multiple par-enteral antibiotic regimen including ceftriaxone, amikacin,and clindamycin except one patient (case 1). However, cef-triaxone was changed to vancomycin in case 2 and case 4for coverage of methycillin resistancy. These medicationswere continued at least for 2–4 weeks, and anticoagulantswere not administered in any patients (Table 3).

All Wve patients underwent the surgeries, including mas-toidectomies and exploration of the lateral sinuses undergeneral anesthesia within 4 days after starting antibiotics.Mastoid surgery was modiWed on each patient, dependingon the suspected disease course such as Bondy operation orradical mastoidectomy. First, we removed all pathologiesincluding cholesteatomas and/or granulation tissues in mid-dle ear clefts and/or mastoid cavities, and then we skeleton-ized the sinus wall and aspirated the sinus with a syringe. Ifthere were no blood return in the syringe, we incised the

sinus and removed the abscess, granulation tissues, andinfected thrombi. In case 2, we opened the sinus wall andremoved almost all infected thrombi until organizedthrombi were seen (Fig. 1b). However, in case 3, weopened the sinus wall and just identiWed already organizedthrombi (Fig. 2b). Evacuation of thrombus was not done,and the sinus was recovered and reconstructed with Gel-foam (Medtronic Xomed, Jacksonville, Florida), Surgicel(Johnson–Johnson Gateway, Piscataway, New Jersey), andPalva Xap. In cases 1, 4, and 5, the sinuses were not openedafter conWrmation of blood Xow by a needle aspiration. Wedid not perform the ligation of IJV in all cases. There wereno mortality and morbidity in any of the patients (Table 3).

Postoperative complications and outcomes

None of the Wve patients suVered from postoperative com-plications, and there was no death among our patients. Thepatients in our series were hospitalized for 14–28 days(mean 18.6 days). All patients were followed-up for 23–28 months (mean 25.2 months) without follow-up loss orsuVering from chronic suppurative otitis media. Therefore,there were no additional surgeries. One patient (case 3)suVered from simple vertiginous symptoms without nystag-mus at 2 months after surgery, however, quickly recoveredonly after symptomatic treatments.

Discussion

LST may be a consequence of acute mastoiditis or achronic infective process in tympanomastoid areas [10].Thrombosis of the lateral sinus usually starts with mastoidbone erosion caused by cholesteatomas, granulation tissues,or coalescence, causing the formation of a perisinus abscess

Table 3 Bacteriology and treatments of Wve patients with lateral sinus thrombosis

PM Proteus mirabilis, MR methycilline resistant, SA Staphylococcus aureus, CNS coagulase-negative Staphylococcus, Tx treatment, IV intravenous, OCM open cavity mastoidectomy, LS lateral sinus, IJV internal jugular vein


Bacteriology – PM MR CNS PM MR CNS MR SA MR CNS –

Medical Tx 12 days 28 days 15 days 22 days 14 days

IV Antibiotics (1) Ceftriaxon (2) Netilmicin (3) Metronidazole

(1) Amikacin (2) Clindamycin (3) Ceftriaxon !

Vancomycin

(1) Amikacin (2) Clindamycin (3) Ceftriaxon

(1) Amikacin (2) Clindamycin (3) Ceftriaxon!

Vancomycin

(1) Amikacin (2) Clindamycin (3) Ceftriaxon

Anticoagulants – – – – –

Surgical Tx Simple mastoidectomy OCM ossiculoplasty Radical mastoidectomy Bondy operation OCM ossiculoplasty

Lateral sinus management

Needling!return of blood

Evacuation of thrombi Open LS and leave organized thrombi



IJV ligation – – – – –

Complication – – – – –

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[11], and these growing tissues and abscess exert pressureon the dural-outer wall of the sinus and the intima, therebycausing the adherence of Wbrin, blood cells and platelets,and resulting in the formation of a mural thrombus. Themural thrombus becomes infected and propagates to forman obliterating thrombus, occluding the lumen of the sinus.Fresh thrombus formed may propagate proximally to theIJV or distally to other dural sinuses through the mastoidemissary vein to the subcutis. Except for direct spread, LSTmay also be caused by osteothrombophlebitis in earlyAOM, in which case the bony sinus plate will be intact atthe time of surgical exploration [11, 12]. In the presentstudy, four cases were all adults and from cholesteatomas,but one case was from AOM in child. The surgical Wndingsshowed that all cholesteatomas and infected granulation tis-sues were tightly packed in mastoid cavities so that theypushed out and eroded the surrounding structures includingbones and lateral sinus. They should have needed promptsurgical handlings to drain out high pressure and to removeinfected sources. Actually, all patients underwent surgerieswithin 4 days after starting antibiotics. The advent anddevelopment of antibiotics immensely reduced the inci-dence of LST, especially from AOM in children and COMin adults [3, 4]. Nevertheless, as in our cases, the risk forLST seems to still remain whenever chronic mastoid infec-tions in adults are related with prolonged cholesteatomas orAOMs in children abruptly aggravate [6, 12].

Fever is a common manifestation of LST, however, thetypical spiking or picket-fence fever curve caused byescape of �-hemolytic Streptoccocus into the circulationhas been seen rarely today [7]. Other frequent presentingsymptoms are headache, otalgia, otorrhoea, nausea andvomiting, and common signs are posterior auricular swell-ing and tenderness, painful neck, papilloedema, and abdu-cens nerve palsy [7, 13]. Sometimes, the tenderness of neckor mastoid, positive Wndings of Toby–Ayer–Queckenstedttest and Greisinger’s sign can also be found [11, 13]. Allour patients presented symptoms and signs compatible toLST. However, only three of our patients showed the spik-ing fever, and two patients did not present fever at visitingthe hospital. These two patients had fever histories and hadbeen taking antibiotics for long time before visiting the hos-pital. Consequently, fever seemed to be decreased ormasked. We have to consider LST even though active feveris not found in the patients who show the symptoms ofLST.

Imaging studies have been considered the diagnosticaids for LST, and deWnitive diagnosis can be made at sur-gery. However, the recent development of imaging tech-niques and experiences enable clinicians to have relativelyprecise view of LST before surgeries [5, 6]. Angiographyand venography are said to be the most deWnitive methodsof demonstrating LST, however, they may be too invasive

procedures to cause stroke or dislodging the thrombus [14,15]. CT scan is useful in demonstrating the classic ‘deltasign’ of perisinus dural enhancement and Wlling defect ofthe lateral sinus [14, 15], and MR imaging is more deWni-tive in conWrming thrombus, because it may show increasedsignal intensity of the thrombus in T1 and T2 images [15,16]. The dura is enhanced with gadolinium, similar to the‘delta sign’ on CT [15, 16]. MR angiography, especiallyvenography, can now be used as a diagnostic method; per-formed rapidly, free of bone-related artifacts, does not useionizing radiation, and is noninvasive [16]. In the presentstudy, CT scan of the temporal bone and MRI of the brainwere performed on all patients and showed pathologic Wnd-ings in all patient’s mastoid cavities and rim enhancementsand Wlling defects of the lateral sinuses in all T1 weightedenhanced MRI scans. All patients were conWrmativelydiagnosed as LST through MR-venographies or Angio-CTscans.

Recently, bacteriology of LST has shifted from �-hemo-lytic Streptococcus to mixed Xora. Seid and Sellars [17]reported Proteus and Pseudomonas as the most commonspecies in LST. This change in bacteriology is thought to bedue to the fact that the disease more commonly proceeds bychronic rather than acute ear infection [17]. Another recentstudy found negative clots and blood cultures which wereprobably due to prior antibiotic treatment [18]. In ourpatients, P. mirabilis and MR-CNS were cultured from twopatients (case 2 and 3), while MRSA and MR-CNS werefrom one patient (case 4). However, the patient with shorthistory of symptoms (case 1) and the patient with pro-longed use of antibiotics (case 5) showed negative culturesof bacteria.

The managements of LTS include the combination ther-apy of appropriate antibiotics and surgeries. A mastoidec-tomy with a removal of the infected clot and thrombus inthe lateral sinus is considered as the standard surgical care[5, 6, 11]. Even though an appropriate management of thethrombus in the sinus is not certain, most authors proposeneedling of the lateral sinus before incision in order to con-Wrm diagnosis [11, 19]. On the other hand, if free blood isaspirated, then no further intervention is required. If there isno return of blood, we can conWrm the diagnosis with inci-sion on the sinus and evacuation of the clots [5–7, 11], andit is not necessary to obtain free bleeding from the sinus[13]. In the present study, we performed needle aspirationof the lateral sinuses in all patients. After no return of bloodin two patients, one patient (case 2) underwent an evacua-tion of thrombi, while the organized thrombi in the otherpatient were left untouched (case 3). We think that theorganized thrombus is an initial step for spontaneous reso-lution, Wnally inducing recanalizaiton of a sinus.

Two controversial issues in the management of LST havebeen discussed in the literatures, the use of anticoagulants

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and ligation of IJV [6, 7]. The use of anticoagulants is not apart of standard care of patients with LST and was morecommon prior to the advent of antibiotics [6, 7]. Their usehas been reserved by some authors for cases in which thethrombus spreads proximally to the IJV or retrogradely tothe more distal intracranial sinuses or non-otogenic LST[6–8, 19]. Anticoagulants may encourage the release ofseptic emboli or cause hemorrhage into the mastoid cavity[6, 7]. We did not use anticoagulants in all cases withoutleaving any complications. We think that LST originatedfrom cholestatomatous otitis media like these four casesseems not to require anticoagulants if they are appropriatelytreated with surgical resection of cholesteatomas andinfected thrombi as the origin of LST. As in the case 3,even organized thrombi in lateral sinus did not also causeany problems after surgical treatment for cholesteatomaand antibiotic management. We consider that there could bemore possibility of using anticoagulants in the cases of LSTin children rather than in adults. Because LST in childrenusually arise from acute middle ear infection and then canbe more easily disseminated beyond a localized are. Ifsymptoms are not improved or the propagation of thrombiis documented on followed-up imaging studies even thoughappropriate surgeries and antibiotics, we may have to useanticoagulants.

Historically, the most common complication of LST wasseptic emboli with involvement of hip, ankle, knee, andshoulder joint [3]. In the pre-antibiotic era, the ligation ofIJV was performed commonly to prevent septic emboli [3,7]. However, as reviewed by Teichgraeber et al. [7], there isstill no consensus concerning the role of IJV ligation forLST. IJV ligation was believed to isolate the cause of infec-tion preventing embolization and not worsen cure rates ofLST [3, 6]. Although IJV ligation may not eliminate septiccomplication due to collateral veins, it may predispose toretrograde-intracranial septic complications and may addsurgical risks of the additional cervical dissection [3, 5].Therefore, the routine use of this procedure has not beenrecommended since the introduction of antibiotics hasmade the complication of septic emboli rare [3, 5, 8].Today, IJV ligation tends to be indicated only for speciWcreasons, when there is persisting septicemia or pulmonarycomplications despite initial treatments with a surgery andantibiotics [5–7, 20]. In the present study, we removedinfected thrombi until looking at the relatively healthyorganized thrombi. We left these organized thrombi in thesinus and did not perform IJV ligation in all Wve cases, nev-ertheless, there was no mortality and morbidity in any ofour patients. Therefore, the ligation of IJV can be consid-ered, we think, only in the cases that show infected thrombiacross the lateral sinus without any organized thrombi inthe mastoid area under exploration of lateral sinus. We do not

recommend routine use of IJV ligation for the managementsof LST.

Conclusion

We have described a series of Wve patients with LST, a con-dition seldom reported in recent years in the developedworld. Although LST is a disease with high mortality, it canbe treated with appropriate antibiotics and early operation,not leaving complications. IJV ligation and anticoagulantsdo not seem to be essential procedures for the managementsof LST, and they should be carefully considered onlyaccording to the extents of disease and states of patients.

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