Ear, Nose & Throat Journal2023, Vol. 102(8) 527 –529© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/01455613211015752journals.sagepub.com/home/ear
Significance StatementSigmoid sinus thrombosis (SST) is a potentially life-threatening complication of otitis media which is nowadays rare due to the widespread use of antibiotics. A high index of suspicion is necessary to allow for a timely diagnostic and therapeutic intervention. Intravenous wide-spectrum antibiotics and a cortical mastoidectomy are the mainstay of treatment. There is no consensus regarding the necessity of anticoagulants in pediatric patients. We present a 6-year-old boy who presented with an SST as a result of acute otitis media.
A 6-year-old male presented with his mother to our emergency ear, nose, and throat clinic, with persistent discomfort in his right ear. The child was diagnosed with acute otitis media 10 days prior to admission and received a 7-day course of oral amoxicillin with clavulanate without much improvement. Medical history was otherwise normal. The child appeared unwell but he was hemodynamically normal and apyrexial. Otomicroscopy revealed a dull tympanic membrane. The Weber tuning fork test lateralized to the right ear while the ipsilateral Rinne was negative. Pure tone audiometry showed conductive hearing loss on the right side.
Laboratory tests showed an increased white cell count (17.60 K/mL) with neutrophilia (87%) and platelet count equal to 565 k/mL. A computed tomography (CT) scan was performed to evaluate the extent of the inflammation. Complete opacification of the right middle ear cavity and mastoid air cells without coalescence were noted. A high riding jugular bulb was shown on the right side (Figure 1).
Due to the persistence of middle ear inflammation and the suspicion of acute mastoiditis, intravenous ceftazidime 1 grams twice a day, nasal decongestants and analgesics were administered. The child did not show significant improvement after 2 days of conservative treatment, and a grommet was inserted on the right side under general anesthesia. A small quantity of clear fluid was drained from middle ear and subsequent culture did not reveal any pathogen. Lack of clinical improvement led us to suspect an intracranial complication, and therefore we requested an urgent magnetic resonance imaging (MRI) including a magnetic resonance venography (MRV). Post-contrast MRI showed right sigmoid sinus enhancement with a central filling defect while the MRV confirmed the occlusion of the right sigmoid sinus. Findings were consistent with right SST due to acute mastoiditis (Figures 2 and 3). An urgent right cortical mastoidectomy was performed. The mastoid process was filled with granulation tissue and purulent material was released upon skeletonization of the sigmoid sinus. Material was sent for culture. Puncture of the sigmoid sinus did not produce any pus. Pediatric neurologists were contacted and the child received enoxaparin. The child recovered and was discharged on day 21 after admission. He underwent repeat MRI and MRV scans at 1 and 6 months post treatment which did not reveal recurrence of infection. The right sigmoid sinus was fully patent.
Sigmoid sinus thrombosis is a rare but serious complication of otitis media and can present along with other intracranial complications such as subdural or a cerebral abscess.1 Sigmoid sinus thrombosis is the result of inflammation spread from the middle ear to the corresponding sigmoid sinus through small emissary veins or through a bone dehiscence of the mastoid process.2
Radiological signs suggestive of SST are opacification of mastoid air cells with a positive delta sign. Bone erosion at the mastoid tegmen adjacent to the sigmoid sinus may be present. The delta sign consists of a triangular area of contrast enhancement that surrounds a hypoattenuating area in the sigmoid sinus which represents the thrombus.1,3 Magnetic resonance imaging is more sensitive in the detection of SST and has been proposed as the gold standard imaging modality especially in young patients.4 Combination with MRV offers the best chances of confirming flow disruption in the sinus and mastoid disease.5
Appropriate management aims at minimizing inflammation in the mastoid and middle ear cavity and restoring the venous flow. The treatment of choice depends on the severity of the disease ranging from ventilation tube placement to a complete cortical mastoidectomy or even a canal wall down procedure. There is no evidence to support the evacuation of the clot by opening the sigmoid sinus wall (early recovery and increased rate of recanalization).2,6 The use of intravenous antibiotics can’t be overemphasized. Culture of mastoid material will adjust initial empiric administration of wide-spectrum antibiotics. Anticoagulation therapy is considered safe and merits strong consideration in pediatric population with SST, especially in the absence of intracranial hemorrhage. This could prevent venous infarction, embolization, and persistent septic thrombophlebitis in untreated patients.7,8
We declare that written informed consent for patient information and images to be published was provided by the patient.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Nikolaos Tsetsos https://orcid.org/0000-0003-1884-6824
1 Department of Otorhinolaryngology–Head and Neck Surgery, “G. Papanikolaou” General Hospital, Thessaloniki, Greece
2 Second Department of Paediatrics, School of Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
Received: March 20, 2021; revised: April 13, 2021; accepted: April 19, 2021
Corresponding Author:Nikolaos Tsetsos, MD, MSc, Department of Otorhinolaryngology–Head and Neck Surgery, “G. Papanikolaou” General Hospital, Thessaloniki, Greece.Email: tsetsosnikos@yahoo.gr
