1. Lateral Sinus Thrombosis
A Complication of CSOM

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. Anatomy
• Formed by the confluence of the superior
petrosal and transverse sinuses
• Becomes internal jugular vein at its exit from
foramen jugulare

6. 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

9. 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

11. Presentation
• Varies according to stage

14. 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

15. 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

16. 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

17. 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

18. 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

20. 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`

21. 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

23. Bacteriology
• Acute
– Hemolytic stretpococci
– Pneumococci
– Staphylococci
• Chronic
– Bacillus Proteus
– Pseudomonas Pyocyaneus
– E.coli
– Bacteroides
– Staphylococci

24. Labs
• Polys on CBC
• CSF examination ICP only
• C/S of ear swab
• C/S of pus material from sinus if available

25. 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

26. Treatment
• Medical + Surgical  Combo
• Medical
– I/V antibiotics
– Anti coagulants only if clot in superior sagittal
sinus or ICP persists despite medical
management

27. 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

28. Follow up
• Post op antibiotics for 2-3 weeks
• Post op MRI & MRV

29. Complications
• Mostly ipsilateral
• At times contralateral due to hematogenous
spread

30. Prognosis
• Mortality has decreased to less than 10% due
to availability of effective medical and surgical
treatment

34. 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