Sigmoid sinus thrombosis with contralateral abducens palsy: First report of a case. (Original Article).

Abstract

Intracranial complications of acute and chronic otitis media can be difficult to recognize because the signs and symptoms are often subtle. This article describes a case of one such complication--sigmoid sinus thrombosis--that was manifested by a contralateral abducens palsy. The author believes that this is the first reported case of such an occurrence. This article also reviews the differential diagnosis of increased intracranial pressure and discusses the recognition and management of lateral sinus thrombosis.

Introduction

Intracranial complications of acute and chronic otitis media can manifest as clinically subtle signs and symptoms. A high index of suspicion followed by radiographic examination and appropriate surgical intervention can help reduce the morbidity caused by these complications. This article describes the case of a patient who experienced sigmoid sinus thrombosis as a complication of otitis media.

Case report

A white 4-year-old boy came to our emergency room with a 2-day history of low-grade fever, vomiting, and double vision. He had otitis media on the right and had been taking oral trimethoprim/sulfamethoxazole, which had been prescribed by his pediatrician 1 week earlier. His medical history was significant for a previous episode of acute right-sided otitis media when he was 2 years old; this earlier episode had resulted in streptococcal meningitis and right anacusis. With the exception of the anacusis, his recovery had been complete, and he had done well. He also had a history of a urticarial rash secondary to penicillin administration. A review of systems and his family history were unremarkable.

Physical examination revealed that the boy was well developed and in no distress. His temperature was 99.5[degrees] F. Neurologic examination detected a complete left abducens palsy and decreased hearing on the right; all other cranial nerves were normal. His mental status was normal, and he had no meningism. Binocular microscopy revealed a right serous otitis with mild myringosclerosis. His left ear was normal. He had no mastoid tenderness and no evidence of a subperiosteal abscess. Tuning-fork testing included a Weber's test, which lateralized to the left ear at 512 Hz. The remainder of the physical examination was normal. An audiogram revealed anacusis on the right and normal hearing on the left (figure 1).

A right tympanostomy with tube placement was performed in the emergency room under local anesthesia with topical lidocaine/prilocaine cream. The patient was admitted, and broad-spectrum intravenous antibiotics were administered. Computed tomography (CT) of the temporal bones was remarkable for opacification of the right mastoid and middle ear (figure 2). Contrast-enhanced magnetic resonance imaging (MRI) of the head revealed a right sigmoid sinus thrombosis (figure 3).

Upon analysis of these images, the patient was emergently taken to the operating room for a right tympanomastoidectomy. Intraoperatively, a right chronic otomastoiditis with a sigmoid sinus thrombosis and a perisinus abscess was observed. A lumbar puncture revealed clear cerebrospinal fluid (CSF) with an opening pressure of 15 cm [H.sub.2]O. Intraoperative cultures were negative, and analysis of granulation tissue obtained from the mastoid and middle ear revealed the presence of inflammatory cells.

The patient's postoperative course was unremarkable, and he was discharged home on postoperative day 2 and prescribed 6 weeks of intravenous cefuroxime. The left abducens palsy resolved over the succeeding 5 months. Since then, the boy has had no other sequelae.

Discussion

In 1931, Symonds suggested the term otitic hydrocephalus to describe a syndrome that featured an increase in intracranial pressure (manifested by headache, vomiting, and papilledema) without abscess formation in association with otitis media. (1) The right-sided chronic otitis media in the patient described in this report was most likely the result of a perisinus abscess, which caused the sigmoid sinus thrombosis. The sinus thrombosis resulted in an increase in pressure in the superior sagittal sinus and a decrease in CSF absorption by arachnoid villi. The higher intracranial pressure was the most likely cause of the contralateral abducens palsy. Other possible causes include venous system obstructions caused by tumor compression, thrombosis, trauma, or systemic illness. These obstructions can occur intracranially, in the jugular vein, or at the superior vena cava. (2)

The administration of antibiotic therapy can mask the intratemporal and intracranial complications of acute and chronic otitis media (table). Patients might have some or all of the following symptoms: headache, otalgia, photophobia, low-grade fever, vomiting, and lethargy. Physical examination also can be unrevealing. CT, MRI, and lumbar puncture might be necessary to arrive at a proper diagnosis.

The management of sigmoid sinus thrombosis includes tympanomastoidectomy, removal of any perisinus infection, and needle aspiration of the sinus. Heparin and/or warfarin therapy and ligation of the jugular vein are no longer indicated in most cases. (3)

References

(1.) Symonds CP. Otitic hydrocephalus. Brain 1931;54:55-71.

(2.) Powers JM, Schnur JA, Baldree ME. Pseudotumor cerebri due to partial obstruction of the sigmoid sinus by a cholesteatoma. Arch Neurol 1986;43:519-21

(3.) Syms MJ, Tsai PD, Holtel MR. Management of lateral sinus thrombosis. Laryngoscope 1999;109:1616-20.

Table

Intratemporal and intracranial complications of otitis media

Brain abscess

Epidural abscees

Facial nerve paralysis

Labyrinthitis 

Mastoiditis 

Meningitis

Otitic hydrocephalus

Subperiosteal abscess