Otogenic sigmoid sinus thrombosis: what is the role of anticoagulation?

OBJECTIVES: The treatment of otogenic sigmoid sinus thrombosis with surgery and antibiotics is well established. However, the role of anticoagulation remains unstudied. The study reviews the signs, symptoms, radiological evaluation, surgical treatment, and medical management of patients with otogenic sigmoid sinus thrombosis treated with or without anticoagulation.

STUDY DESIGN: Retrospective review of nine patients from 1995 to 2001 with sigmoid sinus thrombosis.

METHODS: Patients were identified by a review of all medical and radiological records. Signs, symptoms, diagnostic studies, treatments, and outcomes were recorded. In addition, telephone follow-up was performed. RESULTS Nine patients were identified over a 6-year period from 1995 to 2001. Patients had a mean follow-up time of 9 months (range, 1-24 mo). Of the nine patients identified, eight patients (89%) had tympanostomy tube placement, six patients (67%) had canal wall intact mastoidectomy, and one patient (11%) had canal wall down mastoidectomy. Needle aspiration of the sinus was performed in four of nine patients (44%), and incision of the sinus in two of nine (22%). Treatment with broad-spectrum antibiotics occurred in all patients with a mean duration of 12 days (range, 2-22 d) intravenously and 7 days (range, 0-21 d) orally. Sixty-seven percent of patients (six of nine) were anticoagulated: Five patients received low-molecular-weight heparin, and one patient received heparin-coumadin. No mortality occurred in either the anticoagulated or non-anticoagulated group. One anticoagulated patient did have persistent headaches and otorrhea.

CONCLUSIONS: Surgery and antibiotic therapy are the cornerstones of the management of otogenic sigmoid sinus thrombosis. However, the role of anticoagulation remains unclear. Because complications of embolization and persistent sepsis are low in otogenic sigmoid sinus thrombosis patients treated with or without anticoagulation, withholding anticoagulation in selected patients is reasonable. Serial imaging to monitor for thrombus progression is advisable.