Results:
A total of 10 inpatients were identified. Four patients (40%) had
poorly controlled diabetes. All patients had a history of otitis, either
recurrent acute or chronic otitis media. The mean delay of consultation
was 27 days (extremes: from 7 days to 3 months).
The most commonly reported symptoms were headache in 5patients (50%),
otalgia in all patients, otorrhea in 9 patients (90%), and fever in 3
patients (30%).
The etiology was related to an acute otitis media (AOM) in 4 cases
(40%), cholesteatoma otitis media (COM) in 3 cases (30%), and
necrotizing external otitis (NEO) in 3 cases (30%) (Table 1).
All patients had positive otoscopic findings, which included purulent
ear discharge. Retraction pockets with cholesteatoma debris were present
in 2 patients. Congested and retracted pars tensa was found in one
patient (Table 2). The decreased visual acuity was found in one case.
And conductive hearing decrease was noted in one other case.
All patients were assessed by cerebral CT scan with contrast
(contrast-enhanced computed tomography (CECT)) of the brain and temporal
bones. The “empty delta sign” (central non-enhancing clot surrounded
by enhancing dural sinus wall) which is related to the presence of
thrombus which has been objectified in 7 patients (70%) (Fig1a,b). 3
patients (30%) underwent a MRI.
The thrombus was confined only to the lateral sinus in 5 patients
(50%), extended to the internal jugular vein in 4 patients (40%)
(fig2), and extended to the cavernous sinus in 1 patient (10%) (Fig3).
Regarding the case extension to the cavernous sinus, CT scan showed
low-intensity cavernous sinus, with bulging of its lateral margins,
dilatation of the ophthalmic veins, and bilateral exophthalmia more
marked in the left eye.
The thrombophlebitis was on the right side in 3 cases, on the left side
in 6 cases, and bilateral in 1 case. The occlusion was total in 4 cases
and partial in 6 cases.
Imaging had objectified other associated signs like mastoiditis which
was identified in 5 patients (50%) (fig4), swelling neck in one case,
and a retropharyngeal abscess in one case (fig5).
70% of patients presented other cranial complications associated: such
as frank cerebellar abscess (3 patients) and extradural empyema in two
patients (20%) (fig6), and meningitis in one patient (%).
Complete blood counts showed concentration of hemoglobin < 10
g /dL in 2 (20 %) patients, leukocytosis in 7 (70 %) patients. All
patients had normal plated counts. All patients had normal coagulation
profiles.
Microbiologic cultures were produced from the middle ear of all patients
and 3 of them had negative cultures. Among the positive cultures,
Pseudomonas aeruginosa was isolated in 2 cases, Proteus mirabilis in one
case, Streptococcus in one case, and streptococcus pneumonia in one
case. Mycological cultures were positive in 2 cases: lichetmiae
corymbiform in one case and Candida Albicans in the other case.
All patients received initially a broad-spectrum antibiotherapy,
subsequently adapted according to the isolated germ. Duration of
antibiotic therapy was for 15 days to 3 months (Table 3 &4).
90% of patients were anti coagulated: 6 patients were treated with
subcutaneous low molecular weight heparin (enoxaparin) for an average
period of 60 days, and 3 patients had intravenous unfractionated heparin
for 15 days, then relayed with Sintrom (Acenocoumarol), for a mean
period of 90 days.
Surgical management was completed in 5 cases. It was exclusive in 4
cases (Table 5).
All patients recovered satisfactorily; with complete resolution of their
symptoms and complications except one patient who had a loss of visual
acuity. The middle ear infection was controlled in 9 cases. The
mortality rate was 0%. 4 patients showed recanalization, and one
patient had a significant decrease of the thrombus. The average length
of the follow-up was 16 months (range: 30 days to 36 months).