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).