Phlebitis of the sigmoid sinus: causes, symptoms, diagnosis, treatment

According to VT Palchun et al. (1977), sigmoid and transverse sinuses are most commonly affected (79%), then the jugular vein bulb (12.5%), the remaining cases occur in cavernous and stony sinuses.

Pathological anatomy. The inflammatory process in the sinus can begin with periflebit or endophlebitis, depending on the path of infection.

Periphlebitis occurs with direct infection from the affected area of the middle ear. In this case, the color of the sinus changes from bluish to yellow-gray, its outer wall can be covered with granulations and fibrinous coating, an abscess can form in the neighborhood. Periphlebitis can be limited or common. In the latter case, the inflammatory process spreads to the bulb of the jugular vein and below, and upwards - along the transverse sinus to the hard medullary membranes covering the cerebellum, giving rise to the pachymeningitis of the posterior cranial fossa. Sometimes periphlebitis spreads along the collaterals of the transverse and sigmoid sinuses (stony and arrow-like sinuses, vein emissaries of the mastoid process), and as a result of necrotic perforation of the solid meninges, SDA arise.

Endoflebitis occurs most often when the infection enters the sinus cavity through an emissary, for example through the vein of the mastoid process, entering directly into the sigmoid sinus. Endophlebitis can occur as a result of damage to the sinus wall caused by pereflebit. The condition for the occurrence of endoflebitis is the destruction of the sine wall to its entire thickness, which creates the conditions for the formation of first parietal (parietal endophlebitis), and then of the total thrombus (obliterating endophlebitis). Once emerged, the thrombus continues to grow in both directions, sometimes reaching the opposite lateral sinus, on the one hand, and. Penetrating into the bulb of the jugular vein and into the internal jugular vein, descends into an unnamed vein. The thrombus can be transformed into a fibrous stopper, closely welded to the sinus wall (obliteration of the sinus), which is often found during surgery on the mastoid process with exposure of the sinus. However, more often the thrombus becomes infected and inflamed, which often leads to very dangerous complications (meningitis, cerebral abscess, septicopyemia, lung abscesses.) Purulent emboli, getting into the big circle of blood circulation, can cause purulent inflammation in various parts of the body and internal organs. Different authors, the incidence of metastatic abscesses with thrombophlebitis of sigmoid sinus varies from 30 to 50%.

Pathogenesis of phlebitis of sigmoid sinus. The most frequent cause of phlebitis of the sigmoid sinus and bulb of the jugular vein is chronic purulent inflammation of the middle ear (caries, cholesteatoma, mastoiditis). In more rare cases, the cause of sinuso-vascular phlebitis can be acute purulent otitis media and acute mastoiditis. To promote phlebitis of sigmoid sinus can intraoperative and domestic trauma in the presence of chronic purulent otitis media.

Symptoms of thrombophlebitis of the sigmoid (lateral) sinus are composed of local and general symptoms. Local symptoms are poorly expressed: a slight swelling in the behind-eye area (Grisinger's symptom), painfulness with deep palpation of the posterior margin of the mastoid process and the exit point of its emissaries, tenderness, swelling and hyperemia of the skin along the general jugular vein when the phlebitis spreads to this vein; when the phlebitis and thrombus spread to the upper longitudinal sinus, the blood of emissaries overflows to the convectional surface of the head and the overflow of the veins of the head surface, their expansion and the increase in tortuosity (a symptom of the head of Medusa). Common symptoms are typical for the phlebitis of any intracranial sinus and reflect the general septic state of the body.

The onset of the disease is usually sudden: against a background of acute or exacerbation of chronic purulent otitis, there is a strong chill with a rise in temperature to 40 ° C. Sometimes the force of chills accrues gradually, together with body temperature, from an attack to an attack, reaching a height at a temperature of 40 ° C. Sometimes chills are preceded by an increasing hemicrania on the side of the patient ear, which can serve as an early sign of the beginning phlebitis of the cerebral sinus. After the debut, a characteristic clinical picture is established, which for phlebitis of the lateral (sigmoid) sinus can occur in several forms - from latent and lightest to severe septic.

The latent form proceeds without septicemia with very scarce symptoms. It is often detected only during surgery on the mastoid process. Sometimes there may be mild signs of the symptoms of Grisinger's, Quexenstedt's (a sign of impaired circulation of spinal fluid in sigmoid and transverse sinuses: in healthy people, compression of the jugular vein increases intracranial pressure, which is evident from the increased frequency of droplet discharge in lumbar puncture, with occlusion of sigmoid sinus caused by thrombosis, a tumor, this is not observed) with a positive Stacke's sample (Stackey's symptom - under pressure through the abdominal wall on the lower vena cava, the pressure of the spinal cord increases Liquids). With this form, the size of the thrombus in the sigmoid sinus is limited by the site of the osteitis of the bone wall of the sinus channel, and the proximal end of it remains uninfected.

The pimic form is characterized by septic fever, severe chills and signs of sepsis.

The typhoid form differs from the previous ones by a constant high body temperature without pronounced swings. The patient develops a general severe condition with periodic loss of consciousness, insomnia, toxic disorders of cardiovascular and respiratory activity, an increase in the spleen, multiple intradermal hemorrhages.

The meningeal form is characterized by signs of meningitis and inflammatory changes in the cerebrospinal fluid.

Thrombosis of the bulb of the jugular vein often occurs with acute otitis in children. It manifests a painful swelling and hyperemia of the skin in the upper part of the mastoid process, behind the angle of the lower jaw, at the upper end of the sternocleidomastoid muscle. These phenomena can easily be mistaken for the beginning of mastoiditis, which delays the true diagnosis of thrombophlebitis of the bulb of the jugular vein. When the infection spreads in the direction of the torn opening, the nerves (lingo-pharyngeal, wandering, sublingual) that are involved here may be involved in the inflammatory process, which is manifested in partial signs of the Berne syndrome (alternating paralysis that develops as a result of damage to the pyramidal path in the medulla oblongata, manifested by contralateral spastic hemiparesis, homolateral paralysis of the soft palate, swallowing musculature and larynx muscles). Sometimes thrombophlebitis of the bulb of the jugular vein is not manifested by local symptoms, its presence can be suspected only on the grounds of septicopiaemia and was found during surgery on the mastoid process.

Thrombosis of the jugular vein is manifested by soreness in the neck on the side of inflammation when the head rotates, as well as fiber edema along the jugular vein, which propagates along the outer edge of the sternocleidomastoid muscle, and has a dense and mobile strand in this area (vein and surrounding tissue). If the thrombus of the jugular vein extends before merging with the subclavian vein, then signs of development of the collateral circulation can be detected, manifested by strengthening the venous pattern on the corresponding half of the neck, and also by the absence of a blowing sound in the auscultation of the jugular vein.

Diagnosis of thrombophlebitis of the lateral sinus does not cause any special difficulties if it develops as a consequence of inflammation of the middle ear, mastoiditis and is manifested by the symptoms described above. Differential diagnosis is performed with other otogenic intracranial complications, mastoiditis and its cervical complications.

Treatment otogennogo sinus thrombosis is determined by the state of the primary focus of infection, the degree of severity of the syndrome, the presence or absence of distant pyemic complications. Practically in all cases after the appropriate preoperative rehabilitation preparation, treatment begins with an emergency elimination of the primary focus of infection. An integral part of the treatment is nonoperative measures, including massive antibiotic therapy (intravenous or intra-arterial), normalization of rheological parameters of blood and electrolytes in it, detoxification of the body, saturation with vitamins, and increased immunity. In severe cases resort to the manufacture and use of antitoxic and antimicrobial sera, specific to the pathogenic microbiota.

Surgical treatment of thrombosis of sigmoid sinus. This treatment is urgent even at the slightest suspicion of the onset of this disease. With any kind of intervention on the middle ear and mastoid process, it is necessary to remove as much as possible all the cells of the mastoid process, the whole pathologically altered bone, to expose and open the sigmoid sinus within its pathological changes. After the opening of the sinus, the further course of the surgical intervention is dictated by pathological changes in the sinus and the general condition of the patient. Various options are possible here.

1. The sine is externally normal: its pulsation is determined, the color is bluish, and there are no fibrinous raids and granulations on the surface. In this case, there are two possible ways:
   1. further intervention on the sinus is stopped, and the operation is completed by an extended RO; with such an alternative, there is a risk of subsequent development of sinus thrombosis;
   2. produce a sine puncture, previously washing the wound with a sterile solution of antiseptic (furacilin, rivanol) and a solution of the corresponding antibiotic and treating the surface of the sinus with a weak alcohol solution of iodine. If normal venous blood is found in the punctate of the sinus, then the sine is not opened.
2. The surface of the sinus is hyperemic, covered with granulations or fibrinous plaque, pulsation is absent, a sinus puncture is mandatory. The appearance in the syringe of fresh blood indicates that the pathological process is limited only to the parietal phlebitis and, possibly, the parietal thrombus. In this case, the sinus is not opened and the wound is opened. If you can not get the contents of the sine by suction, or the pus is secreted through the needle, further surgical intervention depends on the general clinical signs of the thrombophlebitis of the sinus:
   1. in the absence of septicemia, some authors recommend not opening the sine and not removing the thrombus, which in this case plays an initially biologically protective role, being a barrier to infection, but taking a wait-and-see attitude; in the case of purulent fusion of only the central part of the thrombus (in the absence of signs of septicemia), this tactic involves removing the purulent focus by aspiration by puncture;
   2. in the presence of septicemia, a sinus opening or removal of a part of its wall (window) is performed with the removal of the thrombus on its entire extent, until the appearance of a proximal part of fresh blood; if the thrombus has a large extent, at which it can not be completely removed, then in this case only the most infected central part is removed; a thrombus is removed only after the sinus is turned off from the circulation by tamponade of its upper and lower ends limited by the size of the longitudinal section of the sinus wall; for this, the ear gauze turunda is injected between the sinus and the external bone wall until the sinus is completely clamped; The operation is completed with a loose tamponade of the operating wound with iodoform; usually after such an operative intervention, the sinus is emptied and sclerotized; if within a few days the signs of septicemia do not disappear, then the pathologically altered internal jugular vein is bandaged and removed.

The prognosis with limited thrombophlebitis of the sigmoid sinus and timely operation, as well as with effective complex medication for life is favorable. The prognosis is cautious and even doubtful in septicemia and septicopyemia, especially when distant foci of infection occur in the internal organs. Often, such foci of infection lead to chronic sepsis, the treatment of which can last for many months.

[1], [2], [3], [4], [5], [6]