PEDIATRICS Vol. 123 No. 2 February 2009, pp. 709-713 (doi:10.1542/peds.2008-0280)
ARTICLE |
Lateral Sinus Thrombosis as a Complication of Otitis Media: 10-Year Experience at the Children's Hospital of Philadelphia
a Departments of General Pediatrics
c Otorhinolaryngology-Head and Neck Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
b Department of Otolaryngology-Head and Neck Surgery, Emory University Hospital, Atlanta, Georgia
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ABSTRACT |
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 TOP ABSTRACT PATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVES. Lateral sinus thrombosis is a rare intracranial complication of otitis media that is traditionally described in countries with poor access to medical care. Our goal was to describe the clinical presentation, management, and outcome of patients diagnosed with lateral sinus thrombosis in a US tertiary care center and to highlight the clinically relevant differences in presentation between these patients and those described in previous reports.
PATIENTS AND METHODS. The medical charts of 13 patients diagnosed with otogenic lateral sinus thrombosis were reviewed. These patients were identified from a manual search of 156 subjects with International Classification of Diseases, Ninth Revision codes corresponding with a diagnosis of mastoiditis or thromboembolism over a 10-year period (1997–2007) at the Children's Hospital of Philadelphia.
RESULTS. In contrast to previous reports in the literature, the majority of patients in this series exhibited cranial neuropathies and signs of raised intracranial pressure. Nearly all of the patients had a history of acute otitis media treated with antibiotics in the weeks preceding admission. However, many patients denied high fevers or active otomastoid symptoms, which are classically associated with lateral sinus thrombosis. The diagnosis was made in all of the children by using computed tomography and MRI/venography. Treatment strategies included myringotomy tube placement, simple mastoidectomy, intravenous antibiotics, and anticoagulation. Posthospitalization follow-up data revealed no significant long-term complications.
CONCLUSIONS. Despite appropriate antibiotic therapy, lateral sinus thrombosis and other intracranial complications of otitis media are still a threat to children in the modern era. Neurologic, rather than otologic, symptoms may dominate the presentation of otogenic lateral sinus thrombosis. Thus, a high index of suspicion may be critical for ensuring timely diagnosis of this rare condition.
Key Words: lateral sinus thrombosis • otitis media • otitic hydrocephalus • mastoiditis • thromboembolism • venous sinus thrombosis
Abbreviations: LST—lateral sinus thrombosis • ICP—intracranial pressure • AOM—acute otitis media • CHOP—Children's Hospital of Philadelphia • CT—computed tomography • MRV—magnetic resonance venography • MRA—magnetic resonance angiography
Lateral sinus thrombosis (LST) is a rare but feared intracranial complication of otitis media and associated mastoiditis. Typically originating in the sigmoid sinus, thrombosis occurs in regions of sinus wall inflammation. The position of the sigmoid sinus in the mastoid bone makes it particularly vulnerable to inflammatory changes, which result from extension of infection from the middle ear cavity.1 As the condition progresses, thrombus may propagate to other sinuses and the internal jugular vein. Vessel occlusion ultimately obstructs cerebrospinal fluid drainage, leading to elevations in intracranial pressure (ICP) and associated hydrocephalus.2,3 In rare cases, emboli may shower to distant locations, resulting in significant morbidity and mortality.4 Indeed, septic LST was considered a uniformly fatal condition until the turn of the 20th century, when the first successful surgical interventions for the condition were performed.5,6 Modern reported mortality rates are lower, but still range from 5% to 10%.4,7,8
The introduction of effective antibiotic therapy for acute otitis media (AOM) has dramatically reduced the incidence of LST.6 Since the 1960s, case series involving children have almost exclusively originated outside of the United States,4,8–12 and the majority have been from countries with limited health care resources.4,8,10–12 Patients in these studies classically present with prominent headache and otologic symptoms, including otalgia, otorrhea, and postauricular tenderness, in the setting of untreated otitis media.4,8–10 In certain series, high-spiking or "picket-fence" fevers and signs of sepsis are described.8,11 Although informative, the data from these studies may be less relevant to physicians practicing in areas with widespread antibiotic availability.
This report retrospectively reviews a decade of experience with otogenic LST at the Children's Hospital of Philadelphia. To our knowledge, it is the largest pediatric series of LST published in the United States. Particular emphasis is placed on the initial clinical differences observed between children in this series and those in previous reports.
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PATIENTS AND METHODS |
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TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The medical charts of all patients hospitalized at the Children's Hospital of Philadelphia (CHOP) between January 1, 1997, and March 31, 2007, were searched for cases corresponding with a diagnosis of mastoiditis (International Classification of Diseases, Ninth Revision, code 383.0) or thromboembolism (International Classification of Diseases, Ninth Revision, code 325.0). Of 156 patients identified with these codes, 13 children (8%) had LST in association with otitis media and mastoiditis. Records of these cases were retrospectively reviewed, and data were collected regarding patient demographics, presenting signs and symptoms, laboratory and radiologic studies, medical management, surgical treatment, and clinical outcomes.
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RESULTS |
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TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Ten boys and 3 girls presented with LST during the 10-year study. Patient age ranged from 2 to 16 years (mean: 9 years). Each child had health insurance and a designated primary care physician on admission to our institution. Five patients presented to our emergency department, and 7 were transferred from community hospitals. Of those patients referred from other institutions, 5 were transferred from emergency departments, and 2 were transferred from inpatient wards, where they had undergone initiation of intravenous antibiotic therapy and surgical intervention. One patient was admitted from the CHOP otolaryngology clinic, where he had presented with worsening postauricular pain after recent mastoidectomy for acute mastoiditis.
Presenting symptoms for each patient are summarized in Table 1. The most common symptom, reported by 10 patients, was headache. The majority of patients (n = 8) also admitted to fevers, but these were generally low grade by history. Only 3 patients had fever documented at admission. More than half of the patients exhibited cranial nerve abnormalities. Seven patients presented with double vision associated with sixth-nerve palsy, and 1 patient presented with facial asymmetry associated with seventh nerve palsy. All 8 of the patients with cranial neuropathies complained of headache, and half of these patients had 
1 other sign of raised ICP, including nuchal rigidity, photophobia, nausea/vomiting, and dizziness. Seven of these patients underwent lumbar puncture and/or funduscopic examination. All 7 had objective evidence of raised ICP. Specifically, 1 patient had an elevated opening pressure, 3 had papilledema, and 3 had both findings.
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None of the 5 children without cranial nerve abnormalities had objective evidence of raised ICP, although 2 reported nausea/vomiting, nuchal rigidity, and ataxia at presentation. The 5 children without cranial neuropathies had more prominent otomastoid symptoms, with each of these children reporting otalgia, otorrhea, and/or postauricular pain. Collectively, less than half of the patients (n = 6) had primary otologic complaints at the time of presentation. One patient who denied otalgia and otorrhea reported isolated postauricular tenderness.
Despite the absence of otomastoid complaints in many patients, the majority of children (n = 11) had a history of AOM that had been treated from 6 to 60 days (mean: 23 days) before presentation. Otoscopic findings were abnormal in all of the patients. Nine patients had findings consistent with AOM, including tympanic membrane erythema or purulent otorrhea. One patient had tympanic membrane retraction, suggestive of otitis media with effusion. Two patients had myringotomy tubes in place, but these tubes were not clearly patent and were associated with tympanic membrane thickening. The tympanic membrane could not be visualized in the remaining patient, who had significant swelling in the external ear canal.
The duration of active symptoms at the time of admission ranged from 6 to 42 days (mean: 17.3 days). The majority of patients (n = 8) had symptoms for 2 weeks, and only 1 patient had symptoms for <1 week. Nearly all of the patients (n = 12) had been treated with antibiotics in the month preceding admission, and 7 patients reported active antibiotic therapy at presentation to our institution. The specific antibiotics reported included amoxicillin, amoxicillin-clavulanate, ceftriaxone, and cefdinir. One patient receiving ceftriaxone was also receiving gentamicin and vancomycin after incision and drainage of a subperiosteal abscess at another hospital. Antibiotics had been initiated within 2 days of symptom onset in 9 of the 12 patients treated before presentation. Delay in treatment for the remaining 3 patients was related to delay in presentation to medical care (1 patient) and diagnostic considerations (2 patients).
Each child studied underwent computed tomography (CT), MRI, and magnetic resonance venography (MRV). With the exception of CT scanning in 3 patients, all of the imaging was performed and interpreted at the CHOP. Sigmoid sinus thrombosis was detected in all of the patients. Eleven patients had extension to the transverse sinus, and 8 also had extension to the internal jugular vein. Imaging revealed coalescent mastoiditis in all of the patients studied. MRI/MRV findings correlated with CT findings in 12 of the 13 patients. In the remaining patient, MRI/MRV revealed thrombus in the sigmoid, transverse, and internal jugular vein that was not visualized on a CT scan. Associated complications, each identified in 2 patients, included dural enhancement, subperiosteal abscess, and epidural abscess. Imaging revealed subtle evidence of raised ICP in only 3 patients. One patient had mild enlargement of the lateral ventricles, and 2 had mild prominence of the optic nerve sheaths. All 3 of these patients presented with diplopia associated with sixth-nerve palsy.
A complete blood cell count, performed in 12 of 13 patients, revealed leukocytosis (range: 14.9–21.5) in only 3 patients. Middle ear cultures were obtained intraoperatively in 12 patients. Six of these patients had sterile cultures. In those patients with positive cultures, streptococcus was the predominant organism identified. Speciation revealed penicillin-susceptible Streptococcus intermedius (2 patients), penicillin-susceptible group A β-hemolytic streptococcus (1 patient), penicillin-susceptible group F β-hemolytic streptococcus (1 patient), and penicillin-resistant Streptococcus pneumoniae (1 patient). Staphylococcus aureus was cultured as a single organism in the remaining patient and was also found as a coexistent species in the patient with group A β-hemolytic streptococcus. Lumbar puncture, which was performed in 6 patients, revealed no growth of organisms. Blood cultures, performed in 7 patients, revealed light growth of a non–anthrax bacillus species in 1 patient. This finding was deemed consistent with probable specimen contamination.
Hospitalization duration ranged from 4.0 to 15.0 days (mean: 7.7 days). Days spent at outside institutions were accounted for in those patients who had been transferred from other hospitals. The surgical management of each patient included myringotomy tube placement and simple mastoidectomy, performed by staff otolaryngologists. In 1 patient, who had been transferred from the otolaryngology clinic with worsening symptoms after mastoidectomy, a repeat mastoidectomy was performed. Two patients underwent intraoperative needle aspiration of the sigmoid sinus, which yielded blood return in both cases. Neither open sinus exploration nor internal jugular vein ligation was performed in any patient. Associated complications of epidural abscess and subperiosteal abscess were managed with incision and drainage at the time of mastoidectomy.
All of the patients were also treated with topical antibiotic ear drops and antibiotics, which were culture directed when possible. Systemic antibiotics were initially delivered parenterally in all of the patients. After hospital discharge, 7 patients continued intravenous therapy, and 6 were converted to oral therapy. The duration of intravenous antibiotics ranged from 3.0 to 30.0 days (mean: 15.0 days), and the total duration of antibiotics ranged from 14.0 to 30.0 days (mean: 22.6 days). Five patients who had objective evidence of raised ICP were treated with acetazolamide. Finally, 12 patients were treated with anticoagulation. Eleven of these children were treated with enoxaparin. The twelfth child was initially treated with enoxaparin but was converted to warfarin therapy.
Follow-up data from the outpatient otolaryngology record and hospital database were available for 11 patients. Complications in the postoperative period included wound cellulitis (2 patients), postoperative bleeding or hematoma (4 patients), and recurrent symptoms of raised ICP (1 patient) that were relieved with repeat mastoidectomy. The duration of follow-up after hospital discharge ranged from 2 to 53 months and ultimately revealed symptom resolution in all 11 of the patients. Formal audiologic evaluation at follow-up demonstrated normal hearing in 6 patients and a mild conductive hearing loss (<30 dB) consistent with middle ear fluid in 5 patients. Surveillance imaging with MRI or MRV was also performed in 11 patients. Complete resolution of thrombus was demonstrated in 3 patients. The remaining 8 patients had evidence of partial recanalization (5 patients) or persistent occlusive thrombus (3 patients).
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DISCUSSION |
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TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The socioeconomic profile of our sample is relatively unique. Studies of LST have primarily involved patients from areas with more limited health care resources, such as South Africa,4,8 New Guinea,11 Turkey,10 and Thailand.12 In contrast, our study was performed in Philadelphia, which affords greater access to teaching hospitals than most cities in the world. All of the patients in our sample had health insurance and were actively followed by a pediatrician. The majority was treated with antibiotics before presentation.
The clinical manifestations of patients in our sample also differed from those reported in most large series. In the pediatric literature, headache is often cited as the most common symptom at presentation.7 This finding was duplicated in our cohort. However, most series of LST also report fevers, otalgia, and/or otorrhea in the vast majority of patients.2,4,6,8–10,13,14 In those series reporting white blood cell counts, leukocytosis is a common finding.6,9,10,14 Patients in our sample frequently related a history of AOM in the weeks preceding admission, but otologic complaints had often resolved. In most patients, blood work failed to reveal the expected leukocytosis, and fevers, when present, were generally low-grade. Instead, the majority of patients had sixth or seventh cranial neuropathies, accompanied by signs and symptoms of raised ICP, including headache, nausea/vomiting, photophobia, nuchal rigidity, and/or ataxia.
This clinical pattern, in which neurologic symptoms are generally more prominent than otologic symptoms, is consistent with other case reports from developed nations with good antibiotic availability.15–17 Indeed, in a smaller, albeit strikingly similar series published in Germany,15 4 of 5 children with otogenic LST initially presented with diplopia associated with sixth-nerve palsy. Like the majority of children in our series, all 4 of the patients had a history of AOM treated with antibiotics in the 1 to 6 weeks before presentation, and all 4 of the patients lacked fever, otologic symptoms, and neutrophilia at the time of LST diagnosis.
Taken together, these findings suggest that otogenic LST should be included in the differential diagnosis of any child presenting with certain neurologic complaints. In particular, physicians should maintain a high suspicion for the diagnosis in children presenting with sixth- or seventh-nerve palsy, especially when accompanied by evidence of possible raised ICP. Our data suggest that these children may not report typical otomastoid complaints, such as otalgia, otorrhea, or postauricular pain and swelling. Even in the absence of otologic symptoms, careful questioning may reveal a history of recent AOM. Indeed, most of the patients in our series admitted to a history of AOM, which was appropriately treated with antibiotics in many cases. All of the patients in our series also had abnormal otoscopic findings. In certain patients without otologic symptoms, these findings were the only indication that the patient's neurologic complaints stemmed from an underlying otologic process. Finally, our data suggest that the duration of presenting symptoms may be helpful in identifying those patients who are at greatest risk for LST. More than 90% of patients in our series had symptoms for >1 week, and 60% had symptoms for >2 weeks. Thus, a longer duration of symptoms may warrant a higher level of suspicion for the diagnosis.
Initial evaluation should include a CT examination of the head with fine cuts through the temporal bones. In our series, CT examination demonstrated evidence of coalescing mastoiditis in each patient. These findings are pertinent because they distinguish otogenic LST from nonseptic LST, which may be secondary to hypercoagulable states, neoplasm, trauma, autoimmune disease, or neurosurgical intervention.13 Patients with nonseptic LST typically have a normal otologic examination. Although they may have mastoid changes related to venous congestion, they fail to exhibit radiologic features of coalescing infection and/or cortical erosion.18 In addition to documenting infectious mastoid cavity changes and associated intracranial pathology, contrast-enhanced CT may demonstrate a filling defect in the affected sinus. In approximately one third of patients, contrast may accumulate in collateral veins surrounding this nonenhancing thrombus to yield a pathognomonic "empty 
" sign.19
In the last decade, several authors have advocated for the use of MRI and magnetic resonance angiography (MRA)/MRV as adjunctive studies to CT for increased diagnostic yield.2,19 MRI offers the advantage of imaging in multiple planes and obviating ionizing radiation. The additional use of MRA/MRV permits the distinction between slow venous flow and occlusive thrombus, which may be difficult to determine from spin echo MRI sequences.19 We used a combination of CT, MRI, and MRA/MRV to document the presence of LST in all of the patients. Of note, MRI was particularly useful in 1 patient in whom CT failed to identify thrombus but MRI/MRV revealed clot burden.
The diagnostic evaluation of our cohort also involved culturing the affected middle ear cavity to facilitate appropriate antibiotic selection. In a recent review of the pediatric literature, 
80% of cultures in cases reported since 1960 failed to yield any organisms.7 Fifty percent of cultured patients in our series had findings consistent with this trend. Of note, >90% of patients in our series had been treated with antibiotics in the month preceding presentation. These findings raise the inevitable question of why patients are developing LST despite seemingly adequate treatment for AOM. Certain authors suggest that this phenomenon may reflect the evolution of antibiotic resistance or delays in antibiotic initiation in a new era of watchful waiting in the approach to AOM.20 Our data largely failed to support either theory. Among the 6 positive middle ear cultures in our series, only 1 yielded a resistant organism. The remaining 5 patients all had organisms that were sensitive to penicillin. Delays in our series were also rare, and they were never associated with a physician decision to withhold antibiotics in the setting of AOM. What our series does reveal, however, is that patients often reported symptoms persisting or evolving well into or beyond antibiotic therapy. Most patients in our series had symptoms for >2 weeks, yet the majority also reported starting antibiotics within 1 to 2 days of symptom initiation. Whether this finding reflects poor adherence with prescribed dosing schedules is unclear. However, it does underscore the importance of symptom surveillance and the need for primary care and emergency department physicians to consider the possibility of LST or other intracranial complication of AOM when even nonspecific symptoms (eg, headache and fever) develop or fail to resolve with antibiotic therapy.
Treatment of patients in our series followed accepted practices for the management of LST. In addition to culture directed antibiotic therapy, previous studies uniformly support myringotomy tube placement and mastoidectomy as the standard treatment for otogenic LST. Although the hematology literature clearly supports the practice in patients with thrombosis of alternative etiology, data pertaining to otogenic LST are limited to case reports and retrospective reviews. A review of cases from the otolaryngological literature supports anticoagulation in select patients who have higher theoretical risk for infarction, embolization, or persistent septic thrombus. Specifically, the authors recommend consideration of anticoagulation in patients with clot burden extending beyond the sigmoid sinus, neurologic changes, embolic events, or persistent fevers despite appropriate surgical intervention.13 Consistent with these suggestions, anticoagulation was used in the majority of patients in our study.
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CONCLUSIONS |
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TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This case series reminds us that serious intracranial complications of AOM still can and do occur in children with excellent access to physicians and antibiotic therapy. Primary care and emergency department providers should maintain a high level of suspicion for LST in all patients with recent AOM who report persistent or evolving complaints despite therapy. Our series reveals that certain children with otogenic LST may present with predominantly neurologic, rather than otologic, complaints. In particular, signs and symptoms of sixth- or seventh-nerve impairment and raised ICP may be important clues to the diagnosis. Our data also suggest that the otoscopic examination in this setting is typically suggestive of either acute or chronic otitis media, even in the absence of active otologic symptoms. Although otoscopic findings may be subtle, they may be the only indication that the child's neurologic impairments stem from an underlying otologic process. Appropriate clinical suspicion, coupled with state-of-the art radiologic imaging, can lead to prompt identification and treatment of LST. The combination of culture-directed antibiotic treatment, myringotomy tube placement, simple mastoidectomy, and anticoagulation can lead to the resolution of neurologic sequelae and restoration of hearing.
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FOOTNOTES |
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Accepted Jun 6, 2008.
Address correspondence to Lisa M. Elden, MD, Children's Hospital of Philadelphia, Department of Otorhinolaryngology-Head and Neck Surgery, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104. E-mail: elden{at}email.chop.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
| What's Known on This Subject LST is a rare intracranial complication of otitis media that has traditionally been reported in nations with limited health care resources. The classically described presentation includes headache, prominent otologic symptoms, high fever, and signs of sepsis.
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| What This Study Adds We describe the largest cohort of pediatric patients with otogenic LST in the United States. These children typically had insidious headaches, low fevers, and cranial neuropathies without ear complaints. This symptom profile has practical implications for differential diagnosis.
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PEDIATRICS (ISSN 1098-4275). ©2009 by the American Academy of Pediatrics
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