TRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.
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January 2019Background
Sigmoid sinus thrombosis (SST) remains a rare but serious intracranial complication of acute mastoiditis. Primary treatment includes surgical drainage by mastoidectomy and broad-spectrum antibiotic therapy. The role of anticoagulation remains controversial. Potential benefits include limiting thrombus propagation, improved sinus recanalization, and reduction in neurological sequelae. These benefits must be considered against potential risks, including intracranial hemorrhage, which is particularly significant in the context of patients who may require further staged surgical intervention.
If a decision is made to anticoagulate, uncertainty exists regarding selection and duration of appropriate agents. Heparin has been the traditional mainstay. However, whereas newer direct oral anticoagulants (DOACs) have transformed the management of lower limb deep-venous thrombosis and pulmonary embolism, their role in SST remains unclear.
Furthermore, although screening for thrombophilia may be helpful in guiding management, recommendations regarding testing in this cohort remain poorly defined.
In this review, we aim to explore relevant literature defining the role of anticoagulation in acute mastoiditis complicated by SST.
Best Practice
Presently, evidence to guide decision making about whether to commence anticoagulation in acute mastoiditis complicated by SST is lacking. Due to the low incidence of disease, recommendations are largely based on uncontrolled and nonrandomized case series. In general, larger studies of cerebral vein thrombosis support the use of anticoagulation and have demonstrated that such treatment can lower the mortality rate for these individuals, as currently supported by British Society of Haematology guidelines. Neurological sequelae are recognized, although these are reported in mixed pediatric cohorts that include non-otologic pathologies.
Currently, there is no evidence to support the use of DOACs or routine thrombophilia testing in this population. Management of this condition is complex and should include advice and support from hematology colleagues (Laryngoscope. 2018;128:2435–2436)