A patient with unsafe CSOM develops spiking 'picket-fence' fever with rigors, postauricular oedema (Griesinger's sign), and headache. Intraoperatively, the sigmoid sinus is found thrombosed. After mastoidectomy and removal of diseased bone, the most appropriate management of the sigmoid sinus thrombosis is:

• A IV antibiotics alone with observation; sinus thrombosis resolves with source control
• B Immediate internal jugular vein ligation at the neck to prevent septic emboli
• C Long-term anticoagulation with heparin followed by warfarin for 6 months
• D Sigmoid sinusotomy with removal of the thrombus and IV antibiotics; IJV ligation only if the thrombus propagates ✓

Explanation

Lateral (sigmoid) sinus thrombophlebitis requires: (1) mastoidectomy with complete disease removal, (2) sigmoid sinusotomy — the outer wall of the sinus is incised and the infected thrombus evacuated by curettage or aspiration, followed by packing if needed. Combined with IV antibiotics (covering anaerobes and Gram-positives). IJV ligation is added only if the thrombus propagates distally despite sinusotomy, or if there are recurrent septic emboli. Anticoagulation is controversial and not routinely used. Griesinger's sign (oedema over mastoid due to emissary vein involvement) is pathognomonic of this complication.

Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.