Otogenic sigmoid sinus thrombosis (SST) is a rare but potentially life-threatening intracranial complication of otitis media, particularly uncommon in adults in the antibiotic era. Diagnosis may be delayed due to nonspecific early clinical features, with rapid deterioration secondary to raised intracranial pressure and impaired venous drainage. We report the case of a 34-year-old woman who presented to the emergency department with a four-day history of progressive right-sided otalgia, headache, and vomiting. She initially presented alert with a Glasgow Coma Scale (GCS) score of 15/15 but rapidly deteriorated to 5/15 (E2 V1 M2), requiring intensive care support. Neuroimaging revealed bilateral otomastoiditis with right tegmen tympani dehiscence and associated pneumocephalus, and further MRI brain revealed extensive non-occlusive thrombosis of the right transverse and sigmoid sinuses extending to the jugular bulb. Viral screen tested positive for respiratory syncytial virus (RSV), and blood cultures grew penicillin-resistant Streptococcus pneumoniae. The patient achieved complete sinus recanalisation and full neurological recovery with conservative management of targeted intravenous (IV) antimicrobial therapy, therapeutic anticoagulation, and neurocritical care, without surgical intervention. This case highlights that otogenic SST remains a medical emergency despite its rarity, and atypical clinical features should not diminish suspicion for severe intracranial pathology. Carefully selected patients without drainable collections or cholesteatoma may achieve excellent outcomes with prompt intensive medical management alone, supported by close radiological and neurological monitoring, even in the presence of extensive venous sinus thrombosis.
Lau et al. (Wed,) studied this question.