From the Guidelines
Sinus venous thrombosis due to sinusitis requires immediate medical attention and typically involves a combination of antibiotics, anticoagulation therapy, and possibly surgical intervention. Treatment should begin with broad-spectrum antibiotics such as vancomycin (15-20 mg/kg IV every 8-12 hours) plus a third-generation cephalosporin like ceftriaxone (2g IV daily) to address the underlying sinusitis infection, as suggested by the American Academy of Pediatrics 1. Anticoagulation with low-molecular-weight heparin (enoxaparin 1 mg/kg subcutaneously twice daily) or unfractionated heparin (initial bolus of 80 units/kg followed by continuous infusion) should be initiated promptly, followed by oral anticoagulants like warfarin (target INR 2-3) for 3-6 months.
Key Considerations
- The diagnosis of acute bacterial sinusitis is based on clinical presentation and physical examination findings, and imaging is not recommended in this context as it does not change management 1.
- Intracranial complications most commonly result from spread of primary infection within the frontal sinuses, and symptoms that suggest intracranial complications include Pott puffy tumor, altered consciousness, seizures, hemiparesis, and cranial nerve palsy 1.
- The American College of Radiology has stated that plain films of the sinuses are inaccurate in a high percentage of patients and should be supplanted by CT imaging, and CT findings that correlate with ABRS include opacification, air-fluid level, and moderate to severe mucosal thickening 1.
Treatment Approach
- Surgical drainage of the infected sinus may be necessary if there is no improvement with medical therapy.
- Patients should be monitored closely for neurological deterioration, seizures, and signs of increased intracranial pressure.
- Supportive care including pain management, adequate hydration, and management of increased intracranial pressure may also be required.
Evidence-Based Recommendations
- The most recent and highest quality study 1 suggests that treatment should begin with broad-spectrum antibiotics and anticoagulation therapy, and possibly surgical intervention.
- The study also highlights the importance of monitoring patients closely for neurological deterioration and signs of increased intracranial pressure.
From the Research
Sinus Venous Thrombosis Due to Sinusitis
- Sinus venous thrombosis (SVT) is a condition that can be caused by various factors, including sinusitis.
- The treatment of SVT is controversial, but heparin has been used as a treatment option 2.
- Studies have shown that anticoagulation with dose-adjusted intravenous heparin is an effective treatment in patients with SVT, and that intracranial hemorrhage (ICH) is not a contraindication to heparin treatment in these patients 2.
- Low molecular weight heparin (LMWH) has been compared to unfractionated heparin (UFH) in the treatment of cerebral venous sinus thrombosis, with some studies suggesting that LMWH may be a preferable option due to its better efficacy and safety profile 3, 4.
Treatment Options
- Unfractionated heparin (UFH) has been traditionally used as a treatment option for SVT, but it has some disadvantages, such as the need for monitoring and a less predictable anticoagulant response 5.
- Low molecular weight heparin (LMWH) has been shown to provide at least as good efficacy and safety outcomes as UFH regimens, with the added advantages of improved bioavailability, once-daily administration, and a more predictable anticoagulant response 5, 6.
- The choice between UFH and LMWH should be based on individual patient factors and the specific clinical scenario 3, 4.
Clinical Outcomes
- Studies have shown that patients treated with LMWH tend to have better clinical outcomes, including higher rates of functional independence and lower rates of mortality and new intracranial hemorrhages 3, 4.
- However, the evidence is not uniform, and more research is needed to fully understand the relative benefits and risks of UFH and LMWH in the treatment of SVT 2, 5.