Open AccessReview Otogenic Lateral Sinus Thrombosis: Controversies and Current Management Strategies 1 General Medicine, “Carol Davila” University of Medicine and Pharmacy, 8th Eroii Sanitari Boulevard, 050474 Bucharest, Romania 2 “Prof. Dr. D. Hociotă” Institute of Phonoaudiology and Functional ENT Surgery, 21st Mihail Cioranu Street, 050751 Bucharest, Romania * Author to whom correspondence should be addressed. Medicina 2026, 62(6), 1093; https://doi.org/10.3390/medicina62061093 (registering DOI) Submission received: 19 April 2026 / Revised: 28 May 2026 / Accepted: 1 June 2026 / Published: 4 June 2026 Abstract Background: Otogenic lateral sinus thrombosis (OLST) is a rare but potentially life-threatening intracranial complication of middle-ear infection. Despite advances in imaging, antimicrobial therapy and otologic surgery, optimal management—particularly anticoagulation—remains controversial, and no standardized clinical guideline is available. Methods: A structured narrative review was conducted using PubMed for English-language human studies published between 1 January 2015 and 31 January 2025. The search was repeated and documented during revision on 12 May 2026. Four searches were run separately; retrieved records were manually merged, and duplicate record occurrences were removed using PMID. The searches retrieved 83 records before deduplication; after removal of 19 duplicates, 64 unique records remained for title and abstract screening. Single case reports and review articles were excluded from the primary descriptive synthesis. SANRA principles guided review quality and transparency. Seven eligible studies comprising 140 confirmed OLST patients were analyzed descriptively; selected clinically relevant but non-comparable publications were retained for contextual discussion. Results: Most included cohorts were pediatric; one study included both pediatric and adult patients. Clinical presentation was heterogeneous and often attenuated by prior antibiotic exposure. Contrast-enhanced CT was frequently used initially, whereas MRI/MRV was most informative for confirming thrombus extent and follow-up. Broad-spectrum intravenous antibiotics and surgical source control represented core treatment. Anticoagulation was reported in six studies, most often with low molecular weight heparin, but indications and duration varied substantially. Outcomes were generally favorable, although visual impairment, hearing loss, behavioral sequelae and incomplete radiological recanalization were reported. Conclusions: OLST management should be individualized according to disease severity, thrombus extent, septic status, and patient-specific risk factors. Antibiotics and source control are essential, while anticoagulation should be considered selectively. A practical management algorithm is proposed, but prospective multicenter data are needed. 1. Introduction Otogenic lateral sinus thrombosis (OLST) represents a rare but severe intracranial complication of acute or chronic otitis media and mastoiditis. In the otologic literature, the term lateral sinus thrombosis is frequently used as an umbrella term that includes sigmoid sinus thrombosis and, in some cases, extension to the transverse sinus, jugular bulb or internal jugular vein. In this review, OLST is retained as the general term, while individual sinus involvement is reported according to the terminology used in each included study [ 1, 2]. The microbiological background differs according to the underlying otologic disease. Acute otitis media and acute mastoiditis are commonly associated with Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae, Staphylococcus aureus and anaerobic pathogens, whereas chronic suppurative otitis media and cholesteatomatous disease may involve Pseudomonas aeruginosa, mixed aerobic–anaerobic flora, and resistant organisms [ 3, 4]. Fusobacterium necrophorum is particularly relevant in acute mastoiditis complicated by septic cerebral venous sinus thrombosis and may be associated with prolonged hospitalization, antibiotic exposure, and recovery [ 5]. 2. Materials and Methods This article was designed as a structured narrative review. The purpose was not to claim systematic completeness or to perform a meta-analysis, but to provide a transparent, clinically oriented synthesis of recent evidence regarding otogenic lateral/sigmoid sinus thrombosis. The manuscript was revised to avoid wording suggestive of a formal systematic review where such methodology was not applied. The review was prepared in accordance with the Scale for the Assessment of Narrative Review Articles (SANRA), which was used as a methodological quality framework for the current narrative review. SANRA was not used as a risk of bias instrument for individual observational studies because the tool was developed to assess narrative review quality rather than primary study validity [ 7]. A completed SANRA self-checklist for the current review is provided as Supplementary Table S1. A PubMed search was performed for English-language human studies published between 1 January 2015 and 31 January 2025. Because the exact day of the original search was not prospectively recorded during manuscript preparation, the search strategy was repeated and documented during revision on 12 May 2026. Four PubMed searches were run separately using the following free text PubMed queries: (1) cerebral venous sinus thrombosis mastoiditis; (2) lateral sinus thrombosis chronic otitis; (3) lateral sinus thrombosis mastoiditis; and (4) sigmoid sinus thrombosis otitis. These terms were chosen to capture both traditional otologic terminology and broader cerebral venous sinus thrombosis terminology used in pediatric, otolaryngological, radiological, and neurological publications. The records retrieved from the four searches were manually merged, and duplicate record occurrences were removed using PMID as the primary identifier. When necessary, title, author list and publication year were also checked to confirm duplicate status. The four searches retrieved 83 records before deduplication. After removal of 19 duplicate record occurrences, 64 unique PubMed records remained for title and abstract screening. All 64 unique records were screened by title and abstract for relevance to otogenic lateral/sigmoid sinus thrombosis. Records clearly unrelated to otogenic infection, lateral/sigmoid sinus thrombosis, mastoiditis or cerebral venous sinus thrombosis were excluded at the title/abstract level. Full-text assessment was performed for records considered potentially eligible for the primary descriptive synthesis or for contextual discussion. After applying the eligibility criteria, seven studies were included in the final primary descriptive synthesis, comprising 140 confirmed OLST patients. The study selection process is presented in Figure 1. Studies were eligible if they reported pediatric or adult patients diagnosed with OLST secondary to acute or chronic otologic infection, including acute mastoiditis, chronic otitis media or cholesteatomatous otomastoiditis, either as an isolated complication or in association with other otogenic intracranial complications, provided that OLST-specific clinical, imaging, management or outcome data were extractable. Eligible domains included clinical presentation, imaging findings, sinus involvement, microbiology, antibiotic therapy, surgical management, anticoagulation, recanalization or clinical outcomes. Single case reports were excluded to reduce anecdotal bias. Review articles were excluded from the primary synthesis to avoid duplication of cases, but selected reviews and guidelines were used for contextual discussion. Studies focused on non-otogenic cerebral venous sinus thrombosis, malignant otitis externa, external auditory canal cholesteatoma or unrelated intracranial complications were excluded. Studies were not excluded solely because some variables were not reported; instead, missing values were recorded as NR (not reported) to preserve transparency and avoid selective exclusion of the limited adult or mixed population evidence. Study selection and data extraction were performed independently by two authors, with discrepancies resolved by consensus. Extracted variables included study year and country, number of OLST patients, age group, sex when available, otologic presentation, neurological findings, sinus involvement, microbiological data, antibiotic therapy, surgical procedures, anticoagulation regimen and duration, clinical outcomes, radiological recanalization and reported sequelae. Due to heterogeneity in study design, patient population, outcome definitions, surgical indications, anticoagulation strategies, and imaging follow-up, meta-analysis was not appropriate. Results were therefore synthesized descriptively, with emphasis on clinically relevant patterns and areas of controversy. Patient counts and event counts were interpreted cautiously because several studies reported overlapping treatment categories or incomplete denominators. 4. Discussion This structured narrative review shows that contemporary OLST evidence remains dominated by small retrospective pediatric cohorts, heterogeneous reporting and limited adult data. The available literature supports a consistent therapeutic foundation: early recognition, urgent imaging, broad-spectrum intravenous antibiotics and surgical control of the otogenic source. In contrast, anticoagulation, duration of therapy and interpretation of recanalization remain incompletely standardized. Antibiotic therapy should be immediate and broad enough to cover the expected spectrum of acute mastoiditis and chronic otologic infection. In acute otitis media and acute mastoiditis, common pathogens include Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae, Staphylococcus aureus and anaerobes. In chronic suppurative otitis media or cholesteatoma, Pseudomonas aeruginosa, mixed aerobic–anaerobic flora and resistant organisms become more relevant [ 3, 4]. The included studies most frequently reported third-generation cephalosporins combined with anaerobic coverage, with glycopeptides or antipseudomonal agents added according to disease severity, chronicity, local microbiology, or culture results. Fusobacterium necrophorum deserves particular attention because it has been associated with sinus thrombosis in acute mastoiditis and a more prolonged course [ 5]. Surgical source control remains fundamental. The goal of surgery is eradication of middle-ear and mastoid infection, drainage of purulent collections, ventilation of the middle ear when appropriate and prevention of further septic propagation. Mastoidectomy, with or without tympanostomy tube placement, was the most frequent intervention in the included studies, although some children with selected disease patterns were treated with tympanostomy alone or even without surgery [ 5, 9]. This interpretation is consistent with earlier systematic and institutional reviews that emphasized multidisciplinary management and a gradual move away from aggressive sinus surgery in selected clinically stable patients [ 14, 15]. Otogenic-specific reappraisals and recent post-search pediatric mastoiditis-associated CSVT data support the same cautious interpretation: anticoagulation is frequently used, but the decision remains dependent on thrombus extent, venous drainage anatomy, intracranial hypertension, postoperative bleeding risk, and multidisciplinary assessment rather than on a universal rule [ 24, 25]. Foundational pediatric series and otologic reference sources were retained as the contextual literature because they document the historical evolution of OLST management, recanalization follow-up, thrombophilia evaluation and the progressive shift away from routine sinus thrombectomy or internal jugular vein ligation [ 17, 18, 19, 20, 26, 27, 28]. Additional clinically relevant, but non-included series further illustrate the heterogeneity of practice. Ryan et al. [ 21] described pediatric OLST management with antibiotics, otologic surgery, and selective anticoagulation, whereas Raja et al. [ 15] reported a more surgically oriented mixed-age institutional approach, including internal jugular vein ligation in selected patients and no anticoagulation exposure. These reports were retained for contextual discussion only and did not contribute patients to the 140-patient primary descriptive dataset because their reporting structure and management paradigms did not allow standardized comparison with the predefined extraction framework for anticoagulation strategy, treatment duration, follow-up imaging and recanalization outcomes. The recent systematic review by Picton et al. provides important post-search contextual evidence and should be interpreted alongside, rather than pooled with, the present 140-patient primary descriptive dataset [ 29]. Picton et al. searched Medline, Embase, Emcare, Cochrane and ClinicalTrials.gov from inception to November 2024 and included 68 papers, comprising 43 case reports and 25 case series with 149 patients. They reported surgery in 88.5% of patients, anticoagulation in 54.8%, complete recanalization in 65% of reimaged patients, and long-term complications in 9.4%. Their conclusion that antibiotics, surgery and anticoagulation were associated with favorable outcomes is broadly concordant with the therapeutic principles identified in the present review. However, because their synthesis included case reports and non-comparative case series, it does not eliminate the need for individualized anticoagulation decisions. Importantly, Picton et al. found no additional benefit from incision and drainage of the sigmoid sinus and reported a higher complication signal with this approach, supporting the contemporary preference for otologic source control while avoiding routine direct sinus intervention. 5. Proposed Management Algorithm 6. Future Directions The rarity of OLST makes randomized trials unlikely in the near future, but multicenter prospective registries are feasible and urgently needed. Future studies should use standardized definitions for sinus involvement, septic versus non-septic thrombosis, intracranial hypertension, recanalization, clinical recovery, visual outcomes, hearing outcomes and anticoagulation-related complications. A minimal OLST registry should capture age, otologic disease type, microbiology, CT and MRI/MRV findings, surgical procedure, anticoagulant agent, timing, dose, duration, bleeding complications, recanalization timing and functional outcomes. Such datasets would allow clinically meaningful subgroup analyses and could help define when anticoagulation is beneficial rather than simply documenting that practice varies. 7. Limitations This review has several limitations. First, the primary search was restricted to PubMed and English-language human studies, which may have excluded relevant reports indexed elsewhere. Second, although the PubMed search was repeated and documented during revision, this article remains a structured narrative review rather than a formal systematic review or meta-analysis; therefore, the findings should be interpreted as a clinically oriented synthesis rather than a pooled estimate of effect. Third, the included evidence consists predominantly of retrospective pediatric cohorts with small sample sizes; adult evidence is scarce and largely dependent on one mixed population study retained mainly for demographic and anatomical comparison. Fourth, publication bias is likely because complicated or successfully managed cases may be preferentially reported. Fifth, outcome reporting was heterogeneous, with inconsistent denominators for sinus involvement, surgery, anticoagulant exposure, imaging follow-up and recanalization. Sixth, anticoagulation strategies were variable and often reported as treatment exposures rather than mutually exclusive patient-level groups, limiting quantitative comparison. Seventh, some included studies provided incomplete treatment or outcome data; these variables were recorded as NR and were not used to support domain-specific conclusions. Eighth, the primary dataset included studies published between 2015 and 2021, despite the updated PubMed search covering 2015 to 2025. The absence of additional eligible primary cohort studies after 2021 reflects the rarity of OLST, the exclusion of single case reports and review articles from the primary dataset and the limited availability of standardized cohort-level data. Recent contextual publications and guidelines were discussed where relevant, but were not included in the 140-patient primary descriptive dataset. 8. Conclusions Otogenic lateral sinus thrombosis remains a rare but clinically important complication of acute or chronic otologic infection. The evidence supports urgent recognition, multimodal imaging, broad-spectrum intravenous antibiotics and surgical eradication of the otogenic source as the core of management. The role of anticoagulation remains unresolved. Current data do not support indiscriminate routine anticoagulation for all patients, but they do support selective use in clinically meaningful subgroups, including thrombus propagation, extensive transverse sinus or internal jugular vein involvement, intracranial hypertension, papilledema, neurological signs, thrombophilia or compromised venous drainage. Conversely, stable isolated sigmoid sinus thrombosis after effective source control may be managed individually with close follow-up when bleeding risk is high. Standardized multicenter data are required to establish evidence-based protocols for diagnosis, surgery, anticoagulation indication and duration, recanalization assessment, and long-term neurological, visual and auditory outcomes. Supplementary Materials The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/medicina62061093/s1, Table S1. SANRA-guided self-checklist for the current narrative review; Table S2. Clinically relevant publications were assessed but not included in the primary descriptive dataset. Author Contributions Conceptualization: A.M.B.-B., V.Z.; methodology: A.M.B.-B., I.G.I.; data curation: A.M.B.-B., M.D.Z., L.G.; formal analysis: A.M.B.-B.; writing—original draft preparation: A.M.B.-B.; writing—review and editing: I.G.I., M.D.Z., L.G., A.R., R.H., V.Z.; supervision: V.Z. All authors have read and agreed to the published version of the manuscript. Funding This research received no external funding. Institutional Review Board Statement Not applicable. Data Availability Statement All data supporting the findings of this review are available within the article and its tables. Acknowledgments Publication of this paper was supported by the University of Medicine and Pharmacy Carol Davila, through the institutional program ‘Publish not Perish’. Conflicts of Interest The authors declare no conflicts of interest. References Figure 1. PRISMA-style study selection flow diagram for the structured narrative review. The figure summarizes PubMed search retrieval, manual deduplication by PMID, title/abstract screening, eligibility assessment, and final inclusion for the primary descriptive synthesis. OLST, otogenic lateral sinus thrombosis; PMID, PubMed identifier. Figure 1. PRISMA-style study selection flow diagram for the structured narrative review. The figure summarizes PubMed search retrieval, manual deduplication by PMID, title/abstract screening, eligibility assessment, and final inclusion for the primary descriptive synthesis. OLST, otogenic lateral sinus thrombosis; PMID, PubMed identifier. Figure 2. Proposed practical management algorithm for otogenic lateral sinus thrombosis. The algorithm synthesizes available evidence from the included studies and current principles of cerebral venous thrombosis management. It is intended as a practical clinical framework and not as a formal guideline. Treatment decisions should be individualized according to disease severity, thrombus extension, septic status, intracranial complications, bleeding risk, thrombophilia and multidisciplinary assessment. CT, computed tomography; IJV, internal jugular vein; MRI, magnetic resonance imaging; MRV, magnetic resonance venography; OLST, otogenic lateral sinus thrombosis; TS, transverse sinus. Figure 2. Proposed practical management algorithm for otogenic lateral sinus thrombosis. The algorithm synthesizes available evidence from the included studies and current principles of cerebral venous thrombosis management. It is intended as a practical clinical framework and not as a formal guideline. Treatment decisions should be individualized according to disease severity, thrombus extension, septic status, intracranial complications, bleeding risk, thrombophilia and multidisciplinary assessment. CT, computed tomography; IJV, internal jugular vein; MRI, magnetic resonance imaging; MRV, magnetic resonance venography; OLST, otogenic lateral sinus thrombosis; TS, transverse sinus. Table 1. Included studies and key clinical characteristics of patients with otogenic lateral sinus thrombosis. Table 1. Included studies and key clinical characteristics of patients with otogenic lateral sinus thrombosis. Study N Age M/F Otologic Symptoms Neurological Findings Sinus Involvement Surgical Treatment Abbreviations: SS, sigmoid sinus; TS, transverse sinus; IJV, internal jugular vein; NR, not reported. Patient counts refer to confirmed OLST cases only. For Vergadi et al. [ 12], only the OLST/CVST subset ( n = 5) was counted; sex distribution for this subset was not separately reported. Huang et al. [ 13] were retained for demographic and anatomical comparison but not for treatment-specific or outcome-specific conclusions where data were NR. Table 2. Anticoagulation regimens, antibiotic therapy and clinical/radiological outcomes in patients with otogenic lateral sinus thrombosis. Table 2. Anticoagulation regimens, antibiotic therapy and clinical/radiological outcomes in patients with otogenic lateral sinus thrombosis. Study Anticoagulation Duration Antibiotics Duration Clinical Outcomes Radiological Outcomes Abbreviations: LMWH, low molecular weight heparin; UFH, unfractionated heparin; NR, not reported. Treatment categories are not mutually exclusive when studies reported transitions or combined regimens. For Vergadi et al. [ 12], only the OLST/CVST subset was counted. Huang et al. [ 13] were not used for treatment-specific or outcome-specific conclusions because the relevant data were NR. Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. © 2026 by the authors. Published by MDPI on behalf of the Lithuanian University of Health Sciences. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license. Share and Cite MDPI and ACS Style Bizdu-Branovici, A.M.; Gherasie, L.; Zica, M.D.; Rusescu, A.; Ionița, I.G.; Hainaroșie, R.; Zainea, V. Otogenic Lateral Sinus Thrombosis: Controversies and Current Management Strategies. Medicina 2026, 62, 1093. https://doi.org/10.3390/medicina62061093 AMA Style Bizdu-Branovici AM, Gherasie L, Zica MD, Rusescu A, Ionița IG, Hainaroșie R, Zainea V. Otogenic Lateral Sinus Thrombosis: Controversies and Current Management Strategies. Medicina. 2026; 62(6):1093. https://doi.org/10.3390/medicina62061093 Chicago/Turabian Style Bizdu-Branovici, Alexandra Madalina, Luana Gherasie, Maria Denisa Zica, Andreea Rusescu, Irina Gabriela Ionița, Razvan Hainaroșie, and Viorel Zainea. 2026. "Otogenic Lateral Sinus Thrombosis: Controversies and Current Management Strategies" Medicina 62, no. 6: 1093. https://doi.org/10.3390/medicina62061093 APA Style Bizdu-Branovici, A. M., Gherasie, L., Zica, M. D., Rusescu, A., Ionița, I. G., Hainaroșie, R., & Zainea, V. (2026). Otogenic Lateral Sinus Thrombosis: Controversies and Current Management Strategies. Medicina, 62(6), 1093. https://doi.org/10.3390/medicina62061093 Article Metrics Article metric data becomes available approximately 24 hours after publication online.
