成人急性中耳炎并发乳突炎及耳源性横窦-乙状窦血栓形成：一例关于感染性发病机制与多学科治疗的病例报告

文献信息

中文摘要

背景： 急性中耳炎通常是一种自限性细菌感染；然而，在少数情况下，感染向乳突及邻近硬脑膜静脉窦的连续扩散可能导致危及生命的颅内并发症。耳源性横窦-乙状窦血栓形成在成人中并不常见，因其早期表现可能无特异性，且指导治疗的证据仍然有限，故在诊断和治疗上均构成挑战。
病例介绍： 我们报告一例32岁男性，无相关病史，因右侧耳漏和耳痛3周就诊，尽管门诊接受阿莫西林-克拉维酸治疗，临床表现仍加重。体格检查发现脓性耳漏、外耳道水肿、鼓膜膨隆、耳后红斑、压痛及Jacques征阳性。增强计算机断层扫描显示急性乳突炎伴乙状窦骨板侵蚀，以及右侧横窦-乙状窦静脉复合体血栓形成并延伸至同侧颈内静脉。磁共振静脉造影证实受累静脉区域无静脉充盈。患者接受了逐步的多学科治疗，包括广谱静脉抗生素、依诺肝素抗凝、鼓膜切开置管术、乳突切除术、侧窦穿刺及乳突尖脓肿引流。抗生素暴露后获取的微生物培养未见生长。患者短期临床及耳科病程良好，1个月时仅有轻度残余传导性听力损失；然而，术后血管影像学检查不可用，无法客观记录静脉再通。
结论： 本病例说明了从急性耳源性感染到邻近乳突受累、乙状窦骨板侵蚀、推测的脓毒性静脉血栓形成及潜在颅内蔓延的病理生理连续过程。它还强调了在成人复杂性耳源性感染中，早期增强影像学检查、针对性静脉评估、抗菌药物升级、手术感染源控制、个体化抗凝及结构化随访的重要性。由于微生物学确认和术后血管影像学检查不可用，感染和血栓形成的解读应被视为临床推断而非直接证实。

英文摘要

BACKGROUND: Acute otitis media is usually a self-limited bacterial infection; however, in rare cases, contiguous spread to the mastoid and adjacent dural venous sinuses may result in life-threatening intracranial complications. Otogenic transverse-sigmoid sinus thrombosis is uncommon in adults and represents a diagnostic and therapeutic challenge because its early presentation may be nonspecific and evidence guiding management remains limited.
CASE PRESENTATION: We report the case of a 32-year-old man with no relevant medical history who presented with a 3-week history of right-sided otorrhea and otalgia, with clinical worsening despite outpatient amoxicillin-clavulanic acid. Physical examination revealed purulent otorrhea, external auditory canal edema, a bulging tympanic membrane, postauricular erythema, tenderness, and a positive Jacques sign. Contrast-enhanced computed tomography demonstrated acute mastoiditis with erosion of the sigmoid plate and thrombosis of the right transverse-sigmoid venous complex extending into the ipsilateral internal jugular vein. Magnetic resonance venography confirmed absence of venous filling in the affected venous territory. The patient was managed using a stepwise multidisciplinary approach that included broad-spectrum intravenous antibiotics, anticoagulation with enoxaparin, myringotomy with ventilation tube placement, mastoidectomy, lateral sinus puncture, and drainage of a mastoid tip abscess. Microbiological cultures obtained after antibiotic exposure showed no growth. The patient had a favorable short-term clinical and otologic course, with mild residual conductive hearing loss at 1 month; however, postoperative vascular imaging was not available to objectively document venous recanalization.
CONCLUSION: This case illustrates the pathophysiological continuum from acute otogenic infection to contiguous mastoid involvement, sigmoid plate erosion, presumed septic venous thrombosis, and potential intracranial extension. It also highlights the importance of early contrast-enhanced imaging, targeted venous assessment, antimicrobial escalation, surgical source control, individualized anticoagulation, and structured follow-up in adults with complicated otogenic infections. Because microbiological confirmation and postoperative vascular imaging were not available, the infectious and thrombotic interpretation should be considered clinically inferred rather than directly demonstrated.