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368                                          THE EAR

nights following operation, or if the sinus wall should appear greyish-yellow
or brownish-green and slough-like at the first or subsequent operations.
Before opening, the sinus plate is removed to expose the healthy sinus wall
above and below the diseased area. Gauze packing is inserted between the
sinus and bone in an attempt to shut off the flow of blood, and the sinus is
slit open and the clot evacuated. In most cases there is free bleeding in spite
of the pack, and a BIPP pack should be introduced into the lumen of the
sinus to check the haemorrhage. Some surgeons like to tie off the internal
jugular vein in the neck at the same operation, but if this is not done routinely
it is called for if the case does not settle down after the initial surgery, or
if there is evidence of blood-borne infection.

Septic thrombosis occasionally follows accidental injury to the sinus
during mastoid operations. Injury to the wall should be treated by the
application of a postage-stamp graft of fascia from the mastoid cortex, or a
piece of temporalis muscle should be cut off and applied. This usually
arrests the bleeding, and very often there is no further trouble. Should rigors
occur postoperatively the case is treated as a sinus thrombosis.


This condition may be caused by thrombosis occurring in a dural blood
sinus, and the symptoms produced are considered to be due to poor absorp-
tion of the cerebrospinal fluid by the arachnoid villi secondary to a choke
in one of the dural sinuses, especially the sigmoid sinus. Severe headache,
which may be intermittent but very intense, is a prominent symptom and
it may be accompanied by vomiting. There is a variable nystagmus, incon-
stant in direction, and papilloedema is frequently present while occasionally
there is involvement of the abducent nerve on the homolateral side of the
ear infection. The pressure of the cerebrospinal fluid is raised to 300 mm
or more, but examination shows a normal cytology. On ventriculography
the ventricles show no variation in size but intraventricular pressure may
be raised. Treatment is by anticoagulant therapy given in the hope of pre-
venting further thrombosis, and by frequent ventricular or lumbar punctures
to relieve the pressure of the cerebrospinal fluid. The therapy may require
to be continued for some time as the condition tends to persist for a month
or longer.