Cavernous sinus thrombosis

Background

• Severe infection involving complications of paranasal sinus and facial infections (ie manipulated midface abscesses, furuncles)
• Frequently associated with
  • Occular symptoms: pain, decreased vision, eye fixed in gaze, exophthalmos, eyelid edema
  • Systemic infection: HA, N/V, fevers, chills
• CN III, IV, V (V1 and V2 branch), VI travel within cavernous sinus and are susceptible resulting in associated palsies
  
• Frequent extension of thrombosis to opposite sinus
• Low frequency, but high rate of morbidity/mortality

Causes

• Staph aureus, strep pneumoniae, gram neg bacilli, anaerobes, Fungi

Clinical Features

• Fevers, chills, N/V, headache
• Eye exam: Exophthalmos (uni/bl), decreased vision, absent pupillary reflexes, papilledema, decreased extraocular movement secondary to CN III, IV, VI, decreased corneal sensation secondary to CN V1
  • CN VI typically affected 1st causing lateral gaze palsy

• If infection spreads into CNS pt. w/ AMS, lethargy

Work Up

• CT Head/Orbits with contrast
  • CT findings can be subtle and if clinical suspicion is high cannot rule out if neg CT
• MRI with MR Venogram - study of choice
• Blood Cx

DDx

• Aneurysmal dilation/rupture of internal carotid artery in cavernous sinus
• Cellulitis
• Orbital/Periorbital infection
• Acute Angle Closure Glaucoma
• Sinusitis

Treatment

• Immediately begin IV antibiotics:
  • 3rd generation Penicillin and
  • Nafcillin or Vancomycin/Linezolid if suspected MRSA and
    
  • Anaerobic coverage if suspected dental source
• Consider heparin if rapidly decompensating and CT neg for intracranial hemorrhage
• Consider steroids to decrease inflammation in conjunction with antibiotics
• Surgical drainage of primary infection if possible

Disposition

• Consult ophthalmology, neurology, ID, surgery specialty (if drainage is needed) and admit ICU

Complications

• Meningitis, septic emboli, remaining visual defects, CNS deficit, pituitary insufficiency,

Source

• Harwood and Nuss
• Tintinalli
• Emedicine