Cavernous sinus thrombosis
Background
- Severe infection involving complications of paranasal sinus and facial infections (e.g. manipulated midface abscesses, furuncles)
- 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
- Decreased EOM 2/2 CN III, IV, VI
- CN VI typically affected 1st causing lateral gaze palsy
- Decreased corneal sensation 2/2 CN V
- If infection spreads into CNS: AMS, lethargy
Work Up
- MRI with MR Venogram - study of choice
- CT head/orbits with IV contrast
- CT findings can be subtle and if clinical suspicion is high cannot rule out if neg CT
- Blood Cx
DDx
- Aneurysmal dilation/rupture of internal carotid artery in cavernous sinus
- Cellulitis
- Orbital/Periorbital infection
- Acute Angle Closure Glaucoma
- Sinusitis
Treatment
- 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