Cavernous sinus thrombosis
Background
- Severe infection involving complications of paranasal sinus and facial infections (e.g. 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