Last reviewed: 25 Dec 2021
Last updated: 13 Nov 2019



History and exam

Key diagnostic factors

  • rapid onset of signs and symptoms (acute septic CST)
  • headache
  • fever
  • periorbital edema
  • chemosis and proptosis
  • lateral gaze palsy
  • ophthalmoplegia
  • profound sepsis (acute septic CST)

Other diagnostic factors

  • ptosis and mydriasis
  • papilledema and/or retinal-vein dilatation
  • decreased corneal reflex
  • hypo- or hyperesthesia in the distribution of the ophthalmic and maxillary nerves
  • mental state changes (e.g., confusion, drowsiness, coma)
  • clinically detectable primary infection site
  • meningismus (nuchal rigidity, photophobia, and headache)
  • positive Kernig or Brudzinski signs
  • seizures
  • loss of visual acuity

Risk factors

  • recent history of acute sinusitis
  • history of facial infections
  • history of periorbital infection
  • history of otitis media, mastoiditis, or petrositis
  • history of dental or oral infection
  • history of sepsis
  • immunosuppression
  • genetic prothrombotic condition
  • acquired and other prothrombotic states
  • history of head and neck trauma
  • use of oral contraceptives
  • history of malignancy
  • history of recent head or neck surgery
  • vascular abnormalities
  • ulcerative colitis
  • volume depletion
  • heroin overdose

Diagnostic investigations

1st investigations to order

  • CBC
  • contrast-enhanced high-resolution CT of head
  • contrast-enhanced MRI of head
  • blood culture
  • microscopy and culture of suppurative fluid or tissue from primary infective source
  • antiphospholid and anticardiolipid antibodies
  • protein S and protein C
  • antithrombin III
  • factor V Leiden
  • hemoglobin electrophoresis

Treatment algorithm



Jayant Pinto, MD

Associate Professor of Surgery

Section of Otolaryngology-Head and Neck Surgery

University of Chicago



JP serves as a speaker and advisor to Optinose and Stallergenes. JP is a member of the advisory board for Genentech and ALK. JP has received grants from the National Institutes of Health.

Mohamad R. Chaaban, MD, MSCR, MBA

Associate Professor

Department of Otolaryngology

University of Texas Medical Branch



MC declares that he has no competing interests.

Peer reviewers

David Rowed, MD

Division of Neurosurgery

University of Toronto





DR declares that he has no competing interests.

Louis R. Caplan, MD

Lecturer in Neurology

Hospital Chief

Cerebrovascular/Stroke Division

Beth Israel Deaconess Medical Center

Division of Cerebrovascular/Stroke




LRC declares that he has no competing interests.

Sorabh Khandelwal, MD

Clinical Associate Professor of Emergency Medicine

Ohio State University




SK declares that he has no competing interests.

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