Thrombus formation within the cavernous sinus, which may be either septic or aseptic in origin. Infection can spread to the cavernous sinus either as an extension of thrombophlebitis or by septic emboli. The origin of aseptic cavernous sinus thrombosis is usually through trauma or a prothrombotic condition.
In the pre-antibiotic era, infections of the middle third of the face were responsible for the majority of cases. Currently, acute sinusitis is the most common predisposing condition.
Diagnosis is usually made through clinical evaluation together with imaging (computed tomography or magnetic resonance imaging).
In the acute presentation, one eye is typically affected first, followed by the second eye within 48 hours of symptom onset.
Must be differentiated from meningitis. Common early clinical features of both conditions include fever, headache, vomiting, and nuchal rigidity.
Antibiotics should be started immediately because they have the greatest effect on prognosis.
Cavernous sinus thrombosis (CST) is the formation of thrombus (clot) within the cavernous sinus, which can either be septic or aseptic. Septic CST is a rapidly evolving thrombophlebitic process with an infectious origin (typically from the middle third of the face, sinuses, ears, teeth, or mouth), affecting the cavernous sinus and its structures. Aseptic CST is usually a thrombotic process that is a result of trauma, iatrogenic injuries, or prothrombotic conditions.
History and exam
Key diagnostic factors
- rapid onset of signs and symptoms (acute septic CST)
- periorbital edema
- chemosis and proptosis
- lateral gaze palsy
- 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
- loss of visual acuity
- 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
- 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
1st investigations to order
- 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
Investigations to consider
- LP with CSF analysis
confirmed septic CST: without hemorrhagic complications
confirmed septic CST: with hemorrhagic complications
confirmed aseptic CST: without hemorrhagic complications
confirmed aseptic CST: with hemorrhagic complications
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
Department of Otolaryngology
University of Texas Medical Branch
MC declares that he has no competing interests.
David Rowed, MD
Division of Neurosurgery
University of Toronto
DR declares that he has no competing interests.
Louis R. Caplan, MD
Lecturer in Neurology
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.
- Periorbital or orbital cellulitis
- Superior orbital fissure syndrome
- Orbital apex syndrome
- ACR appropriateness criteria: headache
- ACR appropriateness criteria: orbits, vision and visual loss
Meningitis and septicemia
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