Cavernous Sinus Thrombosis

I was always taught to have a very healthy respect for infections of the Hands, Feet, or Face. Certainly, the infection itself can be problematic (tenosynovitis, plantar puncture, sinusitis, otitis media), but those particular areas have lots of very delicate and important structures in extremely close proximity… and that combination can lead to significant complications. Fortunately, the potential complications are rarely encountered. Unfortunately, their rarity may make our consideration of them challenging (ex, Gradenigo’s Syndrome). Let us maintain our reasonable vigilance and discuss another important complication – Cavernous Sinus Thrombosis:

Cavernous Sinus

  • The anatomy of the Cavernous Sinus is important to consider.
    • It is an irregular shaped space lined with endothelium.
    • It is on either side of the sella turcica.
    • It is lateral and superior to the sphenoid sinus.
    • It is immediately posterior to the optic chiasm.
  • Venous drainage is from the “Danger Triangle!” [Smith, 2015; Varshney, 2015]
    • Region from the corners of the mouth to the bridge of the nose and inclusive of the nose and maxilla.
    • Venous drainage from:
      • Superior and Inferior Ophthalmic Veins
      • Sphenoid and Middle Cerebral Veins
      • Facial Vein
    • Also drainage from frontal sinuses.
    • The connecting veins to and from the Cavernous Sinus lack valves so blood can flow in either direction… and thrombosis can migrate in both directions. [Varshney, 2015]

Cavernous Sinus Thrombosis

  • Cavernous Sinus Thrombosis is rare, but life-threatening. [Smith, 2015; Frank, 2015]
    • Frequency has been reduced since high utilization of antibiotics.
    • Mortality has been also reduced, but still exists and morbidity can be significant.
    • Usually a late complication of an infection of the central face. [Varshney, 2015]
  • Potential complications of Sinus Thrombosis include:
    • Injury to any of the structures contained within the Cavernous Sinus: [Smith, 2015]
      • CNs III, IV, V1, V2, VI
      • Internal carotid artery
    • Involvement in contiguous / adjacent structures: [Smith, 2015]
  • Prompt recognition is key to limiting complications! [Smith, 2015; Frank, 2015]
    • “Classic Presentation” = severe illness with high, fluctuating fevers in the setting of recent mid-face infection. [Varshney, 2015]
    • Common symptoms:
      • Severe Headache
      • Periorbital Swelling
      • Ptosis
      • Inability to Move Eyes
      • Pain / Numbness around midface and eyes
      • Vision Changes / Double Vision / Loss of Vision [Frank, 2015]
      • Seizures
      • High Fevers

Cavernous Sinus Thrombosis: Management

  • There is no current consensus guidelines for management of Cavernous Sinus Thrombosis. [Smith, 2015]
  • Imaging: [Smith, 2015; Frank, 2015]
    • Contrast-enhanced CT
      • Useful, but has radiation concerns.
    • Contrast-enhanced MRI [Rodriguez-Homs, 2019; Frank, 2015]
      • More difficult to come by in the ED.
      • Not MRV. MRV (venogram) has been found to miss some cases.
      • The slow turbulent flow may allow thrombus to be missed on MRV.
  • Therapy typically includes: [Smith, 2015; Varshney, 2015; Frank, 2015]
    • Antimicrobials
      • Empiric antibiotics (ex, Cephalosporin AND Metronidazole AND Vancomycin) should be initiated early.
      • Typical bacterial infections include:
        • Staph
        • Strep
        • Anaerobic bugs
      • Fungal infections (ex, Aspergillus, Rhizopus) have been shown to be important considerations in:
        • Immunocompromised patients
        • Diabetic patients
        • Patients on chronic steroids
    • Anticoagulation
    • Surgery
      • Functional Endoscopic Sinus Surgery has been advocated for, but not often required emergently.
      • Consultation with ENT early is important to help coordinate care for those who are not improving on antibiotics.

Moral of the Morsel

  • Remain Vigilant! It may be rare… but if there is a mid-face infection and High Fevers, Periorbital Edema, and/or Cranial Nerve abnormalities… think of Cavernous Sinus Thrombosis.
  • Abx STAT! Get the antimicrobial coverage started… and consider antifungals for at risk patients.
  • Consult ENT… but don’t expect emergent surgery.

References

Rodriguez-Homs LG1, Goerlitz-Jessen M1, Das SU1. A 17-Year-Old Girl With Unilateral Headache and Double Vision. J Investig Med High Impact Case Rep. 2019 Jan-Dec;7:2324709619838309. PMID: 31010318. [PubMed] [Read by QxMD]
Rebelo J1, Nayan S2, Choong K3, Fulford M4, Chan A5, Sommer DD6. To anticoagulate? Controversy in the management of thrombotic complications of head & neck infections. Int J Pediatr Otorhinolaryngol. 2016 Sep;88:129-35. PMID: 27497400. [PubMed] [Read by QxMD]
Smith DM1, Vossough A2, Vorona GA2, Beslow LA2, Ichord RN2, Licht DJ2. Pediatric cavernous sinus thrombosis: A case series and review of the literature. Neurology. 2015 Sep 1;85(9):763-9. PMID: 26231260. [PubMed] [Read by QxMD]
Varshney S1, Malhotra M1, Gupta P1, Gairola P1, Kaur N1. Cavernous sinus thrombosis of nasal origin in children. Indian J Otolaryngol Head Neck Surg. 2015 Mar;67(1):100-5. PMID: 25621244. [PubMed] [Read by QxMD]
Frank GS1, Smith JM1, Davies BW2, Mirsky DM3, Hink EM1, Durairaj VD4. Ophthalmic manifestations and outcomes after cavernous sinus thrombosis in children. J AAPOS. 2015 Aug;19(4):358-62. PMID: 26239205. [PubMed] [Read by QxMD]
Reid JR1. Complications of pediatric paranasal sinusitis. Pediatr Radiol. 2004 Dec;34(12):933-42. PMID: 15278322. [PubMed] [Read by QxMD]
Cannon ML1, Antonio BL, McCloskey JJ, Hines MH, Tobin JR, Shetty AK. Cavernous sinus thrombosis complicating sinusitis. Pediatr Crit Care Med. 2004 Jan;5(1):86-8. PMID: 14697115. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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