Cavernous Sinus Thrombosis

Basics

Description

  • Septic thrombophlebitis of the cavernous sinus
  • Causing headache, facial swelling, and cranial nerve deficits
  • Spreads from facial, odontogenic, or sinus infection
  • Exceptionally rare; often difficult to diagnose

Anatomy

  • Cavernous sinuses most centrally located dural sinus:
    • Cranial nerves (CN) III, IV, V1, and V2 traverse the lateral wall of the sinus
    • CN VI and the internal carotid artery occupy the medial portion of the sinus

Pathophysiology

  • Hematogenous spread of facial, otic, or neck infection into venous drainage system:
    • Contiguous spread directly from infected sinus cavities (sphenoid, ethmoid > frontal)
    • Facial infection in the danger triangle of the face
    • Dental infections
    • Otitis media or mastoiditis
  • Bacterial overgrowth leads to inflammation and coagulation, resulting in thrombosis
  • Venous engorgement of cavernous sinus can affect adjacent structures

Etiology

  • Septic:
    • Staphylococcus aureus accounts for 70%
    • Streptococcus pneumoniae, gram-negative bacilli, and anaerobes also seen
    • Fungi less common; include Aspergillus and Rhizopus species
  • Aseptic (uncommon):
    • Granulomatous conditions (TB)
    • Inflammatory disorders
    • Mass effect (tumors at base of skull, aneurysms)

Pediatric Considerations

  • Children may present with nonspecific symptoms such as decreased energy, vomiting, fever
  • Have high level of suspicion for any child with recent otitis or pharyngitis with worsening symptoms, declining mental status, or signs of increased intracranial pressure (ICP):
    • HTN, bradycardia, lethargy, vomiting, gait instability
  • More common in the neonatal period, when diagnosis can be extremely difficult to make

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