Cavernous sinus thrombosis: Difference between revisions
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== Background == | == Background == | ||
*Severe infection involving complications of paranasal sinus and facial infections (e.g. manipulated midface abscesses, furuncles) | *Severe infection involving complications of paranasal sinus and facial infections (e.g. manipulated midface abscesses, furuncles) | ||
*Frequent extension of thrombosis to opposite sinus | *Frequent extension of thrombosis to opposite sinus | ||
*Low frequency, but high rate of morbidity/mortality | *Low frequency, but high rate of morbidity/mortality | ||
== Causes == | == Causes == | ||
*Staph aureus, strep pneumoniae, gram neg bacilli, anaerobes, fungi | |||
*Staph aureus, strep pneumoniae, gram neg bacilli, anaerobes, | |||
== Clinical Features == | == Clinical Features == | ||
*Fevers, chills, N/V, headache | *Fevers, chills, N/V, headache | ||
*Eye exam | *Eye exam | ||
**CN VI typically affected 1st causing lateral gaze palsy | **Exophthalmos (uni/bl) | ||
**Decreased vision | |||
*If infection spreads into CNS | **Absent pupillary reflexes | ||
**Decreased EOM 2/2 CN III, IV, VI | |||
***CN VI typically affected 1st causing lateral gaze palsy | |||
**Decreased corneal sensation 2/2 CN V | |||
*If infection spreads into CNS: AMS, lethargy | |||
== Work Up == | == Work Up == | ||
*MRI with MR Venogram - study of choice | |||
*CT | *CT head/orbits with IV contrast | ||
**CT findings can be subtle and if clinical suspicion is high cannot rule out if neg CT | **CT findings can be subtle and if clinical suspicion is high cannot rule out if neg CT | ||
*Blood Cx | *Blood Cx | ||
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== Treatment == | == Treatment == | ||
*IV antibiotics: | |||
* | |||
**3rd generation Penicillin and | **3rd generation Penicillin and | ||
**Nafcillin or Vancomycin/Linezolid if suspected MRSA and <br> | **Nafcillin or Vancomycin/Linezolid if suspected MRSA and <br> | ||
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== Disposition == | == Disposition == | ||
*Consult ophthalmology, neurology, ID, surgery specialty (if drainage is needed) and admit ICU | *Consult ophthalmology, neurology, ID, surgery specialty (if drainage is needed) and admit ICU | ||
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*Harwood and Nuss | *Harwood and Nuss | ||
*Tintinalli | *Tintinalli | ||
*Emedicine | *Emedicine | ||
Revision as of 17:42, 13 December 2012
Background
- Severe infection involving complications of paranasal sinus and facial infections (e.g. manipulated midface abscesses, furuncles)
- 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
- Decreased EOM 2/2 CN III, IV, VI
- CN VI typically affected 1st causing lateral gaze palsy
- Decreased corneal sensation 2/2 CN V
- If infection spreads into CNS: AMS, lethargy
Work Up
- MRI with MR Venogram - study of choice
- CT head/orbits with IV contrast
- CT findings can be subtle and if clinical suspicion is high cannot rule out if neg CT
- Blood Cx
DDx
- Aneurysmal dilation/rupture of internal carotid artery in cavernous sinus
- Cellulitis
- Orbital/Periorbital infection
- Acute Angle Closure Glaucoma
- Sinusitis
Treatment
- 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