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A 66-year-old female with a history of sinusitis presented with persistent diplopia and worsening eyelid swelling. Examination revealed bilateral vision loss, cranial nerve palsies, left-sided chemosis, proptosis, and edema. Initial imaging showed sphenoid sinus opacification, bilateral ethmoid disease, lack of filling of bilateral cavernous sinuses, and partial thrombosis of the left superior ophthalmic vein. The sinus findings were evaluated with endoscopic sinus surgery, which was unremarkable. Subsequent orbital imaging suggested the lesions were in keeping with tumor thrombus as opposed to bland thrombus. CT scans revealed a large mass in the right axilla, which was biopsied and confirmed the diagnosis of diffuse large B-cell lymphoma (DLBCL). The patient was treated with anticoagulation, steroids, and chemotherapy resulting in marked improvement. Our report highlights a rare case of tumor thrombus from DLBCL causing bilateral cavernous sinus thrombosis and, to the best of our knowledge, the first documented case of superior ophthalmic vein thrombosis from tumor thrombus.
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INTRODUCTION AND IMPORTANCE: Postoperative visual loss (POVL) is a relatively rare but devastating complication. We reported a case of POVL after spine surgery caused by ischemia of retina and optic nerve, and firstly introduced the possibility of cavernous sinus thrombosis in POVL development. CASE PRESENTATION: A 67-year-old woman diagnosed with "lumbar spinal stenosis" was admitted to undergo posterior lumbar spinal canal decompression surgery because of the persistent lumbago and numbness. The operation was performed in the prone position under general anesthesia uneventfully. On the second day, the visual acuity of her right eye suddenly decreased to no light perception. The ophthalmic examination indicated edematous eyelid, chemosis, ptosis, ophthalmoplegia, relative afferent pupillary defect and higher orbital pressure in her affected eye, and funduscopic examination revealed pale optic disc, diffuse retinal welling and attenuated arteries. Cerebral magnetic resonance angiography implied the stenosis of cavernous sinus segment of right internal carotid artery. Aseptic cavernous sinus thrombosis and the secondary combined occlusion of central retinal and optic nerve vessels were suspected. Therefore, anticoagulation, vasodilation, oxygen and anti-inflammation treatment were timely administrated. One month after the treatment, swelling eyelid and ocular motion had markedly improved. However, there was no remarkable improvement in the patient's visual acuity. CLINICAL DISCUSSION: Postoperative visual loss (POVL) after spine surgery is regarded as a serious complication with irreversible vision damage. It was alarming that cavernous sinus thrombosis might be a possible cause of POVL. High-volume fluid replacement, unstable hemodynamic parameters, prone position and prolonged surgical duration might bring about microvascular diseases and hypercoagulable state, contributing to the occurrence of POVL. CONCLUSION: Our study firstly implied the possibility of cavernous sinus thrombosis in the POVL development. Detailed assessment, fluids management, hemodynamic stabilizing and duration optimization were proposed for POVL prevention.
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Brain and ocular infections can be the worst and fatal consequences of sinonasal infections in immunomodulated or immunocompromised patients. We report a case of a 35-year-old female who received an allogenic hematopoietic stem cell transplantation for acute myeloid leukemia, suffering from maxillo-spheno-ethmoidal rhinosinusitis which was complicated by cavernous sinus thrombosis, orbital cellulitis, optic ischemia and cerebritis.
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Diagnosis and management of cavernous sinus thrombosis (CST) can be challenging, but several clinical clues can aid in a more time-efficient and cost-effective approach. This condition is rare which can delay diagnosis and be fatal due to the several important neurovascular structures that run through the cavernous sinus. This report discusses a case of CST in a male with substance use disorder whose signs, symptoms, and diagnostic findings were classic for CST. When patients present with multiple concerns, symptom recognition can be challenging, as in this case. Clinicians need to take all symptoms and physical exam findings into consideration and eliminate any bias to provide proper care for patients. Early detection can lead to a more rapid diagnosis and early initiation of adequate treatment to provide better outcomes. There are limited evidence-based guidelines regarding diagnosis and treatment. This report will also review some of the more recent literature on the topic in an attempt to aid healthcare providers in giving proper care to their patients and thereby increasing knowledge and awareness of the subject.
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INTRODUCTION: Cavernous sinus thrombosis (CST) is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of CST, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: CST is a potentially deadly thrombophlebitic disease involving the cavernous sinuses. The most common underlying etiology is sinusitis or other facial infection several days prior to development of CST, though other causes include maxillofacial trauma or surgery, thrombophilia, dehydration, or medications. Staphylococcus aureus, streptococcal species, oral anaerobic species, and gram-negative bacilli are the most frequent bacterial etiologies. The most prevalent presenting signs and symptoms are fever, headache, and ocular manifestations (chemosis, periorbital edema, ptosis, ophthalmoplegia, vision changes). Cranial nerve (CN) VI is the most commonly affected CN, resulting in lateral rectus palsy. Other CNs that may be affected include III, IV, and V. The disease may also affect the pulmonary and central nervous systems. Laboratory testing typically reveals elevated inflammatory markers, and blood cultures are positive in up to 70% of cases. Computed tomography of the head and orbits with intravenous contrast delayed phase imaging is recommended in the ED setting, though magnetic resonance venography demonstrates the highest sensitivity. Management includes resuscitation, antibiotics, and anticoagulation with specialist consultation. CONCLUSION: An understanding of CST can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Trombose do Corpo Cavernoso , Humanos , Trombose do Corpo Cavernoso/diagnóstico , Trombose do Corpo Cavernoso/terapia , Trombose do Corpo Cavernoso/etiologia , Serviço Hospitalar de Emergência , Tomografia Computadorizada por Raios X , Prevalência , Anticoagulantes/uso terapêutico , Antibacterianos/uso terapêuticoRESUMO
Streptococcus constellatus pharyngis is a gram-positive commensal bacterium commonly found in the oropharynx, gastrointestinal and urogenital tracts. It might be an aggressive opportunistic pathogen causing invasive pyogenic infections in sterile areas, mostly as peritonsillar and orofacial abscesses. We report the case of a 6-year-old girl, who presented multiple head and neck abscesses and bilateral cavernous sinus thrombosis secondary to Streptococcus constellatus pharyngis. Cavernous sinus thrombosis, consequent to this microorganism, has not been reported to date in the literature. Due to the invasive features of this pathogen, a long-term antibiotherapy (up to 9 months) is required. Additionally, a surgical drainage is indicated in case of head and neck, or brain abscesses, larger than 20 or 25 mm respectively. Anticoagulation should be considered in case of venous thrombosis. The interest of this case is not only based on the rarity and severity of the disease, but also on the success of medical and surgical therapy (including long- term antibiotics, anticoagulation and two surgical procedures). This experience may serve as a guide to treat future cases. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-024-04511-3.
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Ophthalmic vein thrombosis is a severe clinical entity with proptosis, eyelid swelling, orbital pain and reduction of visual acuity; its incidence is rare with 3-4 cases /million /year. Clinical manifestations result from venous congestion caused by septic (orbital cellulitis) or aseptic aetiologies (coagulopathies, trauma) and in some cases it could be associated with cavernous sinus thrombosis. In this paper, we describe a case report unique in the literature, of bilateral cavernous sinus and ophthalmic veins thrombosis due to both septic and aseptic causes characterized by unilateral sphenoid sinusitis sustained by Trueperella pyogenes infection. Trueperella pyogenes is an opportunistic animal pathogen, and its infections occur in both domestic and wild animals worldwide but are rare in humans; this is the first instance of human infection in the head and neck with an unknown hypercoagulable state.
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Background: Various diseases involving the cavernous sinus can cause a condition called cavernous sinus syndrome (CSS), which is characterized by ophthalmoplegia or sensory deficits over the face resulting from the compression effect of internal structure. While tumor compression is the most reported cause of CSS, statistical data on CSS caused by infections are limited. Its risk factors, treatment methods, and clinical outcomes are not well-documented. Methods: In this retrospective study, we reviewed the data of patients admitted to a tertiary medical center from 2015 to 2022 with a diagnosis of acute and chronic sinusitis and at least one diagnostic code for CSS symptoms. We manually reviewed whether patients were involved in two or more of the following cranial nerves (CN): CN III, CN IV, CN V, or CN VI, or at least one of these nerves with a neuroimaging-confirmed lesion in the cavernous sinus. Results: Nine patients were diagnosed with rhinosinusitis-related CSS. The most common comorbidity was type 2 diabetes, and the most common clinical manifestations were diplopia and blurred vision. The sphenoid sinus was the most affected sinus. One patient expired due to a severe brain abscess infection without surgery. The remaining patients underwent functional endoscopic sinus surgery, and 50% of the pathology reports indicated fungal infections. Staphylococcus spp. was the most cultured bacteria, and Amoxycillin/Clavulanate was the most used antibiotic. Only four patients had total recovery during the follow-up one year later. Conclusions: CSS is a rare but serious complication of rhinosinusitis. Patients with diabetes and the elderly may be at a higher risk for this complication. Even after treatment, some patients may still have neurological symptoms.
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Purpose: Superior ophthalmic vein thrombosis (SOVT) is a rare clinical entity, which can have a septic and an aseptic cause. Aseptic SOVT is typically treated with anticoagulation. Glucocorticoids are reserved for cases with concurrent orbital inflammation.We present three cases of SOVT due to carotid cavernous fistula not responding to standard treatment, subsequently successfully treated with glucocorticoids. Observations: Three patients with various degrees of proptosis, ophthalmoplegia, orbital stasis and reduced vision are presented. One patient was confirmed to have isolated SOVT, while the other two had associated cavernous sinus thrombosis. All patients had underlying carotid-cavernous fistula without signs of infection. All patients were initially treated with parenteral anticoagulation. Two patients were treated with intraocular pressure-reducing medication. One of whom underwent canthotomy-cantholysis. Two patients experienced a gradual worsening of symptoms during treatment with anticoagulation, while one patient improved before deteriorating. All patients received additional treatment with glucocorticoids consisting of a three-day treatment with intravenous methylprednisolone 500 mg, followed by oral glucocorticoids resulting in total regression of symptoms. Two patients regained 20/20 vision, with some vision field defects, while the third patient regained 20/25 vision. Conclusion and importance: The addition of glucocorticoids in the treatment of aseptic SOVT can lead to improvement of symptoms and a potentially better prognosis. However, the risk of complications of glucocorticoid treatment must be carefully considered on a case-by-case basis.
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We describe a rare and complex case of septic cavernous sinus thrombosis (SCST) in a 70-year-old patient who initially presented with ocular symptoms that rapidly progressed to severe intracranial vascular complications, including subarachnoid hemorrhage (SAH). Despite the use of broad-spectrum antibiotics and anticoagulants, the patient's condition deteriorated. SCST, often caused by sinus infections, presents a significant diagnostic and therapeutic dilemma, with mortality rates exceeding 20%. This report underscores the diversity of clinical presentations, ranging from mild headaches to severe cranial nerve deficits, that complicate diagnosis and treatment. The inability to detect any aneurysms in our patient using magnetic resonance imaging (MRI) and computed tomography angiography (CTA) may indicate an alternative pathogenesis. This could involve venous hypertension and endothelial hyperpermeability. This case illustrates the need for personalized treatment approaches, as recommended by the European Federation of Neurological Societies, and the importance of a multidisciplinary perspective when managing such intricate neurological conditions. Our findings contribute to the understanding of SCST coexisting with SAH.
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Trombose do Corpo Cavernoso , Trombose dos Seios Intracranianos , Hemorragia Subaracnóidea , Humanos , Idoso , Trombose do Corpo Cavernoso/complicações , Trombose do Corpo Cavernoso/diagnóstico , Hemorragia Subaracnóidea/complicações , Trombose dos Seios Intracranianos/complicações , Trombose dos Seios Intracranianos/diagnóstico , Trombose dos Seios Intracranianos/tratamento farmacológico , Anticoagulantes/uso terapêutico , Imageamento por Ressonância Magnética/efeitos adversosRESUMO
Cavernous sinus thrombosis (CST) is a life-threatening condition occurring due to an active infection, coagulation abnormalities, and trauma. Thromboembolic events are known complications secondary to novel coronavirus disease-19 (COVID-19) due to dysfunction in endothelial function and clotting factor dysfunction. We report a case of cavernous sinus thrombosis and delayed ophthalmic vein thrombosis associated with a preceding COVID-19 infection confirmed with a facial computed tomography (CT) scan. Clinicians should have a broad differential in patients with hypercoagulable states, as complications secondary to COVID-19 can be life-threatening.
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Cavernous sinus thrombosis (CST) is a rare, yet severe condition often linked to infections in the nasal and facial areas. We present a case of a 43-year-old male farmer with diabetes who initially showed ear abscess symptoms that progressed to vision loss and CST-like symptoms. Self-treatment and an unidentified medication regimen may have worsened his condition. Advanced diagnostic evaluations, particularly magnetic resonance imaging with magnetic resonance venography, confirmed CST, likely originating from the ear infection spreading to the eyes, causing bilateral orbital cellulitis. Treatment with antibiotics, anticoagulants, and supportive therapy stabilized the patient's condition. This case emphasizes the importance of early detection and intervention in CST, especially in atypical presentations, and the need for comprehensive diagnostic and therapeutic approaches.
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Cavernous sinus thrombosis (CST) is a rare but life-threatening infectious disease whose diagnosis and treatment are challenging. CST can result in ocular and neurologic morbidities, as well as fatal systemic complications due to systemic thrombus. Occasionally, these clinical symptoms can be a result of contralateral sinusitis. A 75-year-old female presented with severe headache and fever. Magnetic resonance imaging revealed a multifocal filling defect in both cavernous sinuses, with heterogeneous enhancement and thrombosis of the right superior ophthalmic vein. Intravenous antibiotic was administered, and endoscopic sinus surgery was performed. The patient was discharged 40 days after admission and there were no neurologic symptoms and no evidence of sequelae during the 10-month follow-up. Symptoms of CST on the contralateral side are often missed, which delays initiation of appropriate treatment. When CST secondary to paranasal sinusitis is diagnosed, clinicians should consider contralateral as well as ipsilateral infection of the paranasal sinus. Preventing disease progression and complications through early and aggressive antibiotic administration along with sinus surgery is crucial.
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BACKGROUND: Orbital cellulitis is an infrequent but serious infectious complication of rhinosinusitis, most commonly seen in the pediatric population. Extension into the cavernous sinus, leading to further infection and thrombosis, is a rare but life-threatening complication. Although COVID-19 has been linked to an increased risk of venous thromboembolism, most cases involve extremity deep venous thrombosis or pulmonary embolism; reports of intracranial or jugular system thrombosis are rare. CASE REPORT: We describe a case of a 17-year-old female patient with no significant medical history or thrombotic risk factors found to have orbital cellulitis and severe pansinusitis, complicated by multiple venous thromboses in the head and neck requiring emergent surgical intervention and pediatric intensive care admission. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Extensive head and neck venous thrombosis and intracranial abscesses are rare complications of pansinusitis and orbital cellulitis, and the thrombotic complications of COVID-19 are well documented. A delay in diagnosis and treatment can lead to potentially devastating consequences.
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Abscesso Encefálico , COVID-19 , Celulite Orbitária , Trombose Venosa , Feminino , Humanos , Criança , Adolescente , Celulite Orbitária/etiologia , COVID-19/complicações , Veias , Trombose Venosa/complicações , Abscesso Encefálico/complicações , Celulite (Flegmão)/complicaçõesRESUMO
BACKGROUND: The Belonidae family of fish has been implicated in various penetrating injuries; to date, however, there have been limited reports of brain injury due to this species. OBSERVATIONS: The authors present the case of a young patient who suffered an ocular penetrating injury from a needlefish with a resultant cavernous sinus thrombosis and concomitant carotid-cavernous fistula. This case highlights the interdisciplinary management of this rare condition through a strategy of anticoagulation titration to the endpoint of fistula closure. LESSONS: Through this report the importance of a high index of suspicion for neurovascular injury and fistula formation in penetrating ocular injuries is highlighted as well as the importance of interdisciplinary management of patients with such injuries and their sequelae.
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Intracranial cavernous sinus metastases of oral squamous cell carcinoma (OSCC) are rare, with a reported incidence of 0.4 %. Due to their extremely infrequent presentation the etiology and management modalities of such complications are not clearly represented in the literature. Here we present a case of a 58-year-old male diagnosed with OSCC of Right Lower Alveolus with underlying bone invasion, cT4aN1M0, Stage IV. He underwent Right Hemi-mandibulectomy with Modified Neck Dissection, Pectoralis Major Myocutaneous Flap, and 60 Gy/30# adjuvant radiotherapy. Six months later, the patient was diagnosed with recurrence involving the right infratemporal fossa with associated right cavernous sinus thrombosis. Immunohistochemistry block review showed PDL1 - Positive. The patient was subjected to Cisplatin and Pembrolizumab immunotherapy. After receiving 35 cycles of Pembrolizumab over a period of 2 years the patient is doing well with no recurrence.
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Carcinoma de Células Escamosas , Trombose do Corpo Cavernoso , Neoplasias de Cabeça e Pescoço , Neoplasias Bucais , Masculino , Humanos , Pessoa de Meia-Idade , Carcinoma de Células Escamosas de Cabeça e Pescoço/terapia , Carcinoma de Células Escamosas/terapia , Carcinoma de Células Escamosas/secundário , Neoplasias Bucais/terapiaRESUMO
Cavernous sinus thrombosis (CST) is an unusual condition that can result in high mortality and morbidity rate if not treated immediately. Case presentation: An Indonesian male, 47 years old, presented with total right ocular ophthalmoplegia followed by blindness, headache, ptosis, periorbital swelling, and hypoesthesia over the left V1 region. MRI of the brain showed suitable cavernous thickening until the right orbital apex, which in contrast showed enhancement suggestive of right Tolosa-Hunt syndrome. The patient was treated with a high dose of steroids, but the patient's complaints did not improve. The patient underwent digital subtraction angiography and found CST. The optical coherence tomography was found to be central serous chorioretinopathy. He was treated with an antibiotic, anticoagulant, and extraction of the right maxillary molar was performed to remove the source of the infection. After 3 weeks, visual acuity and optical coherence tomography examination were improved. Discussion: A comprehensive examination, such as digital subtraction angiography, is essential to confirm CST diagnosis for the patient to obtain the right therapy. This report highlighted the value of the prompt diagnosis of CST through neuroimaging and the importance of proper therapy in patient management. Conclusions: Early diagnosis, comprehensive examination, and proper treatment of CST will increase good prognosis.
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Septic pulmonary embolism (SPE) is a rare complication that happens when infected thrombi from the original site of infection break off and travel to the pulmonary blood vessels, causing an infarction or an abscess. Cases were reported on SPE, with tricuspid or pulmonary valve endocarditis being the most common primary site, especially in intravenous drug abusers. There are, however, very few reports of SPE brought on by septic cavernous sinus thrombosis (CST). Here, we describe the case of an 18-year-old male who had a pustule on his left eyelid, after which he developed fever, spontaneous swelling of his left eye, followed by his right eye, along with bilateral proptosis and diplopia, and new-onset dyspnea. Auscultation revealed decreased breath sounds in the left lung fields. Magnetic resonance imaging (MRI) revealed cavernous sinus thrombosis. Blood cultures isolated Staphylococcus aureus species. High-resolution computed tomography (HRCT) revealed a left-sided pneumothorax with minimal pleural effusion and multiple nodules scattered among both lungs, suggesting septic pulmonary emboli. We report this case to convey how a minor lesion, that is, an eyelid pustule (stye), can get complicated and set off a spiral of events that takes an unexpected tangent, challenging physicians and necessitating a rigorous approach.
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Superior ophthalmic vein thrombosis (SOVT) is a rare, sight-threatening condition. It can be clinically challenging to distinguish from pre-septal cellulitis or cavernous sinus thrombosis. Imaging is often a key to identifying SOVT, and multi-disciplinary input is paramount to ensuring the optimum outcome. This often involves the paediatricians, ophthalmologists and paediatric neurologists if necessary. We report a case of a young boy with right SOVT that had initially been diagnosed as pre-septal cellulitis. A contrast-enhanced computed tomography scan was performed, as the patient developed limited eye movement on elevation, which showed dilatation of the right ophthalmic vein with pansinusitis. He was successfully treated with anticoagulation and antibiotics.