Bilateral cavernous sinus thrombosis complicating acute unilateral pansinusitis in a 15-year-old boy.

Cavernous sinus thrombosis (CST) is a rare and potentially fatal complication of acute sinusitis. Timely diagnosis and management is, therefore, essential in preventing death and neurological disability. Here, we describe the case of a paediatric patient with bilateral CST secondary to acute unilateral pansinusitis that presented with rapidly progressing bilateral periorbital oedema. Initial imaging was negative. This case serves to emphasise the importance of maintaining a high index of suspicion when managing paediatric patients with suspected CST with persistent symptoms. Expeditious investigation and management of our patient in this case resulted in a positive outcome, with resolution of symptoms and no residual neurological deficit.

Use of ventriculostomy in the treatment of septic cavernous sinus thrombosis (SCST).

We present a novel treatment with the use of intraventricular antibiotics delivered through a ventriculostomy in a patient who developed septic cavernous sinus thrombosis after sinus surgery. A 65-year-old woman presented with acute on chronic sinusitis. The patient underwent a diagnostic left maxillary antrostomy, ethmoidectomy, sphenoidotomy and sinusotomy. Postoperatively, the patient experienced altered mental status with episodic fever despite treatment with broad-spectrum antimicrobial therapy. MRI of the brain showed extensive meningeal enhancement with the involvement of the right trigeminal and abducens nerve along with thick enhancement along the right pons and midbrain. MR arteriogram revealed a large filling defect within the cavernous sinus. Intraventricular gentamicin was administered via external ventricular drain (ie, ventriculostomy) every 24 hours for 14 days with continued treatment of intravenous ceftriaxone and metronidazole. The patient improved with complete resolution of her cavernous sinus meningitis on repeat brain imaging at 6 months posthospitalisation.

Cavernous sinus-orbital apex aspergillus infection in a diabetic patient: A case report.

RATIONALE: Cavernous sinus-orbital apex aspergillosis is a rare but serious complication of rhinosinusitis. Pathology results are scarce, and this condition is difficult to diagnose based on clinical and radiological results. PATIENT CONCERNS: A 64-year-old woman presented with cavernous sinus-orbital apex syndrome. Axial and sagittal T1 contrast-enhanced magnetic resonance imaging (MRI) showed a right orbital apex mass abutting the right posterior ethmoid sinus, sphenoid sinus, and cavernous sinus. DIAGNOSIS: Cavernous sinus and orbital apex aspergillosis. INTERVENTIONS: Functional endoscopic sinus surgery was performed, and a biopsy of the lesion tissue was submitted for examination, which showed the presence of aspergillus. OUTCOMES: One year after surgical debridement, antifungal, and anticoagulation treatments, the patient is still asymptomatic without recurrence. LESSONS: Early surgical debridement is crucial to confirm the diagnosis of cavernous sinus-orbital apex aspergillosis and prevent mortality. There is no evidence of negative effects of antibiotic and anticoagulation treatments. Despite controversy, among physicians, most opt to treat patients via anticoagulation therapy.

Cavernous sinus fungal infection: a rare case.

Intracranial fungal infection of the cavernous sinus is a condition that usually affects immunocompromised individuals and is rarely seen in immunocompetent individuals. It is a potentially life threatening condition which requires prompt treatment. Here we present a case of an immunocompetent patient with a fungal infection of the cavernous sinus.

Actinomyces cavernous sinus infection: a case and systematic literature review.

A 63-year-old man presented with a 2-month history of progressive right-sided exophthalmos, painful ophthalmoplegia and fevers. As more features developed, he was diagnosed with giant cell arteritis, then Tolosa-Hunt syndrome, and transiently responded to corticosteroids. A bland cerebrospinal fluid and highly metabolically active brain (18F)-fluoro-D-glucose-positron emission tomography suggested lymphoma. Biopsy of the mass showed sulphur granules with Gram-positive filamentous bacteria with Actinomyces-like colonies. Actinomyces cavernous sinus infections are rare and indolent. They often mimic non-infective causes including other inflammatory and infiltrative conditions, vascular and neoplastic causes, particularly lymphoma. Clinicians should consider infective cavernous sinus syndromes in people with a fluctuating painful ophthalmoplegia that responds poorly to corticosteroids. The term Tolosa-Hunt syndrome is problematic and should be retired or used only with reservation.

A review of eight cases of cavernous sinus thrombosis secondary to sphenoid sinusitis, including a12-year-old girl at the present department.

Cavernous sinus thrombosis (CST) is a severe disease which can result from infection of any of the tissues drained by the cavernous sinus. We here review eight cases, including a 12-year-old girl, all secondary to sphenoid sinusitis. The clinical manifestations, laboratory data, imaging findings, pathogens, medications, surgical treatment and clinical outcomes were analyzed. All eight patients had headache and five of them fever. All cases were associated with one or more ophthalmic symptoms. In four cases, computed tomography/magnetic resonance imaging showed isolated sphenoid sinusitis. In three cases, streptococci were isolated from blood culture and two cases showed Staphylococcus aureus in blood and sinus cultures. In seven cases, surgery was undertaken. All eight subjects received antibiotics, and 5 were administered intravenous ceftriaxone and metronidazole. Six subjects received anticoagulation therapy and one received corticosteroids. No mortality was recorded. Three cases showed sequelae, including Lemierre syndrome, ophthalmic complaints, and cranial nerve paralysis. In conclusion, the management of CST should include intravenous antibiotic therapy, combined with endonasal sinus surgery.

Fatal rhinocerebral mucormycosis with intracavernous carotid aneurysm and thrombosis: a late complication of transsphenoidal surgery?

Mucormycosis is a rare opportunistic fungal infection. Rhinocerebral form of the disease mainly affects diabetic or immunocompromised patients. Mucormycosis have specific tropism for blood vessels leading to mucorthrombosis and less often to mycotic aneurysms. We report on a patient initially presenting with a severe sphenoid sinusopathy, who progressively evolved to cavernous sinus syndrome, internal carotid aneurysm followed by spontaneous thrombosis, chronic meningitis and ultimately fatal hypertensive hydrocephalus. Necropsy revealed a purulent infiltrate containing thin-walled, aseptate, right-angle branching, hyphae consistent with mucormycosis. His only relevant previous medical history was a transsphenoidal surgery for pituitary macroadenoma 21 years before. We hypothesize that post-surgical mucosal changes in the sphenoid sinus have been a favoring factor for delayed and invasive mucor infection.

Septic thrombosis of the cavernous sinus secondary to a Streptococcus milleri oral infection.

Septic thrombosis of the cavernous sinus (STCS) is an uncommon and potentially lethal disease. Sphenoid and ethmoid sinusitis followed by facial cutaneous infections represents the most common aetiologies, with Staphylococcus aureus as the main responsible organism followed by the Streptococcus pneumoniae. Although all infectious foci of the head and neck area can potentially spread to the cavernous sinus, STCS from oral infection is an exceptionally rare occurrence. We report the unusual case of a patient who presented with an acute STCS secondary to a generalized Streptococcus milleri periodontitis. This case highlights the importance of systematically performing a detailed examination of the oral cavity in patients presenting with intracranial infections caused by uncommon pathogens such as the Streptococcus milleri group.

Clival inflammation with cavernous sinus thrombophlebitis and orbital subperiosteal abscess--case report.

A 64-year-old woman presented with a very rare case of three infectious lesions, cavernous sinus thrombophlebitis, clival inflammation, and orbital subperiosteal abscess (SPA), manifesting as abducens palsy. An isolated non-specific mass in upper clivus was initially suspected to be derived from paranasal sinusitis. The clival lesion was approached by an endonasal transsphenoidal route and diagnosed as inflammation. However, progressive enlargement of an orbital mass was recognized, with eyelid erythema and swelling. Magnetic resonance imaging showed massive paranasal sinusitis and an intra-orbital mass, which was proved to be an orbital SPA by open surgery. Cavernous sinus thrombophlebitis might have been caused by primary paranasal sinusitis, and the origin of orbital cellulitis was suspected to be cavernous sinusitis based on the preoperative radiological findings. These unusual lesions should be kept in mind as one of the differential diagnoses.

A successful combined endovascular and surgical treatment of a cranial base mucormycosis with an associated internal carotid artery pseudoaneurysm.

OBJECTIVE: We report a rare case of internal carotid artery pseudoaneurysm owing to rhinocerebral mucormycosis and review 40 reported cases from 1980 to present. CLINICAL PRESENTATION: A 38-year-old Caucasian man presented with a 3-day history of headache, diplopia, and numbness in the distribution of the left ophthalmic and maxillary branches of the trigeminal nerve. A complete left cavernous syndrome was discovered upon neurological examination. Magnetic resonance imaging scans revealed an inflammatory process involving the paranasal sinuses with extension into the left cavernous sinus, temporal fossa, and petrous bone. INTERVENTION: The patient was immediately treated with amphotericin B, atorvastatin, and daily hyperbaric oxygen sessions before surgical intervention. The patient underwent endovascular treatment of the associated mycotic pseudoaneurysm after carotid test occlusion in addition to a radical bilateral debridement of the paranasal sinuses and infratemporal and temporal fossa. CONCLUSION: Aggressive multimodal therapy is imperative for late-stage rhinocerebral mucormycosis. Extensive resection of infected tissue combined with amphotericin B, atorvastatin, and hyperbaric oxygen seems to be the best course of management. If the internal carotid artery is involved, endovascular intervention is clearly an option to attain this goal. Further research and longer follow-up periods are required to better understand the long-term implications of endovascular coiling and hyperbaric oxygen therapy for rhinocerebral mucormycosis.

Cavernous sinus thrombophlebitis caused by porphyromonas gingivalis with abscess formation extending to the orbital cavity. Case report.

A 67-year-old man presented with a rare case of cavernous sinus thrombophlebitis (CST) caused by Porphyromonas gingivalis with abscess formation extending to the orbital cavity. Neuroimaging demonstrated a cystic lesion in the right cavernous sinus that was hyperintense on diffusion-weighted imaging. The patient was successfully treated with surgical drainage and antibiotic administration. CST is rare and often has a fulminant progression with high rates of morbidity and mortality. The differential diagnosis of cavernous sinus lesions should include CST. Early recognition and differentiation from other diseases with aggressive medical and possible surgical intervention are necessary to reduce mortality and long-term sequelae. Diffusion-weighted imaging is useful for the early recognition and differentiation of CST from other diseases.

Otogenic skull base osteomyelitis caused by invasive fungal infection. Case report and literature review.

Otogenic skull base osteomyelitis (SBO) of fungal etiology is a very rare but life-threatening complication of inflammatory processes of the ear. The authors present a case of otogenic SBO caused by Aspergillus flavus in a 65-year-old man with a fatal course. Because of the encountered difficulties with the proper diagnosis and treatment, the authors reviewed the literature on the subject.

Successful treatment of invasive cavernous sinus aspergillosis with oral itraconazole monotherapy.

An 83-year-old woman receiving long-term prednisolone treatment presented with a right optic neuropathy and right third, fourth, fifth, and sixth cranial nerve palsies secondary to sino-orbital aspergillosis with cavernous sinus involvement. Because the patient refused conventional treatment, she was given a two-year course of oral itraconazole 200 mg/day, leading to a complete imaging resolution of the lesion. Three years after completing treatment, there is no clinical or imaging evidence of disease recurrence. Visual and ocular motor function did not recover, but ptosis and proptosis improved. We believe this to be the first documented case of successful treatment of such a lesion with oral itraconazole monotherapy.

Cavernous sinus anatomy as a basis for interpretation of the clinical picture and radiological investigations in a case of Entomophthorales infection.

Several cranial nerves traverse the cavernous sinus producing the typical symptom complex seen during cavernous venous sinus thrombosis in Mucorales infection. Fungi of the order Entomophthorales display different pathological and histological characteristics although belonging to the same class of fungi. A case is presented, wherein the anatomy of the cavernous sinus forms the basis in explaining the presenting symptoms of a patient with Entomophthorales infection. The anatomical explanation for the presenting neurological symptoms is confirmed by radiological investigations and further supports the diagnosis of Entomophthorales infection.

Aspergillus granuloma of the cavernous sinus: magnetic resonance imaging with pathologic correlation.

This case illustrates the correlation between Magnetic Resonance Imaging (MRI) and the pathological findings in a case of cavernous sinus (CS) aspergilloma.