Posterior Nasal Septal Abscess Detected During Evaluation of Cavernous Sinus Thrombosis.

Septic cavernous sinus thrombosis (CST) is a rare, life-threatening condition that commonly originates from sinusitis. Posterior nasal septal abscess (NSA) is an extremely rare cause of septic CST because it is a very rare condition by itself. Here we report a rare case involving an elderly woman with septic CST associated with a posterior NSA that was successfully treated without any sequelae. Incision and drainage of the posterior NSA were performed under local anesthesia, and the nasal packing was removed 2 days postoperatively. Pus from the abscess was sent for culture and sensitivity analyses, which revealed Enterococcus faecium . She was treated with intravenous (IV) third-generation cephalosporin (2 g twice daily) and IV vancomycin (0.75 g twice daily) for 4 weeks. IV low-molecular-weight heparin was administered at a dose of 40 mg twice daily for 4 days, followed by warfarin (3 mg once a day) for 21 days. The patient was discharged without any sequelae after 4 weeks. At the 2-month follow-up, she did not complain of any further symptoms. The findings from this case suggest that clinicians should maintain a high index of suspicion and provide prompt treatment to prevent mortality and morbidity associated with septic CST.

Septic cavernous sinus thrombosis after minor head trauma: A case report.

RATIONALE: Septic cavernous sinus thrombosis (SCST) is a rare but life-threatening condition that commonly arises from infections, including paranasal sinusitis, otitis media, and skin infection. Meanwhile, head trauma as a predisposing factor of SCST has been scarcely reported. We report a case of SCST complicated by meningitis after minor head trauma, even in the absence of identifiable fractures. PATIENT CONCERNS AND DIAGNOSIS: A 77-year-old female presented with diplopia combined with ocular pain and headache lasting a week. She had a recent blunt head trauma 2 weeks before the diplopia onset. The trauma was not accompanied by identifiable skull fractures, bleeding, or loss of consciousness. Neurological examination revealed incomplete ptosis, eyelid swelling, and medial and vertical gaze limitations of both eyes. Gadolinium-enhanced brain magnetic resonance imaging demonstrated multifocal thrombotic filling defects, including those of the cavernous sinus, sinusitis involving the sphenoid and ethmoid sinuses, and otomastoiditis. The cerebrospinal fluid assay result was compatible with bacterial meningitis. A tentative diagnosis of SCST complicated by bacterial meningitis and multifocal cerebral venous thrombosis was made based on clinical, laboratory, and neuroradiologic findings. INTERVENTION: Intravenous triple antibiotic therapy (vancomycin, ceftriaxone, and ampicillin) for 2 weeks combined with methylprednisolone (1 g/d for 5 days) was administered. Despite the initial treatment, carotid-cavernous fistula was newly developed during hospitalization. Therefore, coil embolization was performed successfully for the treatment of carotid-cavernous fistula. OUTCOMES: The symptoms of the patient including diplopia gradually improved during the 8-month follow-up period. LESSONS: Minor head trauma is a rare but possible cause of SCST. Early recognition and prompt treatment are essential for improving outcomes. Moreover, close observation is warranted, even if apparent serious complications were absent during initial evaluations in minor head trauma.

Clinical Profile and Long-Term Outcomes in Pediatric Cavernous Sinus Thrombosis.

BACKGROUND: Pediatric cavernous sinus thrombosis (CST) is a rare condition with limited data regarding its clinical characteristics and long-term outcomes. The objective of this study was to describe the clinical and radiologic features, diagnostic evaluation, management, and long-term prognosis and to identify clinical variables associated with long-term outcomes in pediatric CST. METHODS: A retrospective chart review of patients younger than 18 years diagnosed with a CST between 2004 and 2018 at a single center was conducted. RESULTS: We identified 16 (M:F = 10:6) children with CST with a mean age of 7.6 years (10 days to 15 years) and average follow-up duration of 29 months (3 weeks to 144 months). The most common symptom and examination finding at presentation was eyelid swelling (n = 8). Six patients had bilateral CST. The most common etiologies were sinusitis (n = 5) and orbital cellulitis (n = 5). Treatments included antibiotics (n = 14), anticoagulation (n = 11), and surgery (n = 5). Only one patient died due to intracranial complications. Twelve patients had a normal examination at follow-up. None of the clinical variables including age (P = 0.14), gender (P = 0.09), use of antibiotics (P = 1.00) or anticoagulation (P = 1.00), surgery (P = 0.28), parenchymal abnormalities (P = 0.30), additional cerebral venous thrombosis (P = 0.28), and early versus late commencing of anticoagulation (P = 1.00) were significant when comparing patients with full/partial resolution versus those with no resolution of thrombosis on follow-up neuroimaging. CONCLUSIONS: Our study is one of the largest cohorts with the longest follow-up data for the pediatric CST. Most of our patients had favorable outcomes at follow-up. We found no statistical difference between clinical variables when comparing patients with full/partial resolution versus those with no resolution of thrombosis on follow-up neuroimaging.

Cavernous Sinus Thrombosis and Blindness After Simple Tooth Extraction in Patient Who Recovered From Coronavirus 2019: A Case Report.

The pandemic Coronavirus 2019 is a disease transmitted either by droplets from a person's sneeze or cough or direct spread; also known as severe acute respiratory syndrome coronavirus-2. Although the morbidity of the disease is mainly related to respiratory distress, the associated inflammatory response can induce various coagulopathies despite an anticoagulant therapy. The authors are documenting a case of a diabetic patient who recovered from Coronavirus 2019 and is on prophylactic anticoagulant therapy after routine extraction of a maxillary second molar that progressed to unilateral cavernous sinus thrombosis and loss of vision.

Cavernous sinus thrombosis followed by brain ischaemia in a type-1 diabetic patient: a persistent endodontic infection report.

Central nervous system infections and cavernous sinus thrombosis are associated with high mortality rates and may be a consequence of oral infection propagation. A 24-year-old woman has attended a private dental office with a pain complaint in the upper right central incisor and had the endodontic treatment completed. However, the patient returned to the dental office reporting pain in the same tooth and the presence of swelling. Then, the root canal was retreated. After one week, the patient presented to a Basic Health Unit with a history of vomiting and convulsion crisis followed by loss of consciousness. A computed tomography exam showed cavernous sinus thrombosis and brain ischaemic areas. The present report describes a rare case of cavernous sinus thrombosis followed by brain ischaemia in a type-1 diabetic patient, associated with persistent endodontic infection, with subsequent patient's death.

Septic cavernous sinus thrombosis: A review.

Septic cavernous sinus thrombosis (SCST) is a rare, yet severe, process typically arising from infections of the paranasal sinuses (predominately ethmoid and/or sphenoid sinusitis) and less commonly, otogenic, odontogenic, and pharyngeal sources. Clinical symptoms of SCST arise from obstruction of venous drainage from the orbit and compression of the cranial nerves within the cavernous sinus. In the preantibiotic era SCST was considered universally fatal (80-100%); however, with the introduction of antibiotics the overall incidence, morbidity, and mortality of SCST have greatly declined. In spite of dramatic improvements, morbidity and mortality remain high, with the majority of patients experiencing neurological sequalae, highlighting the severity of the disease and the need for prompt recognition, diagnosis, and treatment. Here we review of the literature on SCST with a focus on the current recommendations and recent evidence for diagnostic and medical management of this condition.

Septic cavernous sinus thrombosis in a paediatric patient with undiagnosed thrombophilia.

A previously healthy 8-year-old girl presented to the hospital with right periorbital and forehead swelling in the setting of a 1-week history of upper respiratory symptoms. Contrast-enhanced CT revealed pansinusitis with orbital and frontal abscesses and thrombosis of the anterior portion of the superior sagittal sinus. She was treated with surgical drainage, antibiotics and anticoagulants. After 2 days she developed cranial nerve (CN) VI palsy. Contrast-enhanced MRI revealed small epidural abscess, right-sided thrombi of the cavernous sinus, internal carotid artery and internal jugular vein, in addition to the superior sagittal sinus. Thrombophilia workup revealed heterozygosity for factor V Leiden. She underwent 6 weeks of parental antibiotic therapy, 3 months of anticoagulation therapy and 7 days of steroids. With treatment, her visual acuity returned to baseline, CN VI palsy resolved and repeat imaging showed resolution of thrombi and epidural abscess, but persistent narrowing of the internal carotid artery.

Diagnosis and Management of Cerebral Venous Diseases in Neuro-Ophthalmology: Ongoing Controversies.

Diseases of the cerebral venous system frequently lead to neuro-ophthalmic complications. Cortical venous sinus thrombosis and dural arteriovenous fistulas may be complicated by elevation of intracranial pressure, with secondary papilledema or abducens palsies. There is increasing recognition that stenosis at the transverse sinus-sigmoid sinus junction plays a role in the pathophysiology of idiopathic intracranial hypertension and offers a new avenue of treatment in patients who fail medical therapy. Diseases of the cavernous sinus manifest with their own set of neuro-ophthalmic symptoms, reflecting the presence of all 3 ocular motor nerves and the oculosympathetic fibers within its walls, along with its role as the primary drainage pool of the globe and orbit. Numerous questions and controversies remain regarding the diagnosis and optimal treatment of cerebral venous disease, including the role of venous stenting in idiopathic intracranial hypertension, the role of anticoagulation in cavernous sinus thrombosis, and the risks and benefits of embolization of mild indirect cavernous carotid fistulas.

Prognosis of septic cavernous sinus thrombosis remarkably improved: a case series of 12 patients and literature review.

PURPOSE: Septic cavernous sinus thrombosis (CST) is a rare complication of infections in the head and neck area. CST is notorious for its bad prognosis, with high mortality and morbidity rates described in literature. However, these rates are based on old series. We question whether the prognosis of CST is currently still as devastating. The primary purpose of this study is to assess the mortality and morbidity of CST. METHODS: Using the databases of all relevant specialties in our tertiary referral hospital, we collected all the patients treated for CST in the period 2005-2017. In addition, a PubMed search, using the mesh term 'cavernous sinus thrombosis', was performed. RESULTS: We found 12 patients with CST in the study period. Of the 12 patients, 11 survived and 9 recovered without any permanent deficits. Seven patients were treated with anticoagulation, and in none of the patients we saw hemorrhagic complications. In literature, older articles describe higher mortality rates (14-80%), but more recent articles report mortality and morbidity rates similar to our results. CONCLUSIONS: The prognosis of CST nowadays is more favorable than previously described. Anticoagulation seems to be a safe addition to antibiotic and surgical treatment, at least in patients without central nervous system infection.

Transfemoral thrombectomy in the cavernous sinus and superior ophthalmic vein.

Cavernous sinus thrombosis (CST) is a rare condition that can cause death, neurologic disability, and visual loss. A pre-teen with septic CST leading to ocular hypertension and acute visual loss was treated at our institution with thrombectomy and thrombolysis of the cavernous sinuses and superior ophthalmic veins. Successful recanalization of the bilateral cavernous sinuses and superior ophthalmic veins was achieved in two separate procedures without complication. The patient showed immediate symptomatic relief. He was neurologically intact without visual deficits at the 2 month follow-up. This is the first report in the literature showing the feasibility of cavernous sinus thrombectomy using current devices and techniques. Early endovascular therapy may help preserve vision in patients with acute CST.

[Septic thrombus of the cavernous sinus]. / Septicheskii tromboz kavernoznogo sinusa.

The present review was designed to represent modern views of the problem of etiopathogenesis, clinical features, diagnostics, and treatment of septic thrombus of the cavernous sinus with special reference to the currently available methods for the detection and management of this condition.

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.

[Cavernous sinus thrombosis as a rare cause of exophthalmos in childhood : A case report]. / Sinus-cavernosus-Thrombose als seltene Ursache eines Exophthalmus im Kindesalter : Ein Fallbericht.

Complications of acute bacterial sinusitis mostly occur in children and adolescents. In particular, intracranial spread of the infection can lead to severe even fatal courses of the disease. This article is a case report about a 13-year-old boy suffering from left-sided headache, meningismus and exophthalmos as presenting symptoms. Cranial magnetic resonance imaging (MRI) showed merely right-sided sphenoid sinusitis; however, the diffusion-weighted MRI sequence indicated a left-sided cavernous sinus thrombosis, which could be confirmed by computed tomography (CT) angiography. Cerebrospinal fluid diagnostics showed significant leukocytosis confirming secondary meningitis. Finally, exophthalmos was explained by parainfectious cavernous sinus thrombosis and periorbital edema. This case report highlights the importance of extended and specific diagnostic imaging in cases of clinically suspected complications in children and adolescents with sinusitis and the diagnostic significance of diffusion-weighted MRI.

Double ophthalmic arteries arising from the internal carotid artery: a case report of a hidden second ophthalmic artery.

A case of double ophthalmic arteries arising from the internal carotid artery with unique features is reported. This case was discovered following in the course of time the progress of a thrombosis of the anterior cavernous sinus associated with a low-flow direct arteriovenous fistula of the superior ophthalmic vein. At different time points, the same patient underwent four angiographic studies and one computerized tomography with contrast medium. Angiographies showed that the double internal carotid artery origin of the ophthalmic artery was detectable only within a short range of time. To the best of our knowledge, this case is unique as it demonstrates that a second ophthalmic artery may lie hidden, showing itself only under particular hemodynamic requirements.

Ophthalmic manifestations and outcomes after cavernous sinus thrombosis in children.

PURPOSE: To review the causes, treatment, and outcomes of cavernous sinus thrombosis (CST) in children. METHODS: The medical records of children (<18 years of age) diagnosed with thrombophlebitis of an intracranial venous sinus were reviewed to identify cases of CST presenting to Children's Hospital Colorado from January 2000 through January 2013. Cases were evaluated for etiology, symptoms, imaging characteristics, treatment, and outcomes. RESULTS: A total of 110 children with a venous thrombus of an intracranial sinus were included. Of these, 9 had a CST. All cases were confirmed by magnetic resonance imaging. All 9 had sinusitis, 4 had orbital involvement, and 1 resulted from a nasal septal abscess. Eight cases presented with ophthalmoplegia, and 5 presented with decreased vision. Every patient underwent sinus surgery: 4 underwent orbitotomy for abscess drainage, and 1 required bilateral exenteration. Cultures were inconclusive in 2 cases, and 2 cases were culture positive rhino-orbital mucormycosis. There was 1 case of methicillin-resistant Staphylococcus aureus. Of the 9 cases, 4 returned to normal vision and ocular motility; 5 had permanent ophthalmoplegia and vision loss. There were no cases of mortality. CONCLUSIONS: CST is a rare complication of orbital and sinus disease. High clinical suspicion, early neurologic imaging, and a multidisciplinary approach to management are key factors in reducing morbidity and mortality from CST in children.