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.

Cavernous sinus thrombosis with bilateral orbital vein involvement and diffuse ischemic retinopathy / Trombose do seio cavernoso com envolvimento bilateral das veias orbitais e retinopatia isquêmica difusa

ABSTRACT A 53-year-old man with a 3-day history of periorbital swelling and vision loss in the left eye was found to have septic cavernous sinus thrombosis with bilateral orbital vein involvement causing congestive orbitopathy. He was treated with an emergent canthotomy and cantholysis, intraocular pressure-lowering drops, antibiotics, anticoagulation, and serial examinations. Optical coherence tomography ultimately revealed diffuse ischemic destruction of both layers of the retina, which suggested occlusion of the ophthalmic artery or the short posterior ciliary arteries and central retinal artery without intracavernous internal carotid artery involvement. The patient remained without light perception in the left eye after treatment.

RESUMO Um homem de 53 anos, com história de 3 dias de edema periorbital e perda de visão no olho esquerdo, apresentou trombose séptica do seio cavernoso com envolvimento bilateral das veias orbitais, causando uma orbitopatia congestiva. O paciente foi tratado com uma cantotomia e cantólise de emergência, colírios para redução da pressão intraocular, antibióticos, anticoagulantes e exames seriados. A tomografia de coerência óptica finalmente demonstrou destruição isquêmica difusa de ambas as camadas da retina, sugerindo uma oclusão da artéria oftálmica ou das artérias ciliares posteriores curtas e da artéria retiniana central, com ausência de envolvimento do segmento intracavernoso da artéria carótida interna. O paciente permaneceu sem percepção luminosa no olho esquerdo.

Cavernous sinus thrombosis with bilateral orbital vein involvement and diffuse ischemic retinopathy.

A 53-year-old man with a 3-day history of periorbital swelling and vision loss in the left eye was found to have septic cavernous sinus thrombosis with bilateral orbital vein involvement causing congestive orbitopathy. He was treated with an emergent canthotomy and cantholysis, intraocular pressure-lowering drops, antibiotics, anticoagulation, and serial examinations. Optical coherence tomography ultimately revealed diffuse ischemic destruction of both layers of the retina, which suggested occlusion of the ophthalmic artery or the short posterior ciliary arteries and central retinal artery without intracavernous internal carotid artery involvement. The patient remained without light perception in the left eye after treatment.

Odontogenic Lemierre's syndrome with septic superior ophthalmic vein and cavernous sinus thrombophlebitis complicated by blindness and ophthalmoplegia.

Lemierre's syndrome is a triad consisting of oropharyngeal infection, internal jugular vein thrombophlebitis, and systemic embolisation typically involving lung and brain. Orbital involvement in this life-threatening condition is rare but potentially blinding and may be an indicator of intracranial involvement. We describe a case of odontogenic Lemierre's syndrome complicated by extensive orbital and intracranial septic venous thrombosis, with optic and cranial neuropathy resulting in monocular blindness and ophthalmoplegia. A multidisciplinary approach with abscess drainage, antibiotic and antithrombotic therapy, and close radiological monitoring was critical for preserving contralateral vision and neurological function.

Orbital cellulitis and cavernous sinus thrombosis with contralateral sinus disease in a COVID-19 positive adolescent patient.

Patients with COVID-19 have been reported to have elevated coagulation factors, which is a well-documented cause of venous thromboembolism events such as deep vein thrombosis and pulmonary embolism. Other venous thrombotic events, however, such as cavernous sinus thrombosis (CST) have been less commonly observed, specifically in combination with primary orbital cellulitis. Due to its unique anatomic location, the cavernous sinus is susceptible to thrombophlebitis processes including septic thrombosis and thrombosis most commonly from sinusitis. Many studies have shown that in the antibiotic era thromboembolic events of the cavernous sinus are less common due to infection spread from the orbit or facial region. This case report describes a 17-year-old COVID-19 positive male who presented with a left-sided primary orbital cellulitis with CST without radiographic evidence of ipsilateral sinus disease.

Radiographic and Clinical Analysis of Cranio-Maxillofacial Complications of Cavernous Sinus Thrombosis Among 256 COVID-19 Patients.

BACKGROUND: A heavy burden of cranio-maxillofacial complications may be encountered in corona virus disease-2019 patients due to the associated coagulopathy and inflammatory consequences of the disease. This study aims to describe clinical and radiographic features of these complications in 256 patients who developed 1 or more of the following complications: cavernous sinus thrombosis, osteomyelitis or necrosis of the jaws. METHODS: Clinical assessment of cranial nerve function and general clinical assessment were performed. Imaging techniques used were multi-slice computed tomography, magnetic resonance imaging, and MRI with contrast enhancement. RESULTS: Thromboembolism of brain and facial blood vessels were associated with inflammation and necrosis. Multi-slice computed tomography/MR angiography showed thrombotic occlusions of the internal carotid artery in the area of the cavernous sinus, and in the ophthalmic veins. Cavernous sinus thrombosis was attributed to coagulopathy and, inflammation of the paranasal sinuses, especially sphenoiditis. A noticeable increase in the size of the cavernous sinus was detected. Compression of the cranial nerves in the cavernous sinus (CS) region causes dysfunction and pathology in the corresponding regions.

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 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.

Oculomotor synkinesis: an uncommon sequela of paediatric cavernous sinus thrombosis.

We report an unusual case of acquired oculomotor synkinesis as a sequela of cavernous sinus thrombosis in a child. A 4-year-old male child presented to our emergency services with sudden onset periorbital swelling with complete ptosis of the left upper eyelid. This was preceded by a febrile episode and a furuncle at the tip of the nose. Computerised axial tomography of the orbit revealed orbital cellulitis in the left eye. The child was started on systemic antibiotics followed by a short course of systemic steroids. MRI of the brain with contrast revealed left cavernous sinus and superior ophthalmic vein thrombosis. Following administration of systemic anticoagulants and antibiotics, the ocular motility and ptosis improved remarkably. However, 6 months post-treatment, the child developed signs of aberrant regeneration of the third cranial nerve (oculomotor synkinesis).

Lemierre's syndrome with cavernous sinus thrombosis caused by dental infection.

Lemierre's syndrome is a rare multisystemic infection beginning in oropharynx commonly caused by oral anaerobic organisms and leading to internal jugular vein thrombosis with septic emboli. Here, we describe a 45-year-old woman with hypertension and unrecognised type 2 diabetes who presented to a community hospital with fever, double vision and septic shock. Examination showed neck pain aggravated by neck flexion, limited ocular movement of right lateral rectus, left medial rectus and left superior oblique and incomplete ptosis of the left eye. These symptoms were suggestive of bilateral cavernous sinus syndrome. CT of the brain showed bilateral proximal internal jugular vein and cavernous sinus thrombosis. CT angiography revealed septic emboli at both upper lungs. The patient had good improvement of neurological symptoms after dental extraction, intravenous antibiotic and anticoagulant.

Bilateral cavernous sinus and left dural sigmoid sinus thrombosis associated with extreme exertion: a case report.

Septic cavernous sinus thrombosis is a rare but often debilitating and potentially fatal disease. We describe a case of bilateral orbital cellulitis with rapidly progressing cavernous sinus thrombosis and left sigmoidal sinus thrombosis in an immunocompetent 20-year-old military man who had undergone intensive physical training. The patient presented with rapid painful swollen left eye for 2 days. The examination results were gross proptosis with total ophthalmoplegia. He was treated with intravenous antibiotics and corticosteroid. At 1 week, visual acuity improved to 20/20 OU, with a normal intraocular pressure. There was a significant improvement in proptosis. The ocular motility of the right eye was fully restored, with slight residual ophthalmoplegia in the left eye. There was no residual illness or recurrence of illness at 3 months' follow-up.

Bilateral cavernous sinus and left dural sigmoid sinus thrombosis associated with extreme exertion: a case report / Trombose bilateral do seio cavernoso e do seio sigmoide esquerdo associada a exercício extremo: relato de caso

ABSTRACT Septic cavernous sinus thrombosis is a rare but often debilitating and potentially fatal disease. We describe a case of bilateral orbital cellulitis with rapidly progressing cavernous sinus thrombosis and left sigmoidal sinus thrombosis in an immunocompetent 20-year-old military man who had undergone intensive physical training. The patient presented with rapid painful swollen left eye for 2 days. The examination results were gross proptosis with total ophthalmoplegia. He was treated with intravenous antibiotics and corticosteroid. At 1 week, visual acuity improved to 20/20 OU, with a normal intraocular pressure. There was a significant improvement in proptosis. The ocular motility of the right eye was fully restored, with slight residual ophthalmoplegia in the left eye. There was no residual illness or recurrence of illness at 3 months' follow-up.

RESUMO A trombose séptica do seio cavernoso é uma condição rara, mas frequentemente debilitante e potencialmente fatal. Descrevemos um caso de celulite orbital bilateral com progressão rápida para trombose do seio cavernoso e trombose do seio sigmoide esquerdo, em um militar imunocompetente de 20 anos de idade que havia sido submetido a treinamento físico intenso. O paciente apresentou um inchaço rápido e doloroso no olho esquerdo por 2 dias. Os resultados do exame foram proptose macroscópica com oftalmoplegia total. Ele foi tratado com antibióticos intravenosos e costicosteróide. Em 1 semana, a acuidade visual melhorou para 20/20, com pressão intraocular normal. Houve uma melhora significativa na proptose. A motilidade ocular do olho direito foi totalmente restaurada, com leve oftalmoplegia residual no olho esquerdo. Não houve doença residual ou recorrência da doença após três meses de acompanhamento.

Internal Jugular Vein and Cerebral Venous Sinus Infective Thrombophlebitis Detected With 99mTc-HMPAO White Blood Cell Scintigraphy.

ABSTRACT: A 35-year-old man with a history of renal transplant, congenital cystinosis, and diabetes was admitted to the hospital with fever, bilateral parotid gland swelling, and acute renal failure. He had 99mTc-HMPAO-WBC (99mTc-hexamethylpropyleneamineoxime white blood cell) imaging for the evaluation of possible parotitis. There was intense radiopharmaceutical uptake along the right internal jugular vein extending to the right sigmoid and transverse and superior sagittal sinuses, suggestive of infective thrombophlebitis or Lemierre syndrome. This study illustrates the value of 99mTc-HMPAO-WBC imaging as a tool for evaluating thrombophlebitis, particularly in patients with renal failure in whom contrast-enhanced CT may not be possible.

Septic cavernous sinus thrombosis-Case series and review of the literature.

BACKGROUND AND PURPOSE: Septic cavernous sinus thrombosis (CST) is a rare, life-threatening disease with infectious thrombosis causing associated complications resulting in high morbidity and mortality. We report a series of CST patients with assessment of arterial and intracranial complications. METHODS: We used the radiology database from a large, academic tertiary care center to collect all patients treated with CST between 2002 and 2019. Patient demographics, source of infection, treatment course and outcomes were evaluated. A review of the recent literature was also performed for similar reported complications from CST. RESULTS: 14 patients with CST treated during this time period were assessed. Of the 14 patients, 1 patient died. 7 patients had unilateral narrowing of ICA while 3 patients had bilateral narrowing. The ICA narrowing was reversible in 10/12 patients and improvement but persistent narrowing in one patient. One patient had an infectious pseudo aneurysm that was treated by coiling. Extension of thrombosis to the transverse- sigmoid sinuses and internal jugular vein were seen in 3 patients. Three patients had subdural empyema which was treated surgically. CONCLUSION: The prognosis of CST has improved with advancement in treatment, but complications are not infrequent.

Our experience in the management of orbital complications in acute rhinosinusitis. / Nuestra experiencia en el manejo de las complicaciones orbitarias en la rinosinusitis aguda.

BACKGROUND AND OBJECTIVE: The spread of an infection from the paranasal sinuses is rare but severe. Between 4% and 20% of all rhinosinusitis can become complicated, orbital involvement being the most frequent (60-75%). Orbital complications are more common in children but more severe in adults. We aim to analyse the epidemiological characteristics of these patients and to propose a management algorithm. MATERIALS AND METHODS: We carried out a retrospective review of 21 patients with orbital complications of acute rhinosinusitis diagnosed in the same institution from 2005 to 2018. The diagnosis was based on clinical history, endoscopic examination and imaging tests. All patients received an intravenous antibiotic and were assessed by ophthalmology. An immediate surgical treatment was performed in the case of an abscess or poor response to medical management. RESULTS: The average age was 24 years. Fifty-two percent were males and 48% females. According to Chandler's classification, 43% (9/21) had preseptal cellulitis (7 adults and 2 children), 10% (2/21) orbital cellulitis (one adult and one child), 43% (9/21) subperiosteal abscess (2 adults and 7 children), there was one case of orbital abscess in an adult and there were no cases of cavernous sinus thrombosis. A CT scan was performed in all patients and the cases of subperiosteal or orbital abscess were treated surgically, except 2 paediatric patients (<4 years) with a small and medial subperiosteal abscess (<4mm) who responded well to medical treatment. The surgical approach is performed by endonasal endoscopy, perforating the lamina papyracea in cases of subperiosteal abscess and also opening the periorbita in orbital abscess. It was combined with an external palpebral approach in the 4 cases that presented a superior or lateral abscess. Two young adults (10%) presented an intracranial complication concomitantly. CONCLUSION: Orbital complications of acute rhinosinusitis are rare but potentially severe. It is important to be aware of and suspect them in order to act quickly. It is essential to define the location and extension of the infection for correct management, as well as multidisciplinary treatment. The surgical approach is performed by endonasal endoscopy. It is limited by abscesses located on the roof of the orbit or on the lateral wall, when a combined external palpebral approach is required.