Cavernous sinus thrombosis
Septic thrombosis of the cavernous sinus from spreading facial, sinus, or orbital infection, marked by fever, proptosis, chemosis, and cranial nerve palsies that classically become bilateral. It is a neuro-ophthalmic emergency treated with immediate broad-spectrum IV antibiotics, source control, and consideration of anticoagulation.
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What this article covers
- Overview
Septic dural venous sinus thrombosis: infected clot within the cavernous sinus, a paired blood-filled venous space flanking the pituitary gland, arising when uncontrolled infection of the central…
- Epidemiology
Rare complication of common infections: follows a small fraction of central facial, sinus, or orbital infections, most often when the primary infection was treated late or inadequately, across children and adults.
- Risk factors
Uncontrolled central facial skin infection: furuncles or cellulitis in the "danger triangle" of the nose, upper lip, and medial cheek, draining directly into the cavernous sinus via the facial and ophthalmic veins.
- Pathophysiology
Valveless venous route from the face to the brain: the facial and ophthalmic veins draining the central face, orbit, and paranasal sinuses have no valves and communicate directly with the cavernous…
- Clinical features
Headache, typically the first symptom: severe, often unremitting head or periorbital pain, frequently preceding the ophthalmic and cranial nerve findings.
- Differential diagnosis
Orbital cellulitis: proptosis, chemosis, and ophthalmoplegia from postseptal orbital infection, but stays unilateral without rapid bilateral progression or disproportionate multi-nerve palsies; imaging distinguishes the two.
- Diagnosis
Confirmed by contrast-enhanced venous imaging plus a compatible septic clinical picture: there is no formal clinical criteria set; the diagnosis is established by demonstrating thrombosis of the…
- Management
Start empiric broad-spectrum IV antibiotics immediately, before imaging confirmation if suspicion is high, targeting Staphylococcus aureus, streptococci, gram-negatives, and anaerobes from the likely…
- Complications
Blindness: from corneal exposure, elevated intraocular pressure, central retinal vein occlusion, or optic nerve ischemia; the complication that most urgently drives ophthalmology involvement.
- Prognosis
Mortality has fallen with modern antimicrobial therapy: current antibiotic regimens have lowered both incidence and mortality compared with the pre-antibiotic era, when the disease was almost…
- Prevention
Treat central facial and sinus infections promptly and completely: a furuncle or cellulitis in the nose, upper lip, or medial cheek, or acute bacterial sinusitis with worsening facial pain, high…
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