Septic Cavernous Sinus Thrombosis Associated With Orbital Cellulitis: A Report of 6 Cases and Review of Literature

Abstract

Purpose: To describe risk factors, clinical parameters, treatment, and prognosis for patients with septic cavernous sinus thrombosis presenting with orbital cellulitis. Methods: Retrospective case series of 6 patients identified with septic cavernous sinus thrombosis and orbital cellulitis confirmed by magnetic resonance imaging at a tertiary care center from January 1980 to December 2016. Medical records were reviewed for demographics, risk factors, symptoms, etiology, radiographic diagnosis, complications, treatments, and outcomes. In addition, a literature review was performed from 2005 to 2018, and 119 cases of septic cavernous sinus thrombosis confirmed by imaging were included for aggregate comparison. This study adheres to the tenets of the Declaration of Helsinki, and institutional review board approval was obtained. Results: All 6 cases presented with headache, fever, ocular motility deficit, periorbital edema, and proptosis. The primary source of infection included sinusitis (n = 4) and bacteremia (n = 2). Identified microorganisms included methicillin resistant Staphylococcus aureus (n = 3) and Streptococcus anginosus (n = 1). All cases were treated with broad-spectrum intravenous antibiotics and anticoagulation, and one case underwent endoscopic sinus surgery. The mean time between initial presentation to diagnosis of cavernous sinus thrombosis was 2.8 days, and the average length of hospital admission was 21 days. The mortality rate was 0%, but 4 cases were discharged with neurological deficits including vision loss (n = 1) and ocular motility disturbance (n = 3). Literature review produced an additional 119 cases. Conclusions: Early diagnostic imaging with contrast-enhanced CT or MRI should be initiated in patients with risk factors and ocular symptoms concerning for cavernous sinus thrombosis. Treatment entails early administration of broad-spectrum intravenous antibiotics, anticoagulation, and surgical drainage when applicable.

Cavernous sinus thrombosis: An insidious and dangerous “do‐not‐miss” diagnosis

“…One retrospective review has shown that antibiotic treatment in combination with early anticoagulation therapy reduces the morbidity associated with blindness, stroke, and ophthalmoplegia, among other complications 17 . Other retrospective reviews have indicated that anticoagulation therapy is safe in CST after the exclusion of patients with intracranial hemorrhage and other possible bleeding disorders 7 . Anticoagulation therapy was not administered to the patient in the present case out of concern for the potential risk of hemorrhage and further extension of the septic emboli.…”

“…Both bacteria and fungi have been shown to cause CST. The most common causative bacterial pathogens are Staphylococcus aureus (60%–70%), Streptococcus (17%), gram‐negative bacteria (5%), and Pneumococcus (5%), whereas the most common pathogenic fungal infections that could result in CST include those caused by Rhizopus and Absidia and mucormycosis (most frequently seen in patients with diabetes) 7,8 . In this patient, the blood cultures that were grown before antibiotic use revealed the presence of S .…”

Management of an old woman with cavernous sinus thrombosis with two different mechanisms: case report and review of the literature

“…Other data are narrowing of the ipsilateral intracranial internal carotid artery, and enhancement of the arterial wall. Ischemic strokes or cerebral hemorrhages may be noted [ 19 , 20 , 21 , 22 , 23 ].…”

Cavernous Sinus Thrombosis: Efficiently Recognizing and Treating a Life-Threatening Condition

“…There are also Streptococcus pneumoniae, Gram-negative bacilli, and anaerobes present. Fungi, which include Aspergillus and Rhizopus species, are a less common pathogen [9][10]. Henry Gray (1918) Anatomy of the Human Body.…”

“…The cavernous sinuses are trabeculated cavernous cavities generated by the layers of dura mater and filled with venous blood (one on each side of the sella turcica, above and lateral to the sphenoid sinuses, anteriorly superior orbital fissure, and posteriorly petrous section of the temporal lobe). The superior and inferior ophthalmic veins, as well as the superficial cortical veins, drain into the basilar plexus anteriorly, whereas the superior and inferior petrosal sinuses drain into the basilar plexus posteriorly [ 8 - 10 ]. The close proximity of veins, arteries, nerves, meninges, and paranasal sinuses contributes to the development and presentation of CST as can be observed from Figure 1 .…”