1. The cavernous sinus is located on either side of the body of the sphenoid bone and contains several important structures like cranial nerves and blood vessels. 2. Septic cavernous sinus thrombosis is usually caused by infection spreading from nearby sites like the nose, orbit, or teeth. Common symptoms include proptosis, ophthalmoplegia, and fever. 3. Treatment involves intravenous antibiotics, anticoagulation with heparin, and sometimes steroids; early diagnosis and treatment can help reduce mortality and long-term complications, which remain significant risks.

1. Dr. Parag Moon
Senior resident
GMC, Kota

3.  Paired venous sinus, on either side of body of
sphenoid.
 2cm in length, height of 1cm
 Traversed by numerous trabeculae, dividing it
into a several caverns (spaces) hence
cavernous.

4.  Relations:
◦ Medial – pituitary above, sphenoidal air cell below
◦ Lateral – temporal lobe, uncus
◦ Anterior - superior orbital fissure
◦ Posterior - petrous apex
◦ Superior – optic chiasm

5.  Tributaries:
– Superior and inferior opthalmic veins
– Sphenoparietal sinus
– Inferior cerebral veins
– Superficial middle cerebral veins
– Central vein of retina
 Drainage:
– Superior petrosal sinus---> transverse sinus
– Inferior petrosal sinus --->internal jugular vein

6.  Communication:
– Intercavernous sinuses – communication between
the 2
– Pterygoid plexus – via emissary veins passing
through foramen ovale, emissary sphenoidal
foramen and foramen lacerum.
– Pharyngeal plexus – via a vein passing through
carotid canal.
– Facial vein – via superior opthalmic vein.

7. Contents of cavernous sinus
 - Internal Carotid artery with sympathetic
plexus
 - CN 3
 - CN 4
 - CN 5 (1st and 2nd divisions)
 - CN 6

10.  Includes cases of phlebitis, thrombo-phlebitis
and aseptic thrombosis
 Septic type (most common) - coagulase
positive staphylococcus
 Aseptic types may follow trauma, local stasis
or a failing circulation.

11. Septic CST
 Infectious
Aseptic CST
 Trauma
 Post surgery
Rhinoplasty
Base of skull
Tooth extraction
 Hematologic
 Malignancy
Nasopharyngeal Ca.
 Dehydration

12.  More commonly seen with sphenoid and
ethmoid and to a lesser degree with frontal
sinusitis
 Staphylococcus aureus -70% of all infections.
Streptococcus pneumoniae, gram-negative
bacilli, and anaerobes can also be seen.
 Fungi are a less common pathogen and may
include Aspergillus and Rhizopus
species(more common in diabetics)

13.  No valves in dural sinuses, cerebral and
emissary veins
 Infection of upper lip, vestibule of nose and
eyelids-> spread by way of angular,
supraorbital, supratrochlear veins to
ophthalmic veins=commonest route
 Intranasal operation of septum, turbinates,
ethmoid/sphenoid sinus infection->through
ethmoidal veins

14.  Operation of tonsil, peritonsillar abcess,
maxillary osteomyelitis/surgery, dental
extraction->spread by pterygoid plexus or
direct extension in internal jugular vein
 Involvement of middle ear/mastoid ->
retrograde spread through petrosal sinus to
cavernous sinus

15. Sources:
 Nose – Paranasal 40%
 Orbit- Face 35%
 Mouth – Teeth 13%
 Ear 9%
 Other – tonsil, soft palate, pharynx, posterior
portions of the superior and inferior alveolar
arches 3%

17. 1. Sepsis
2. Venous obstruction
3. Involvement of cranial nerves

18.  Pyrexia
 Rapid, weak, thready pulse
 Chills and sweats
 Delirium - meningitis supervenes terminally
 Septic emboli to various other parts of body.

19.  Proptosis (first oedema & chemosis)
 Oedema of eyelids and bridge of nose
 Dilatation and tortuosity of retinal veins
 Retinal hemorrhages
 Involvement of the contralateral eye – (48
hours)
 When pterygoid plexus is occluded along with
sinus, - oedema of the pharynx or tonsil

20.  First CN involved is VI
 Ptosis - paralysis of oculomotor nerve
 Dilatation of pupil- third nerve and
stimulation of sympathetic plexus
 Decreased abduction (paralysis of abducens
nerve)
 Complete opthalmoplegia
 Loss of vision
 Retro-orbital pain and supra-orbital
headache->V

22.  Strong clinical suspicion
1)Orbital venography
 Not recommended
 Difficult to puncture facial veins in odema
 May help in dissemination of infection

23. 2) Contrast enhanced CT
 Slice thickness 3mm or less
 Shows enlargement and expansion of
cavernous sinus cavity with flatening or
convexity of lateral wall
 Multiple or single filling defect with
enhancing CS.
 Exopthalmos, soft tissue edema
 Dilation of superior ophthalmic vein

25. 3) MRI:
 – A sensitive, noninvasive
 Can be combined with venography to
demonstrate lack of blood flow in the
cavernous sinus
 Show associated meningitis, involvement of
pituitary gland

27. 4) CSF examination
 Elevated protein
 Normal sugar
 Mild pleocytosis
5) Complete blood count
 Elevated TLC
 Leucocytosis
6) Blood culture
7) Local tissue culture

28.  Intracranial extension of infection->
meningitis, encephalitis, brain abcess,
pituitary infection,epidural, subdural
empyema
 Cortical vein thrombosis->hemorrhagic
infarction
 Extension to other sinuses

29.  Orbital cellulitis–differentiated from CST by B/L
involvement, papillodema, dilated pupil,
decreased periocular sensation, abnormal spinal
fluid in latter
 Preseptal cellulitis- no proptosis
 Orbital apex syndrome- more visual loss,
opthalmoplegia, less proptosis, periorbital
odema
 Sinusitis
 Orbital malignancy
 Facial Cellulitis
 Glaucoma-angle closure

31.  Immediate empiric antibiotic coverage must
include gram-positive, gram-negative and
anaerobic bacteria.
 Later treatment can be narrowed, adjusted to
cultures and sensitivities
 Third generation cephalosporin+vancomycin
with metronidazole
 Duration- 3-4 weeks

32.  Used in setting of fungal sinusitis
 More common in diabetics
 Aspergillus more common
 Parentral amphotericin B for 3 weeks followed
by posaconazole(400mg BD) prophylaxis
 Dose-0.5-1.5mg/kg/day(deoxycholate), 5-
10mg/kg/day(liposomal)

33.  Intravenous heparin (maintaining the partial
thromboplastin time or thrombin clot time at
1.5 to 2 times that of the control)->24,000-
30,000 U/day.
 Warfarin sodium (maintaining the
prothrombin time at 1.3±1.5 times the
control) -continued for 4 to 6 weeks to allow
adequate collateral channels to develop

34.  Mortality was lower among patients who
received heparin treatment, 14% vs. 36%
 Early administration of heparin may serve to
prevent spread of thrombosis to the other
cavernous sinus as well as to the inferior and
superior petrosal sinuses.

35.  Not influence mortality
 May prevent residual cranial nerve
dysfunction caused by inflammation.
 Dexamethasone used most commonly

36.  Surgical drainage of affected sinuses
 Endoscopic sinus surgery
 Surgical debridement in fungal sinusitis
 Surgical drainage of any collection

37.  100% mortality prior to antibiotics
 30% mortality despite aggressive treatment
 44% of survivors remain with chronic
sequelae,
 Roughly one sixth of patients are left with
some degree of visual impairment
 One half have cranial nerve deficits
 Hypopituitarism- rare, can occur before or
after 1 year.

39.  Septic cavernous sinus thrombosis-Neurology
and Neurosciences;2014;4:117-118
 Treatment of Cavernous Sinus Thrombosis;
IMAJ 2002;4:468±469
 Septic thrombosis of cavernous sinus-Arch
Intern Med;2001;161:2671-2676