Carotid-cavernous fistula after partial maxillectomy: Case report

Abstract

An otherwise healthy 18-year-old white man underwent a right partial maxillectomy for treatment of an osteoblastoma, which included the maxilla from the first premolar posteriorly and included the pterygoid plates. The operation was uneventful except for the unplanned inclusion in the resection of a less than 1 cm segment of the floor of the middle cranial fossa at the superior aspect of the medial pterygoid plate. No cerebrospinal fluid (CSF) leak or other evidence of dural perforation were noted. The immediate postoperative course was uneventful, and the patient was discharged the day after surgery. The patient returned 5 days later, reporting discomfort associated with his left eye, double vision, nausea, and vomiting. He also reported postoperative sinus congestion on the right, which had resulted in his blowing his nose “a lot.” He denied any fever or chills. On presentation, he was afebrile, and his vital signs were within normal limits. The expected amount of postoperative right facial swelling was present. His pupils were equal, round, and reactive to light and accommodation. The extraocular movements were intact, with the exception of the complete inability to abduct the left eye (Fig 1). There was mild chemosis and minimal edema of the left upper and lower eyelids, without discoloration and injection of the sclera. Funduscopic examination was normal, and visual acuity was 20/40. There was no lymphadenopathy, and the remainder of the physical examination was unremarkable. Laboratory values were significant only for a white blood cell count of 12,400 cm, with a normal differential count. A computed tomography (CT) scan was obtained which, in addition to the expected surgical defect, showed air-fluid levels in the right ethmoid and maxillary sinuses and the sphenoid sinuses bilaterally. The sphenoid sinuses were noted to be large. There was also moderate venous engorgement around the left globe, but no retrobulbar swelling. Additionally, there was enhancement adjacent to the left cavernous sinus and extradural air in the right temporal region. The patient was admitted to the hospital with a presumptive diagnosis of early left cavernous sinus thrombosis and started on ampicillin-sulbactam, morphine, and aspirin. On the first hospital day, he developed increased pain behind the left eye along with proptosis (6 mm) of the left globe (Fig 2). In addition, he began complaining of some neck stiffness andwas found to have minimal nuchal rigidity. Neurosurgery and infectious disease consults were obtained. There was concern that the patient had sinusitis, and was developing an early meningitis; therefore, ceftriaxone was added to his antibiotic regimen. A magnetic resonance imaging (MRI) scan was obtained, which showed flow through the cavernous sinuses along with a small amount of blood in the epidural and subdural spaces. An incidental finding was a cerebral vascular malformation in the left occipital area. At this point, the presumptive diagnosis was inflammation of the dura and sphenoid sinusitis. Steroids were considered, but withheld in view of a possible infectious cause. On the second hospital day, the physical findings were unchanged, and the white blood count had decreased to 11,600 cm. The ampicillin-sulbactam was stopped, and clindamycin was started. On the third hospital day, the patient claimed the discomfort associated with his left eye was less severe, but his physical findings remained unchanged. However, the following day, he began complaining of left forehead numbness and decreased visual acuity in the left eye. A second CT and MRI were completed, which *Formerly, Dennis A. and Roberta R. Youde Fellow in Head and