Challenging presentations of cavernous sinus thrombophlebitis

Courtney L Kraus,Susan M Culican

doi:10.1007/s12348-011-0053-7

Abstract

AimThe purpose of this study was to describe two challenging cases of septic cavernous sinus thrombosis (CST), which presented with vastly different clinical signs and symptoms.MethodsWe present two cases of CST with markedly differing clinical presentations, medical comorbidities, and degree of impairment. Initial imaging of each patient failed to show thromboembolic disease.ResultsBoth patients required multiple imaging procedures to arrive at the correct diagnosis. Each child did respond to treatment once the correct diagnosis was made.ConclusionCST can have a highly variable clinical presentation, from a subtle sixth nerve palsy to complete ophthalmoplegia and loss of periorbital sensation and corneal reflex. Onset of symptoms may be acute and fulminant or indolent and delayed. The diagnosis is challenging, requiring clinical suspicion and confirmation by imaging. These cases illustrate the importance of retaining clinical suspicion when cranial nerve palsies persist and how valuable rescanning a patient can be.

Highlights

Cavernous sinus thrombosis (CST) is a rare phenomenon that requires clinical suspicion and emergent imaging for correct diagnosis
We report two cases of CST where initial imaging failed to show a thrombus
A valveless system of sinuses and veins allows for easy spread of bacteria

Summary

Introduction

Cavernous sinus thrombosis (CST) is a rare phenomenon that requires clinical suspicion and emergent imaging for correct diagnosis. We report two cases of CST where initial imaging failed to show a thrombus. When both patients continued to deteriorate despite medical and surgical intervention, repeat scanning confirmed suppurative thromboembolism. A 16-year-old girl presented to the emergency department with 3 days of headache, diplopia and progressive rightsided periorbital edema, and ptosis. Her medical history was significant for type 1 diabetes mellitus and asthma, for which she took oral prednisone. Visual acuity was decreased to 20/40 in her right eye. External exam demonstrated significant upper and lower lid edema and erythema, ptosis, and moderate proptosis She had diminished sensation in the distribution of cranial nerve (CN) V1.

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