Septic cavernous sinus thrombosis with bilateral secondary orbital infection

Pediatric cavernous sinus and superior ophthalmic vein thrombophlebitis complicated by peri-venous orbital abscesses

Purpose

This case report documents a 13-year-old male with bilateral cavernous sinus thrombosis and left superior ophthalmic vein thrombosis secondary to sphenoid sinusitis who subsequently developed peri-venous orbital abscesses.

Observations

Although the patient initially improved clinically with intravenous antibiotic therapy and therapeutic anticoagulation, his symptoms returned and repeat imaging demonstrated two well-circumscribed, rim-enhancing lesions in the left orbit concerning for abscesses. Surgical intervention revealed that these purulent collections were contiguous with the superior and inferior ophthalmic veins with the superior collection also containing hemorrhagic material. Despite aggressive management, the abscess in the inferolateral orbit recurred, requiring repeat surgical intervention. The patient was ultimately discharged on parenteral antibiotics and anticoagulation, and on outpatient follow-up, there was no evidence of recurrence.

Conclusions and Importance

This case report describes a pediatric patient with bilateral cavernous sinus thrombosis who developed the rare complication of multiple peri-venous orbital abscesses despite appropriate treatment with antibiotics. The patient's complex clinical course highlights the importance of prompt repeat imaging and possible surgical intervention upon clinical changes, especially in patients with infections from the Streptococcus milleri group.

Cavernous sinus thrombosis caused by Streptococcus constellatus-associated Lemierre syndrome presenting as an isolated abducens nerve palsy

Purpose

To describe a patient with Streptococcus constellatus-associated Lemierre syndrome complicated by eventual cavernous sinus thrombosis (CST) that manifested as an isolated abducens nerve palsy.

Observations

A patient with a history of heavy alcohol use presented with Lemierre syndrome caused by an odontogenic infection due to Streptococcus constellatus. Despite initiation of intravenous antibiotics and eventual eradication of her bacteremia, she developed an isolated abducens nerve palsy on hospital day 7 due to associated CST.

Conclusions and Importance

CST is a rare complication of odontogenic infection and Lemierre syndrome. This case demonstrates the potential for primary odontogenic infections to progress to life- and sight-threatening diseases. This case also illustrates the importance of considering uncommon pathogens as the etiology of CST based on the suspected source of primary infection.

Septic Cavernous Sinus Thrombosis: A Case Report

Introduction

Septic cavernous sinus thrombosis (CST) is a rare condition that can result in high mortality and morbidity rates if not treated immediately. CST may be aseptic or septic. Less common primary sites of infection include the tonsils, soft palate, middle ear, and orbit. Reported cases of middle ear infection are very rare, and response to treatment is poor.

Case Presentation

The present study is a case report of acute otitis media which led to septic cavernous sinus thrombosis in a 56-year-old woman in Bojnord city, North Khorasan, Iran.

Conclusions

Findings of laboratory tests and magnetic resonance imaging (MRI) confirmed the clinical diagnosis. Clinical-based medical care led to successful management of the patient with broad spectrum intravenous antibiotics that prevented serious complications.

MRI in the Evaluation of Acute Visual Syndromes

Acute visual symptom emergencies occur commonly and present a challenge to both clinical and radiologic facets. Although most patients with visual complaints routinely require clinical evaluation with direct ophthalmologic evaluation, imaging is rarely necessary. However, there are highly morbid conditions where the prompt recognition and management of an acute visual syndrome (AVS) requires an astute physician to probe further. Suspicious symptomatology including abrupt visual loss, diplopia, ophthalmoplegia, and proptosis/exophthalmos require further investigation with advanced imaging modalities such as magnetic resonance imaging and magnetic resonance angiography. This review will discuss a variety of AVSs including orbital apex syndrome, cavernous sinus thrombosis, cavernous carotid fistula, acute hypertensive encephalopathy (posterior reversible encephalopathy syndrome), optic neuritis, pituitary apoplexy including hemorrhage into an existing adenoma, and idiopathic intracranial hypertension. A discussion of each entity will focus on the clinical presentation, management and prognosis when necessary and finally, neuroimaging with emphasis on magnetic resonance imaging. The primary purpose of this review is to provide an organized approach to the differential diagnosis and typical imaging patterns for AVSs. We have provided a template for radiologists and specialists to assist in early intervention in order to decrease morbidity and provide value-based patient care through imaging.

Cavernous sinus thrombosis progression from trismus

In the Department of Oral and Maxillofacial Surgery, patients with trismus can be easily identified. If the cause of trismus is infection of the masticatory space near the pterygoid plexus, the possibility of cavernous sinus thrombosis should be considered. We report the case of a patient who presented with limited mouth opening and progressed to cavernous sinus thrombosis, along with a review of the relevant literature.

Orbital masses: CT and MRI of common vascular lesions, benign tumors, and malignancies

A wide variety of space occupying lesions may be encountered in the orbit. CT and MR imaging frequently help confirm the presence of a mass and define its extent. Characteristic imaging features may help distinguish among lesions that have overlapping clinical presentations. This review focuses on some of the common orbital masses. Common vascular lesions that are reviewed include: capillary (infantile) hemangioma, cavernous hemangioma (solitary encapsulated venous-lymphatic malformation), and lymphangioma (venous-lymphatic malformation). Benign tumors that are reviewed include: optic nerve sheath meningioma, schwannoma, and neurofibroma. Malignancies that are reviewed include: lymphoma, metastasis, rhabdomyosarcoma, and optic glioma. Key imaging features that guide radiological diagnosis are discussed and illustrated.

Ophthalmic and facial veins are not valveless

BACKGROUND

The ophthalmic and facial veins are frequently stated to be devoid of valves, facilitating the spread of infection from the mid-face to the cavernous sinus.

METHODS

Twelve superior and eight inferior ophthalmic veins together with 13 angular and facial veins were harvested from adult cadavers. Each vein was opened longitudinally and examined by stereomicroscopy; the number, location and geometry of valve cusps were recorded.

RESULTS

Ten valves were identified in nine (75%) superior ophthalmic vein specimens: four valves were in the superior ophthalmic vein and the remainder were located near its origin from angular and supra-orbital tributaries. No valves were seen in the inferior ophthalmic vein. Seventeen bicuspid valves were identified in tributaries of the angular vein or in the facial vein, but none were in the angular vein itself. Four of seven facial vein segments extending to the lower border of the mandible had valves. The orientation of valve cusps predicted the following blood flow: in the facial vein, inferiorly; in the superior ophthalmic vein, towards the cavernous sinus; and in the angular vein, to the facial or superior ophthalmic vein.

CONCLUSIONS

This study demonstrates, for the first time, the existence of valves in the superior ophthalmic vein and its two main tributaries. Valves were also seen in the facial vein. It is not the absence of venous valves but the existence of communications between the facial vein and cavernous sinus and the direction of blood flow that is important in the spread of infection from the face.