From One Sinus to Another

1Inova Fairfax Hospital, Falls Church, VA
2Inova Fairfax Hospital, Falls Church, VA
3Inova Fairfax Hospital, Falls Church, VA

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 463

Case Presentation:

A 19‐year‐old female with a history of juvenile rheumatoid arthritis on immunosuppressants presented with 3 days of fevers, flank pain, and headaches. Two weeks prior, she was treated with penicillin because of a positive pharyngeal rapid streptococcal test. Her temperature was 39.4°C, heart rate 140 per minute, respiratory rate 28 per minute, and blood pressure 94/42 mm Hg. She appeared toxic and demonstrated right costovertebral angle tenderness. A complete neurologic examination was normal. Laboratory data demonstrated mild leukocytosis and pyuria. The patient was admitted to the ICU for septic shock and pyelonephritis. Lumbar puncture demonstrated a neutrophilic pleocytosis with normal glucose and protein. Blood, urine, and cerebrospinal fluid cultures were negative. The patient stabilized quickly and was transferred to the medical floor. After transfer, the patient complained of diplopia and was found to have a right lateral rectus palsy with ptosis. Physician examination did not demonstrate chemosis or periorbital edema. Noncontrast CT of the brain showed bilateral sphenoid sinus opacification. Contrast enhanced MRI of the brain, orbits, and paranasal sinuses demonstrated absence of normal enhancement of the right cavernous sinus with dural thickening — establishing the diagnosis of cavernous sinus thrombosis (CST; Figs. 1 and 2). Intravenous steroids and heparin were added and sphenoid sinus drainage was performed by otolaryngology. The patient improved, and she was discharged one week after surgery to complete a course of antibiotics and steroids as well as warfarin anticoagulation for 6 months. At the 1‐year follow‐up, her cranial neuropathies had resolved.

Discussion:

CST is a rare condition that can arise from sphenoid sinusitis because of the close proximity between the sphenoid and cavernous sinuses ‐ the latter which carry portions of cranial nerves II, III, IV, V1, V2, and VI. Typically, patients seek medical attention because of headaches. Periorbital edema, chemosis, and ophthalmoplegia are common findings later in the disease course — some of these findings may have been absent in our patient because of her immunosuppressed state. CT with contrast of the orbits and sinuses or MRI using flow parameters may reveal the source of infection or abnormalities within the cavernous sinus. Immediate broad spectrum intravenous antibiotics, including anti‐staphylococcal coverage, are the mainstay of therapy. Delay in initiation can result adverse outcomes including septic shock and death. Surgical drainage of the sphenoid sinus is required for cases of concomitant sphenoid sinusitis. Use of adjunctive anticoagulation and corticosteroids remains controversial. Half of all patients will develop persistent cranial neuropathies.

Conclusions:

Rapid diagnosis and prompt treatment of CST requires a high index of suspicion, especially in immunosuppressed individuals. Concomitant sphenoid sinusitis should prompt an otolaryngology consultation for sinus drainage.

Figure 1.Axial fat‐saturated T2‐weighted image shows sphenoid sinus opacification with abnormal hyperintensity.

Figure 2.Contrast‐enhanced axial fat‐saturated T1‐weighted image with findings of septic thrombophlebitis of the right cavernous sinus. Absence of normal enhancement of the right cavernous sinus centrally (large arrow) with prominent dural thickening along the lateral wall of the cavernous sinus (open arrow). This has originated from sphenoid sinusitis extending through a defect in the right posterior wall (arrowhead). Small focus of involvement in the left cavernous sinus (small arrow).

To cite this abstract:

Venkatesan C, Mushtaq E, Mehfoud D. From One Sinus to Another. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 463. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/from-one-sinus-to-another/. Accessed November 18, 2019.

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