A 45‐year‐old man with no medical history presented for evaluation with 2 weeks of left eye swelling, double vision, headaches, and right‐sided neck pain. Review of systems was notable for fever and night sweats. On physical exam, he was febrile and tachycardic to 119. He had severe left‐sided chemosis with restricted gaze and swelling of the right neck. His vision and retinal exam were normal. His WBC count was 27,000 cells/mm3. CT of the head showed left‐sided proptosis, soft‐tissue swelling, mastoiditis, and thickening of the right platysma muscle. Empiric vancomycin and piperacillin/tazobactam were started. The following day, the patient's eye swelling increased and his vision deteriorated. CT angiography of the head showed left cavernous and dural sinus thrombosis and right internal jugular vein thrombosis. A heparin infusion was started. Over the next 48 hours, the patient's vision improved. His fever and leukocytosis resolved. Otoscopic exam of the left ear revealed purulent material and tips of cotton swabs in the tympanic membrane. On questioning, he remembered using cotton swabs to clean his ears in the past. Blood cultures grew Actinomyces naeslundii and meyeri. He received antibiotics for six weeks and warfarin for three months. He was counseled on ear hygiene and the risks associated with the use of cotton swabs. The patient fully recovered with the exception of a persistent left abducens palsy.
Cerebral venous sinus thrombosis (CVST) is an uncommon condition that is becoming more frequently recognized with the availability of MRI. Seventy‐five percent of patients are women. Most patients have thrombosis in more than one area of the cerebral drainage system. Headache is the most common symptom. Other signs/symptoms include evidence of intracranial hypertension (vomiting, papilledema, visual disturbances), neurologic deficits, seizures, and coma. Infectious cavernous sinus thrombosis, as in this patient, classically causes headache, fever, and eye symptoms. Patients with severe papilledema may develop permanent vision deficits without treatment. Importantly, head CT is normal in up to 30% of cases. Brain MRI is the most sensitive exam for identifying occlusions with CT venography as an alternate modality. Predisposing factors include malignancy, prothrombic states, pregnancy, infection, inflammatory disease, and trauma. In this patient, otitis media after cotton swab‐induced injury and foreign body retention led to septic thrombophlebitis, and no further workup for malignancy or prothrombotic state was pursued. Treatment consists of reversing the underlying cause if possible, controlling seizures and intracranial hypertension if present, and initiating anticoagulation, although the optimal duration of therapy is unknown. If detected early, most patients make a complete recovery.
This case illustrates the importance of recognizing the signs and symptoms of CVST and obtaining appropriate imaging to initiate early treatment.
To cite this abstract:Kay J, Smith D. “Tips” for Avoiding Cavernous Sinus Thrombosis. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 435. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/tips-for-avoiding-cavernous-sinus-thrombosis/. Accessed November 16, 2019.