3. Paired venous sinus, on either side of body of
sphenoid.
2cm in length, height of 1cm
Traversed by numerous trabeculae, dividing it
into a several caverns (spaces) hence
cavernous.
4. Relations:
◦ Medial – pituitary above, sphenoidal air cell below
◦ Lateral – temporal lobe, uncus
◦ Anterior - superior orbital fissure
◦ Posterior - petrous apex
◦ Superior – optic chiasm
5. Tributaries:
– Superior and inferior opthalmic veins
– Sphenoparietal sinus
– Inferior cerebral veins
– Superficial middle cerebral veins
– Central vein of retina
Drainage:
– Superior petrosal sinus---> transverse sinus
– Inferior petrosal sinus --->internal jugular vein
6. Communication:
– Intercavernous sinuses – communication between
the 2
– Pterygoid plexus – via emissary veins passing
through foramen ovale, emissary sphenoidal
foramen and foramen lacerum.
– Pharyngeal plexus – via a vein passing through
carotid canal.
– Facial vein – via superior opthalmic vein.
10. Includes cases of phlebitis, thrombo-phlebitis
and aseptic thrombosis
Septic type (most common) - coagulase
positive staphylococcus
Aseptic types may follow trauma, local stasis
or a failing circulation.
11. Septic CST
Infectious
Aseptic CST
Trauma
Post surgery
Rhinoplasty
Base of skull
Tooth extraction
Hematologic
Malignancy
Nasopharyngeal Ca.
Dehydration
12. More commonly seen with sphenoid and
ethmoid and to a lesser degree with frontal
sinusitis
Staphylococcus aureus -70% of all infections.
Streptococcus pneumoniae, gram-negative
bacilli, and anaerobes can also be seen.
Fungi are a less common pathogen and may
include Aspergillus and Rhizopus
species(more common in diabetics)
13. No valves in dural sinuses, cerebral and
emissary veins
Infection of upper lip, vestibule of nose and
eyelids-> spread by way of angular,
supraorbital, supratrochlear veins to
ophthalmic veins=commonest route
Intranasal operation of septum, turbinates,
ethmoid/sphenoid sinus infection->through
ethmoidal veins
14. Operation of tonsil, peritonsillar abcess,
maxillary osteomyelitis/surgery, dental
extraction->spread by pterygoid plexus or
direct extension in internal jugular vein
Involvement of middle ear/mastoid ->
retrograde spread through petrosal sinus to
cavernous sinus
15. Sources:
Nose – Paranasal 40%
Orbit- Face 35%
Mouth – Teeth 13%
Ear 9%
Other – tonsil, soft palate, pharynx, posterior
portions of the superior and inferior alveolar
arches 3%
18. Pyrexia
Rapid, weak, thready pulse
Chills and sweats
Delirium - meningitis supervenes terminally
Septic emboli to various other parts of body.
19. Proptosis (first oedema & chemosis)
Oedema of eyelids and bridge of nose
Dilatation and tortuosity of retinal veins
Retinal hemorrhages
Involvement of the contralateral eye – (48
hours)
When pterygoid plexus is occluded along with
sinus, - oedema of the pharynx or tonsil
20. First CN involved is VI
Ptosis - paralysis of oculomotor nerve
Dilatation of pupil- third nerve and
stimulation of sympathetic plexus
Decreased abduction (paralysis of abducens
nerve)
Complete opthalmoplegia
Loss of vision
Retro-orbital pain and supra-orbital
headache->V
21.
22. Strong clinical suspicion
1)Orbital venography
Not recommended
Difficult to puncture facial veins in odema
May help in dissemination of infection
23. 2) Contrast enhanced CT
Slice thickness 3mm or less
Shows enlargement and expansion of
cavernous sinus cavity with flatening or
convexity of lateral wall
Multiple or single filling defect with
enhancing CS.
Exopthalmos, soft tissue edema
Dilation of superior ophthalmic vein
24.
25. 3) MRI:
– A sensitive, noninvasive
Can be combined with venography to
demonstrate lack of blood flow in the
cavernous sinus
Show associated meningitis, involvement of
pituitary gland
26.
27. 4) CSF examination
Elevated protein
Normal sugar
Mild pleocytosis
5) Complete blood count
Elevated TLC
Leucocytosis
6) Blood culture
7) Local tissue culture
28. Intracranial extension of infection->
meningitis, encephalitis, brain abcess,
pituitary infection,epidural, subdural
empyema
Cortical vein thrombosis->hemorrhagic
infarction
Extension to other sinuses
29. Orbital cellulitis–differentiated from CST by B/L
involvement, papillodema, dilated pupil,
decreased periocular sensation, abnormal spinal
fluid in latter
Preseptal cellulitis- no proptosis
Orbital apex syndrome- more visual loss,
opthalmoplegia, less proptosis, periorbital
odema
Sinusitis
Orbital malignancy
Facial Cellulitis
Glaucoma-angle closure
30.
31. Immediate empiric antibiotic coverage must
include gram-positive, gram-negative and
anaerobic bacteria.
Later treatment can be narrowed, adjusted to
cultures and sensitivities
Third generation cephalosporin+vancomycin
with metronidazole
Duration- 3-4 weeks
32. Used in setting of fungal sinusitis
More common in diabetics
Aspergillus more common
Parentral amphotericin B for 3 weeks followed
by posaconazole(400mg BD) prophylaxis
Dose-0.5-1.5mg/kg/day(deoxycholate), 5-
10mg/kg/day(liposomal)
33. Intravenous heparin (maintaining the partial
thromboplastin time or thrombin clot time at
1.5 to 2 times that of the control)->24,000-
30,000 U/day.
Warfarin sodium (maintaining the
prothrombin time at 1.3±1.5 times the
control) -continued for 4 to 6 weeks to allow
adequate collateral channels to develop
34. Mortality was lower among patients who
received heparin treatment, 14% vs. 36%
Early administration of heparin may serve to
prevent spread of thrombosis to the other
cavernous sinus as well as to the inferior and
superior petrosal sinuses.
35. Not influence mortality
May prevent residual cranial nerve
dysfunction caused by inflammation.
Dexamethasone used most commonly
36. Surgical drainage of affected sinuses
Endoscopic sinus surgery
Surgical debridement in fungal sinusitis
Surgical drainage of any collection
37. 100% mortality prior to antibiotics
30% mortality despite aggressive treatment
44% of survivors remain with chronic
sequelae,
Roughly one sixth of patients are left with
some degree of visual impairment
One half have cranial nerve deficits
Hypopituitarism- rare, can occur before or
after 1 year.
38.
39. Septic cavernous sinus thrombosis-Neurology
and Neurosciences;2014;4:117-118
Treatment of Cavernous Sinus Thrombosis;
IMAJ 2002;4:468±469
Septic thrombosis of cavernous sinus-Arch
Intern Med;2001;161:2671-2676
