History does repeat itself!
Suganya Appugounder, DMD, MS,* Olivia Pop, MD, † John. P. Kelly, DMD, MD‡
Cavernous sinuses are the most centrally located of the three dural sinuses. The venous supply of the head and neck lacks valves; hence blood can flow in either direction based on the pressure gradient making them the frequently infected dural sinuses.
Cavernous venous thrombosis (CVT) is rapidly progressive and can be life threatening if not diagnosed and treated at the earliest possible.4 It requires immediate intensive treatment including broad-spectrum antibiotics and surgical drainage of the source of infection. Most cases are due to an acute infection in an otherwise healthy individual making it very hard to make an accurate diagnosis of CVT.
A systematic review of the literature was conducted to better understand the etiology and establish the diagnostic criteria and outline management of this condition. In addition we present a recent case of cavernous sinus thrombosis following a tooth extraction. The CVT was first reported in 1825 by Ripes. Since then only a few hundred cases have been reported so far. Most of the published cases before 1950’s were post mortem.1 The publications discussed different etiologies, management and prognosis of the conditions. The factors associated with CVT vary from local to systemic, drug induced, blood dyscrasias and coagulopathies. The clinical presentation can be extremely varied.3
Our case is of a 77 year old female patient who developed facial swelling and neck pain 4 days after having three teeth extracted from the left maxilla. Patient assumed symptoms were due to positioning in the dental chair and took OTC analgesics. Patient went to see her primary care physician that week who treated her with analgesics for pain in the neck and occipital area. Re-evaluation by the treating dentist on post operative day 5 and “bone pieces” were removed from the extraction site. Patient started having blurred vision on post-operative day 7. She was evaluated by an ophthalmologist and was placed on steroids suspecting temporal arteritis. Patients condition improved week 2 and the steroid dose was tapered which in turn resulted in worsening of the symptoms. Patient was admitted to the hospital on post operative day 14 and was diagnosed with bilateral cavernous sinus thrombosis on hospital day 7. She was started on antibiotics and anticoagulants. Patient made a complete recovery within 2 weeks.
Historically this condition had high morbidity and mortality in the pre-antibiotics era. Prior to the advent of effective antimicrobial agents, the mortality rate from CVT was 100%. Typically, death is due to sepsis or CNS infection. When managed aggressively the mortality rate is <30% but the morbidity still remains high (60-75%).5 Since the condition mimics many benign conditions such as head ache, the biggest challenge is in establishing an early diagnosis.
- Resident, Department of Oral and maxillofacial surgery, Hospital of Saint Raphael, New Haven, CT
- Resident, Department of Internal Medicine, Hospital of Saint Raphael, New Haven, CT
- Professor, Head, and Program Director, Department of Oral and maxillofacial surgery, Hospital of Saint Raphael, New Haven, CT
References:
- Dorland Smith MD: Cavernous sinus Thrombosis, with notes of five cases, Bridgeport, Conn. 1925
- J Kimber: Cerebral venous sinus thrombosis Q J Med 2002; 137-142
- Mark J. DiNubile, MD Septic thrombosis of the cavernous sinuses Arch Neurol May 1, 1988 45: 567-572
- John R. Ebright, MD; Mitchell T. Pace, MD; Asher F. Niazi, MD Septic Thrombosis of the Cavernous Sinuses Arch Intern Med. 2001;161:2671-2676
- The prognosis and treatment of cavernous sinus thrombosis. Review of 878 cases in the literature. Yarington CT., Jr Ann Otol Rhinol Laryngol. 1961 Mar;70:263–267