1. Dr. Parag Moon
Senior resident
GMC, Kota

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.

7. Contents of cavernous sinus
 - Internal Carotid artery with sympathetic
plexus
 - CN 3
 - CN 4
 - CN 5 (1st and 2nd divisions)
 - CN 6

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%

17. 1. Sepsis
2. Venous obstruction
3. Involvement of cranial nerves

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

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

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

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

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.

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