May 2015
A 67-year-old man with diabetes, with facial swelling and fever following a dental procedure (incomplete molar tooth extraction). History of myasthenia gravis treated with steroids.
Septic Cavernous Sinus Thrombosis following Tooth Extraction
- Septic cavernous sinus thrombosis (SCST) is thrombophlebitis of the cavernous sinus of infectious origin.
- Most commonly, SCST results from spread of infection from the paranasal sinuses, or from the middle one-third of the face. Less commonly, infection from teeth, nose, tonsils, soft palate, pharynx, and ears may constitute the primary source of the infection. Dental infections constitute less than 10% of the cases.
- Dental infection commonly spreads via involved pterygoid venous plexus.
- Onset is acute, usually with unilateral periorbital edema and proptosis associated with headache and photophobia. Examination may reveal ophthalmoplegia.
- Diagnosis of CST is made on clinical grounds. Confirmed by appropriate radiographic studies.
- Key Diagnostic Features: MRI and MR venography are more sensitive than CT scan for diagnosis. Filling defect within cavernous sinus is seen. This is often times associated with involvement of the superior ophthalmic vein.
- S. aureus most frequently cultured organism in these infections: 70%; Streptococcus species: 20%
- Rx: High-dose intravenous antibiotics. Patients are usually treated for 3 to 4 weeks. The role of anticoagulation therapy is still controversial. Early initiation (within 5–7 days) may help in reducing morbidity, but delayed use provides no benefits.
- With the availability of good broad-spectrum antibiotics, the prognosis of septic CST has improved, reducing mortality from near 100% to 20–30%.
