The Cavernous sinus thrombosis was initially described by Bright in 1831 as a redoubtable complication of epidural and subdural infections. In fact, the cavernous sinus thrombosis consists in the appearance of a clot (thrombus) in the cavernous sinus and occurs most often in the late complications of the frontal and para-nasal sinus infections. Other causes for its occurrence are bacteremia, trauma, and ear infections (otitis) or maxillary teeth infection. It is an infectious process with a fulminant evolution and with a high morbidity and mortality rate. However, using the prompt and the effective antimicrobial agents, the incidence of thrombosis was significantly reduced in the last period.
The Epidemiology
Cavernous sinus thrombosis is rare today, the literature is recognizing only a few hundred cases, mostly dating from the pre antibiotics period (however, at that time all infections had a poor prognosis).
Mortality / Morbidity
Before the discovery of antibiotics, the mortality rate was 100%. The patients died due to sepsis or due to a central nervous system infection. Currently, under the correct treatment, aggressive and fast set up, the mortality dropped to 30%. However, the morbidity rate remains high, and the total recovery of the normal functions is quite rare: 1 / 6 of the patients remain with some degree of visual impairment and they will never resume its full functions of the cranial nerves initially trapped in the infectious process.
The cavernous sinus thrombosis does not affect a certain race or sex, but it was observed that the average age for the occurrence is quite low: 22 years.
Signs and symptoms
The initial signs and symptoms of the cavernous sinus thrombosis are often nonspecific and because of this the correct diagnosis may be delayed (because thrombosis is rare, it is less suspected in the initially diagnosis). The patients show a wide range of signs and symptoms. Therefore, any person complaining of persistent headache, refractory to common analgesic and has the objective neurologic signs of impaired cranial nerves must be investigated properly for possible cavernous sinus thrombosis. The patient’s symptoms are correlated with the anatomical structures affected by the infectious process, as follows:
- Sinusitis or infection localized in the dermatology segment of the facial median (the middle) – most commonly a furuncles (over 50% of cases) – with the evolution of 5-10 days. In more than 25% of cases the furuncles is the precipitating factor of the infection, especially if it was drained in any way (by the patient or the surgical procedures).
- Headache is the most common accusation: it precedes fever, periorbital edema and signs of impaired cranial nerves. The pain is usually acute, progressively increased in intensity and it is located in the regions innervated by the eye nerve and the jaw branch of the trigeminal nerve.
- If the infection diffuses to the back, the patients complain of orbital pain and permanent feeling of tension, accompanied by periorbital edema and visual disturbances.
In the absence of an effective treatment, the signs appear to the controlateral eye. The periorbital edema begins as a unilateral process but it is expanding rapidly to the other eye (within 24-48 hours if the infection spreads via the intra cavernous sinus). This bilateral disease is pathognomonic to the cavernous sinus thrombosis.
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