Cavernous Sinus Thrombosis
Successful Treatment Using Functional Endonasal Sinus Surgery
Ramzi T. Younis, MD, Rande H. Lazar, MD

Objective: Infections of the paranasal sinuses can be
complicated by septic thrombosis of the cavernous
sinuses. After standard antibiotic treatment,
fewer than 50% of the patients recover completely, and
the mortality rate is approximately 30%. We chose to
treat this potentially catastrophic complication with
functional endonasal sinus surgery in addition to standard antibiotic therapy.

venous

Intervention: The patient was started on a regimen of
cefuroxime and nafcillin sodium and was scheduled for
emergency functional endonasal sinus surgery to drain
the primary sites of infection. After surgery, the patient
was placed on a 3-week regimen of cefotaxime sodium,
metronidazole hydrochloride, vancomycin hydrochloride, and heparin sodium.
Results: During surgery, the frontal recess and ethmoid,

sphenoid, and maxillary sinuses were found to be filled
with polypoid tissue and purulent material. Functional

Design: Case study.
Patient: A 15-year-old boy presented to the emergency room of LeBonheur Children's Medical Center,
Memphis, Tenn, with right proptosis, chemosis, ptosis,
ophthalmoplegia, cranial nerve palsies, and paresthesia.
The physical examination and computed tomographic
scans of the sinuses and orbits revealed edema of the
right orbit and pansinusitis, with secondary right cavernous sinus thrombosis and right superior ophthalmic
vein thrombosis.

The

endonasal sinus surgery restored the sinuses to their normal physiologic state. The sinuses demonstrated the progress
observed clinically.
Conclusions: The improvement in outcome effected by
standard antibiotic therapy can be significantly augmented by using functional endonasal sinus surgery in
the treatment of cavernous sinus thrombosis.

(Arch Otolaryngol Head Neck Surg. 1993;119:1368-1372)

postmortem

changes

of septic cavernous sinus
thrombosis were first de¬
scribed by Duncan1 in
1821. All of the initial at¬
tempts to treat the condition with sur¬
gery failed.2·3 In 1936, Grove4 reviewed
400 cases and reported a mortality rate
of 100%. One year later, MacNeal and
Cavallo5 described the first survivor after
using sulfonamides and antistreptococcus serum.

From the Otolaryngology

Consultants of Memphis (Tenn),
LeBonheur Children's Medical
Center.

Since the advent of antibiotics, the
incidence and mortality rate for cavern¬
ous sinus thrombosis have decreased.
New diagnostic and therapeutic modali¬
ties have markedly improved outcome,
but this infectious complication still car¬
ries a significant risk of morbidity and
mortality. The customary treatment in-

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eludes drainage of the primary focus of
infection, high doses of intravenous an¬
tibiotics, and subclinical doses of hep¬
arin sodium. With standard treatment,
fewer than 50% of the patients recover
completely, and approximately 30% of
them die, emphasizing the need for im¬

proved treatment.

We report the case of a child with

pansinusitis in whom right cavernous si¬
thrombosis developed. He was suc¬
cessfully treated with intravenous antibi¬
otics, a subclinical dose of heparin, and

nus

functional endonasal sinus surgery
(FESS). The pathogenesis, diagnosis,
roentgenographic findings, and treat¬
ment of this potentially lethal comp¬
lication are discussed, highlighting the
role of FESS as a new therapeutic mo¬

dality.

0.92 neutrophils. The leukocyte count

dropped progressively during treat¬

ment and was normal at the time of

hospital discharge. From the time of
hospital admission to hospital discharge,
results of all serum chemistry studies
were normal. His partial thromboplastin time was maintained between 25.0
and 35.0 seconds. Group C Strepto¬
coccus grew from one of three blood

cultures. Group C Streptococcus and
coagulase-negative Staphyloccus grew
from intraoperative cultures of his si¬
nuses. Analysis also revealed anaero¬
bic organisms, including Streptococ¬
cus viridans and Bacteroides melaninoFigure 1. Left, Axial computed tomographic scan of the brain (April 3, 1989) shows right-sided facial
and orbital swelling and proptosis and thrombosed right superior ophthalmic vein (arrow). Right,
Computed tomographic scan shows enhancement of the right internal carotid artery (arrow) within a
thrombosed cavernous sinus (no uptake of contrast) and the left cavernous sinus (enhanced with

contrast).

REPORT OF A CASE

diagnosis of
right cavernous
sinus thrombosis, neurosurgical, neu¬
rologic, and ophthalmologic consul¬
tations were requested. Informed con¬

erate edema. After the

acute sinusitis with

A 15-year-old boy presented to our

emergency room at LeBonheur
Children's Medical Center, Memphis,
Tenn, on April 3,1989. One day be¬
fore hospital admission, the patient
had swelling of the right eye with pain
and diplopia. For 3 weeks, he had had
an upper respiratory tract infection and
right-sided headache, but his medi¬
cal history was essentially unrevealing. Physical examination disclosed that
he had a temperature of 39.5°C, heart
rate of 102 beats per minute, respi¬
rations of 24/min, and blood pressure
of 120/64 mm Hg. He had right prop¬
tosis, chemosis, ptosis, and ophthalmoplegia. The boy had third, fourth,
and sixth cranial nerve palsies and paresthesia over the maxillary branches
of the trigeminal nerve, but he was oth¬
erwise neurologically intact with no

meningeal signs.
The physical examination also
revealed congested erythematous na¬
sal mucosa with bilateral purulent na¬
sal discharge. The right side of his

face was swollen and tender. Com¬
puted tomographic (CT) scans of the
sinuses and orbits revealed pansi¬
nusitis, with secondary right cavern¬
ous sinus thrombosis and right su¬
perior ophthalmic vein thrombosis
(Figure I ). The right orbit had mod-

sent for treatment was obtained after

the procedures were explained.
The patient was started on a regi¬
men of 1.5 mg of cefuroxime given
intravenously every 8 hours and 2 g
of nafcillin sodium given intrave¬
nously every 4 hours. He was also
scheduled for emergency FESS. Dur¬
ing surgery, the ethmoid and sphe¬
noid sinuses were found to be filled
with polypoid tissue and purulent ma¬
terial. The frontal recess and maxil¬
lary sinuses were also filled with poly¬
poid disease. Results of the pathologic
examination of these specimens were
compatible with chronic sinusitis.
After surgery, the patient was
transferred to the intensive care unit,
where he was started on a regimen
of 3 g of cefotaxime sodium, 500 mg
of metronidazole hydrochloride, given
intravenously. The heparin dose was
altered according to the results of the

daily partial thromboplastin time.
The patient's laboratory profile
was carefully monitored during hospitalization. At the time of hospital ad¬
mission, he had a hemoglobin value
of 122 g/L, hematocrit of 0.36, and
leukocyte count of 24.7 X109/L, with

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genicus.
The patient was extubated on
the second postoperative day and
closely observed. A repeated CT scan
of the sinuses and orbits on April 6
showed further progression of the
thrombosis of the facial veins and increased soft-tissue swelling
(Figure 2). However, because the
patient's clinical condition was im¬
proving, the same therapeutic regi¬
men was maintained. On April 10,
the facial edema and right eye proptosis were regressing. Another CT scan
of the sinuses and orbits (Figure 3)
on the same day demonstrated clini¬
cal improvement.
The patient was transferred to
a regular nursing floor, where he was
treated with 7500 IU of heparin so¬
dium administered subcutaneously ev¬
ery 6 hours. Treatment with beclo¬
methasone dipropionate spray and sa-

Figure 2. Axial computed tomographic scan of
the brain (April 5, 1989) shows increased
right-sided facial and orbital swelling and
proptosis (small arrows) and thrombosed right
superior ophthalmic vein (solid white arrow).

Figure 3. Left, Axial computed tomographic scan of the brain (April 10, 1989) shows regression of
the right-sided facial and orbital swelling. Right, Axial computed tomographic scan of the brain (April
10, 1989) shows recanalization (enhancement) of the cavernous sinus (arrow).

Figure 4. Axial computed tomographic scan of
the brain (April 20, 1989) shows recanalization
of the right superior ophthalmic vein (arrow).

line nasal washes was also started.
The antibiotic and heparin therapy
was continued for a total of 21 days.
Another CT scan of the sinuses

less venous channels within the leaves
of the dura. The right and left cav¬

this sinus may affect all of these ana¬

ernous sinuses communicate

The cavernous sinuses drain
the anterior portion of the face,
oral cavity, tonsils, pharynx, nasal
cavity, orbit, eye, paranasal si¬
nuses, middle ear, mastoid region,
cerebral cortex, and the pituitary.
The cavernous sinuses empty into
the superior and inferior petrosal
sinuses and ultimately drain into
the internal jugular vein. Because
of these associations, focal infec¬
tion of the head or neck region
may produce septic thrombosis of
the cavernous sinuses.
Infections of the medial third of
the face, including the nose, orbit,
tonsils, and soft palate, were the most
common causes of cavernous sinus
thrombosis in the past.6"8 Bacteria can
enter the facial or pterygoid plexus
and reach the cavernous sinus by the
superior or inferior ophthalmic veins.
After antibiotics were introduced, si¬
nusitis involving the sphenoid and
ethmoid air sinuses became a more
frequent antecedent condition. Of the
eight patients reviewed by Southwick and colleagues,8 all had sphe¬
noid or ethmoid sinusitis before cav¬

(Figure 4) performed on April 20

demonstrated the progress observed
clinically. On April 24, the patient
was in good condition and was dis¬
charged from the hospital to his home.
COMMENT

The cavernous sinuses, located at the
base of the skull superolateral to the
sphenoid sinus (Figure 5), are valve-

through

the intercavemous sinuses, which pass
anteriorly and posteriorly to the sella
turcica and pituitary gland. The ocu¬
lomotor nerve (III), trochlear nerve
(IV), and the ophthalmic and max¬
illary branches of the trigeminal nerve
(V) course along the lateral wall of
the cavernous sinus. The internal ca¬
rotid artery, sympathetic plexus, and
the abducens nerve (VI) traverse the
center of the cavernous sinus near
its medial wall. Thrombophlebitis of

tomic structures.

sinus thrombophlebitis
developed. The predisposing infec¬
tion may spread from the air sinuses
by small emissary veins, the sphe¬
noid vein, or directly from the sphe¬
noid sinus. Infrequently, infections
of the ear spread by way of emissary
veins to the sigmoid sinuses and reach
ernous

Figure 5. Anteroposterior vertical cross-section of the cavernous sinus anatomy. CS indicates
cavernous sinus; IC, internal carotid artery; III, oculomotor nerve; IV, trochlear nerve; V, and V2,
ophthalmic and maxillary branches of the trigeminal nerve; VI, abducens nerve; H, hypophysis; and S,
sphenoid sinus.

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Table 1. Clinical Manifestations of
Cavernous Sinus Thrombosis
Manifestations

Headache
Retro-orbital pain
Fever
Periorbital edema
Ptosis

Proptosis
Chemosis
Ocular muscle palsies (lll-VI)
Reduced visual acuity

Papilledema
Nuchal rigidity
Lethargy

tus.9 Meningismus occurs in a few

patients. As the thrombophlebitis ex¬

Coma

the cavernous sinus through the in¬
ferior petrosal sinuses.8
The many clinical manifesta¬
tions of cavernous sinus thrombosis
are given in Table 1. Most patients
have spiking fever and chills. Other
signs of toxemia include profuse per¬

spiration, rapid thready pulse, nau¬
sea, vomiting, confusion, delirium,

and coma. Headache may occur in
as many as 50% of the patients who
eventually have development of cav¬
ernous sinus

paresthesia of the
upper two thirds of the face, which
can exacerbate headache and oblit¬
erate the corneal reflex. The pupils
in patients with cavernous sinus
thrombosis become fixed and di¬
lated after the loss of parasympa¬
thetic control. However, if the inter¬
nal carotid artery sympathetic plexus
is affected, the pupil may be small
and fixed.10,11 More than half of the
patients exhibit changes in neural sta¬
nerve can lead to

thrombosis.9

The first signs of venous ob¬
struction are eyelid edema and chemo¬
sis, followed by proptosis, ptosis, and
edema of the bridge of the nose.
Periorbital edema occurs in approxi¬
mately 75% of these patients.9 It is
initially confined to one side, but it
often progresses to involve the con¬
tralateral eye within 2 days.810

Diplopia and photophobia are
early complaints. Ophthalmoplegia secondary to orbital con¬
gestion, dilatation, and possibly

uncommon

thrombosis of the facial vein may de¬

velop.9
Limitation of the extraocular

muscles can be demonstrated at some
point in most patients.8"10 Lateral gaze
palsy may be an isolated early neu¬
rologic finding because the ab¬
ducens nerve is the only cranial nerve
that traverses the cavernous sinus.9
Involvement of the ophthalmic and
maxillary branches of the trigeminal

tends through the intercavernous si¬
nuses, the signs and symptoms be¬
come bilateral, and the toxic
manifestations increase.10
The diagnosis of cavernous si¬
nus thrombosis is usually based on
clinical findings. According to Price
et al,12 five criteria are required to
make the diagnosis of cavernous si¬
nus thrombosis (Table 2). The di¬
agnosis is further confirmed by roentgenographic and laboratory studies.13
Computed tomography with en¬
hancement is the best available ra¬
diologie tool. Coronal CT scans of
the sinuses can demonstrate any sinus disease, and a contrastenhanced CT scan of the brain may

help in diagnosing cavernous sinus
thrombosis.1413 Although a CT scan

may fail to demonstrate occlusion of
the cavernous sinus, it may reveal pro¬
vocative findings, such as throm¬
bosed superior ophthalmic vein, cor¬

tical venous infarcts, or an orbital
abscess.9 The diagnostic yield can be
improved by infusion of higher doses
of contrast material followed by rapid
sequential views of the cavernous si¬
nus and by employing thin sections
with multiple relationships and di¬
rect coronal scanning.9
Radionuclide brain scans usu¬
ally impart nonspecific findings, but

magnetic resonance imaging can aid

the diagnosis.9 Carotid audiography
or orbital venography can be used,
but these are highly invasive and do
not provide more information than
enhanced CT.
Leukocytosis, elevated protein
level in cerebrospinal fluid, pleocy-

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tosis, and normal glucose level are
usually detected among the labora¬

tory findings. Blood cultures are usu¬

ally positive.

The mainstay of therapy in cav¬
high doses
of intravenous antibiotics. A combi¬
nation of antibiotics effective against
gram-positive, gram-negative, and
anaerobic organisms should be in¬
stituted before the results of cul¬
tures and sensitivity studies are avail¬
able. Staphylococcus aureus is
documented in more than 67% of
these patients.9 Pneumococci and
other streptococcal species account
for most of the remaining cases.8"10
Gram-negative bacilli and anaer¬
obes are occasionally isolated.
ernous sinus thrombosis is

A penicillinase-resistant peni¬
cillin, such as nafcillin, and a

third-generation cephalosporin,

such as ceftazidime or cefotaxime
sodium, provide good initial com¬
bination therapy. Chloramphenicol
can also be used with nafcillin to
combat anaerobes.8"10·16 Medical
treatment should be continued for
2 to 4 weeks after local and gen¬
eral signs of infection have sub¬
sided.10 Our patient was treated
with cefotaxime, a wide-spectrum
antibiotic that covers gramnegative bacilli. Metronidazole was
given to cover anaerobes and van¬
comycin was administered to opti¬
mize coverage for S aureus.
The use of heparin is contro¬
versial, but it can benefit patients with
early unilateral manifestations of cav-

Table 2. Diagnostic Criteria for
Cavernous Sinus Thrombosis*
Criteria
Bilateral involvement or sequential
progression to the contralateral eye
Proptosis, chemosis of conjunctiva,
eyelid edema
Limitation of extraocular motion
Meningismus, may include cerebrospinal
fluid pleocytosls
Residual cranial nerve palsy of cranial
nerves III, IV, or V after arrest of
process
"From Price et al.'2

ernous sinus thrombosis. Southwick and associates8 showed that mor¬
tality was decreased with heparin use.
Anticoagulation may prevent fur¬
ther spread of thrombosis and may
prevent septic emboli to the other
venous sinus. It may also contribute
to recanalization and dissolution of
the clot, allowing the antibiotic to
reach the infected thrombosis more
readily.10·17 Alternatives to heparin
include warfarin sodium (Couma-

din), dextran, streptokinase, or

streptodornase.10 Anticoagulation
should be considered only if there

is no clinical or CT evidence of

of sinusitis as the principal source of
infection in cavernous sinus throm¬

bosis, FESS may eventually prove to

be an essential step in the treatment
of these patients. Rapid improve¬
ment occurred in all three patients
who underwent débridement of the
sphenoid sinuses in the series of
Southwick et al.8 We believe that our
strategy of employing antibiotics, hep¬
arin and, FESS provided optimal treat¬

ment because our

patient's condi¬
tion began to improve within 2 days
and he recovered without adverse

sequelae.

cortical venous infarction.9·10

Intravenous

corticosteroids may sometimes serve

adjunctive therapy, es¬
pecially if there is a lack of
response to high-dose an¬
as

tibiotics.10·11 Corticosteroids are oc¬
casionally used to decrease orbital congestion, and they may prevent
addisonian crisis if the septic throm¬
bosis has spread to the pituitary.8·18

Therapeutic hypothermia is some¬
times employed to control fever and

decrease cerebral edema.19
In cases of cavernous sinus
thrombosis, surgery is indicated to
drain the primary site of infection.
Surgical intrusion into the cavern¬
ous sinus is difficult and not rec¬
ommended. If sphenoid or eth¬
moid sinusitis is documented by
CT scans, surgical drainage of
these infected pockets should be
performed promptly. Functional
endonasal sinus surgery is a quick
and effective procedure for these
patients.20 The procedure restores
the sinuses to their normal physi¬

ologic state by providing adequate

CONCLUSION

Antibiotics revolutionized the out¬
come of treatment for cavernous si¬
nus thrombosis. In 1961, Yarrington22
reported a mortality rate of 80%, with
a morbidity rate of 75% among the
survivors. With standard treatment,
the mortality rate dropped to ap¬
proximately 30%, and full recovery
was observed for fewer than half of
the patients. We believe the dra¬
matic improvement in outcome ef¬
fected by antibiotics can be signifi¬

cantly augmented by employing FESS

in the treatment of cavernous sinus
thrombosis. Sinusitis has increas¬
ingly become the primary source of
infection leading to cavernous sinus
thrombosis, and skillfully executed
FESS provides drainage of the in¬
fected sinuses.
The introduction of potent an¬

tibiotics, adjunctive therapies, and ad¬
vanced surgical techniques has mark¬
edly improved the outcome of septic
thrombosis of the cavernous sinus, but
it remains a potentially catastrophic

disorder. Prevention, prompt diagno¬
sis, and optimal treatment exploiting
all existent therapeutic modalities of¬
fer the best hope for recovery.

aeration and restoring normal mucociliary flow through patent sinus
ostia.21 Functional endonasal sinus
surgery adequately drains the in¬
fected sinuses with little morbid¬

Accepted for publication December 11,

ity. If the patient cannot withstand
general anesthesia, FESS can be

ogy Consultants of Memphis, LeBon¬
heur Children's Medical Center, 777

performed under local anesthesia.

With the increasing incidence

1992.

Reprint requests to Otolaryngol¬

Washington Ave, P240, Memphis, TN

39105 (DrYounis).

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