Introduction

Cavernous sinus thrombophlebitis (CST) is a rare, but severe condition with a mortality rate of approximately 25% [1]. It is associated with frequent complications and requires immediate treatment. The condition arises from infections spreading from adjacent tissues either through direct extension or via valveless veins [1, 2].

The most common causes include sinusitis (particularly of ethmoid and sphenoid sinuses), infections of the upper lip and nasal tissues, odontogenic infections, maxillofacial surgery, otitis media or mastoiditis [3, 4]. In most cases, the etiology is bacterial, with Staphylococcus aureus being the most frequently implicated pathogen [5, 6].

Symptoms result from impaired venous outflow from the cavernous sinus and compression of nearby structures (cranial nerves, arteries, veins) [1]. General symptoms include fever, chills, headaches, weakness, nausea and vomiting [7]. Ocular symptoms are common and may include exophthalmos, orbital edema, ptosis, photophobia, diplopia, ocular motility disorders, and pain [8].

Neurological symptoms may occur, such as facial sensory disturbances, altered consciousness, meningeal signs and facial nerve involvement [7]. The most accurate imaging method in this case is magnetic resonance imaging (MRI) [9, 10].

The mainstay of treatment is intravenous broad-spectrum antibiotic therapy, glucocorticosteroids and anticoagulants may also be considered [11, 12]. Surgical intervention is typically reserved for addressing the primary site of infection [13].

Case report

A 78-year-old female patient was admitted to the Poznan University Hospital with a severe headache persisting for one week, characterized by intense pressure in the parietal region. On admission, the patient was cardiovascularly and respiratorily stable. The patient had previously been hospitalized at another medical facility due to severe headaches, right upper eyelid ptosis, restricted adduction of the right eyeball, and diplopia.

An MRI scan performed on October 1, 2024 revealed polypoid lesions within the ethmoid sinuses bilaterally, complete opacification of the right sphenoid sinus with fluid signal characteristics without air-fluid levels, complicated by septic thrombosis of the cavernous sinus and the right superior ophthalmic vein.

The patient’s medical history revealed the presence of hypertension and heart failure. A thorough ear, nose and throat (ENT) examination revealed no abnormalities.

The patient was scheduled to undergo an emergency surgical procedure on October 7, 2024, but it was postponed due to elevated blood pressure levels, with a systolic pressure of 190 mm Hg.

On the following day, the patient underwent functional endoscopic sinus surgery (FESS) under general endotracheal anesthesia. Using a 0-degree rigid endoscope for visualization, the anterior and posterior ethmoid sinuses were meticulously opened, and polypoid lesions in the posterior ethmoid were excised. A maxillary antrostomy was performed to inspect the right maxillary sinus, which revealed no pathological findings.

Subsequently, a wide sphenoidotomy was carried out, releasing purulent material under pressure from the right sphenoid sinus. The sinus cavity was thoroughly irrigated, and a specimen was collected for microbiological analysis. A nasal packing was placed to ensure hemostasis.

Pathological examination later confirmed chronic polypoid inflammation of the sinus mucosa.

On the first postoperative day, neurological consultation confirmed that the patient was in stable condition, though the patient reported persistent headaches. The Glasgow Coma Scale score was 15. No meningeal signs were observed, and the patient’s pupils were equal, round, and reactive to light and accommodation. Cranial nerves examination revealed no abnormalities. No limb paresis was detected. However, a decrease in superficial sensation was noted in the right lower limb. Tendon reflexes were symmetrical in the upper limbs but slightly asymmetrical in the lower limbs. Coordination was intact but Romberg’s test was unsteady/positive.

Due to the high mortality risk associated with the infection and thrombosis, ongoing hospitalization and observation were recommended. Radiological follow-up was recommended after 2 weeks. Anticoagulant therapy was advised, initially with low molecular weight heparin (Clexane 0.8 ml twice daily), transitioning to vitamin K antagonists (warfarin or acenocoumarol).

The antibiogram identified methicillin-sensitive Staphylococcus aureus (MSSA), with no anaerobic microorganisms or fungi cultured. Based on recommendations from the consulting microbiologist and the antibiogram, the patient received a three-week course of intravenous antibiotics: ceftriaxone 1 g twice daily and clindamycin 600 mg three times daily.

During the perioperative period, elevated blood pressure was observed, prompting multiple cardiology consultations. Despite implementing recommendations, no significant improvement in blood pressure was observed.

The anterior nasal packing was removed on the second postoperative day. However, on the sixth postoperative day, bleeding from the right nasal cavity occurred, with a systolic blood pressure of 170 mm Hg. Due to ongoing active bleeding, tamponade was inserted again. Antihypertensive medications were adjusted. On the eighth postoperative day, the anterior tamponade was removed, and the nasal cavities were cleared. The patient, in good condition, was subsequently transferred to the internal medicine department with pertinent recommendations. After adjustment of the antihypertensive therapy, the patient was discharged home in good general condition and remains under the care of the outpatient ENT clinic for follow-up.

Discussion

Cavernous sinus thrombophlebitis is an uncommon but life-threatening condition with a significant mortality rate of approximately 25% [1]. The clinical manifestations of the condition are often non-specific and may overlap with other orbital or neurological pathologies, which can result in delayed diagnosis and treatment. However, early diagnosis and treatment are critical to improving outcomes [5, 14].

This case demonstrates the significance of sphenoid sinusitis as a primary source of infection, which subsequently led to CST. The dissemination of infection occurs through valveless venous connections, thus emphasizing the anatomical predisposition for such complications [15]. The patient’s symptoms, including headaches, ptosis, diplopia, and restricted ocular movements, align with the classical presentation of CST [16].

The diagnosis of CST is challenging and relies heavily on MRI, particularly due to the subtle and non-specific nature of its early clinical presentation [9]. MRI, especially when combined with magnetic resonance venography (MRV), provides high-resolution visualization of the cavernous sinus and adjacent structures, allowing for the detection of thrombus formation, venous congestion, and associated inflammation [17].

Moreover, a multidisciplinary approach is integral to the effective management of this condition and includes the following: endoscopic sinus surgery (ESS), targeted intravenous antibiotics based on antibiograms, and anticoagulation therapy [18].

It is imperative that patients with CST are closely monitored, given the potential for serious and rapidly evolving complications [16]. A particular concern is the risk of intracranial or orbital hemorrhage, especially in patients receiving anticoagulation therapy [5].

Additionally, perioperative hypertension can exacerbate intracranial pressure and increase the risk of hemorrhagic events. Regular neurological assessments, serial imaging, and close hemodynamic control are essential to promptly identify and manage these risks, ultimately improving patient outcomes and reducing the likelihood of permanent neurological impairment or mortality [19, 20].

The case aligns with existing literature on the importance of early intervention but also highlights challenges, such as perioperative hypertension.

Conclusions

CST is a rare but severe complication of sinus infections that require prompt diagnosis and aggressive treatment. The presented case underscores the importance of advanced imaging (e.g. MRI) for accurate diagnosis and highlights the efficacy of a multidisciplinary approach combining surgery, antibiotics, and anticoagulation therapy.

It is imperative to emphasize that patients with this condition require meticulous observation due to the likelihood of severe and rapidly evolving complications. The impact of concomitant conditions, particularly hypertension, on CST management and complications warrants further investigation.

This case contributes to the extant/existing literature by demonstrating effective management strategies and emphasizing the need for individualized care in complex presentations.

Funding

No external funding.

Ethical approval

Not applicable.

Conflict of interest

The authors declare no conflict of interest.

References