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KISEP Case Reports J Rhinol 4((((1)))), 1997
Lateral Sinus Thrombophlebitis Caused by Isolated Sphenoid Sinusitis
Ic-Tae Kim, M.D., Ki Young Park, M.D., Young Min Kim, M.D., Kyung Hun Yang, M.D. and Young Min Park, M.D.
ABSTRACT
Lateral sinus thrombophlebitis is a very rare complication of paranasal sinusitis. This disease can result in a fatal outcome if not treated with proper antibiotics or surgical intervention. Recently, the authors came across a case of lateral sinus thrombop- hlebitis resulting from cavernous sinus thrombophlebitis complicated by isolated sphenoid sinusitis. Because of a severe and persistent headache, the case was initially admitted and managed as though the patient was suffering from Tolosa-Hunt syndrome.
Hemifacial hypoesthesia, periorbital swelling and meiosis on the right side developed during tentative treatment. High resolution computed tomography showed isolated sphenoid sinusitis with partial bony dehiscence on the roof of left sphenoid sinus. Magnetic resonance images showed multiple thrombosis in the cavernous sinus, internal carotid artery, sigmoid sinus and lateral sinus on the right side. Antibiotics, thrombolytics and endoscopic surgical intervention of sinusitis prevented a fatal outcome in spite of remaining hemifacial hypoesthesia and ptosis on the right side.
KEY WORDS：Lateral sinus thrombophlebitis·Cavernous sinus thrombophlebitis·Sphenoid sinusitis.
INTRODUCTION
Lateral sinus thrombophlebitis is a serious infectious cond- ition extending from sigmoid sinus thrombophlebitis, and is usually caused by acute or chronic otitis media. Midfacial in- fections such as cellulitis of the face, paranasal sinusitis or otitis media can be spread to the cavernous sinus thrombophlebitis and eventually to the lateral sinus thrombophlebitis.
Recent developments in antibiotics have effectively reduced the occurrence of this kind of potentially fatal condition. Ho- wever, if magnetic resonance imaging results in a high signal along the lumen of lateral sinus, aggressive management with proper antibiotics and thrombolytics should be made as soon as possible. In the lateral sinus thrombophlebitis, only early diagnosis and effective management can prevent a fatal out- come.
CASE REPORT
A 43-year-old man was admitted to the department of ne- urology for evaluation of a severe headache in the left parie-
totemporal area. The patient had been healthy until a squeezing and stinging headache had developed the week before he re- ported to the hospital. Two days prior to admission, painless swelling and reddish discoloration had occurred in the left periorbital area. There was nothing particularly significant in his past medical history except for smoking and drinking.
On the admission day, ptosis developed in the left eye wi- thout ophthalmoplegia. Other clinical findings including vital signs were normal and laboratory examinations showed no si- gnificant abnormalities except increased ESR (26 mm/hr).
Initial brain CT showed no abnormal findings and T2-weigh- ted magnetic resonance imaging depicted an increased signal around the left cavernous sinus area. Under the impression of Tolosa-Hunt syndrome, a nonspecific granulomatous disease of cavernous sinus with symptoms of facial pain and headache, steroid and heparin were administered. On the fifth hospital day a high fever developed and continued for five days in spite of the administration of antibiotics. Coagulase-negative Staphylococcus was identified in the peripheral blood culture.
After that, the patient was relatively well for a week before the sudden development of right periorbital swelling, ptosis and a severe non-localizing headache. On examination, fixed miosis and hemifacial anhydrosis were found on the right side without a decrease in visual acuity and field. The result of bl- ood examination showed leukocytosis of 11,240/mm3 and ESR of 37 mm/hr. Follow-up T1-weighted magnetic resonance im- aging showed an increased signal in the right cavernous sinus area when compared with the left side.
The patient was referred to our department to focus on the Department of Otorhinolaryngology, Hallym University College
of Medicine, Seoul, Korea
Address correspondence and reprint requests to Ic-Tae Kim, M.D., Department of Otorhinolaryngology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1 Daerim 1-Dong, Youngdungpo-Gu, Seoul 150-071, Korea Tel：82-2-829-5217, Fax：82-2-832-0661
Accepted for publication April 4, 1997
Kim et al.：Lateral Sinus Thrombophlebitis / 69
detection of possible infection. A thread of pus was noted in the nasopharyngeal wall by meticulous nasal endoscopic exa- mination. High resolution paranasal sinus CT showed bony dehiscence in the roof of the left sphenoid sinus, and mucosal thickening in both sphenoid sinuses (Fig. 1). Using endoscopic sinus surgery, the sphenoid ostia were opened wide and mu- copus was evacuated from the sphenoid sinuses and reserved for culture, eventually revealing Proteus mirabilis. After the operation, the patient was well except for a mild headache.
On the fifth postoperative day, a sudden high fever, severe headache, projectile vomiting and neck stiffness developed.
Turbid cerebrospinal fluid was noted at a lumbar puncture.
With a diagnosis of meningitis, the antibiotics were switched from cefoperazone to cefotaxime and vancomycin. After one week of treatment with these antibiotics, the symptoms and signs of meningitis were resolved. Follow-up MRI for re- examination due to a residual mild headache and right facial hypoesthesia showed a bright signal along the internal car- otid artery within the cavernous sinus area (Fig. 2), the sig- moid sinus and the lateral sinus (Fig. 3) in the right side.
Carotid angiography revealed no arterial shadow above the cavernous sinus level in the arterial phase. Heparin therapy, which was discontinued at the development of meningitis, was resumed with the antibiotics. MRI on the 24th day after the operation showed no evidence of thrombi formation adv- ancing toward the vein of Labb and the confluence of sinuses.
The patient was discharged with unimproved ptosis and hem- ifacial hypoesthesia in his right side. This symptom remained unimproved six months after the patient’s discharge.
DISCUSSION
The etiologic sources of dural sinus infections are facial infection (60%), paranasal sinusitis (15%), odontogenic in- fection (7%) and otitis media (8%).1)2) Dural sinus infections are very rare in this postantibiotic era, but they should be treated immediately and aggressively because of potential severity of complications which could result in death.3)4) Ot- itis media or mastoiditis is the main cause of lateral sinus thr- ombophlebitis, covering about 70% of all cases, but paranasal sinusitis encountered in this case is rare.5) Interestingly, the case in question occurred from isolated sphenoid sinusitis, which can be either acute or chronic, without lesions in any other sinuses. The bony dehiscence in the roof of the left sp- henoid sinus strongly suggested a possible route in which the infection had spread to the cavernous sinus area. However, the reason why the right cavernous sinus was injured permanently rather than the left, cannot be explained clearly.
Anatomically, infection of the midfacial region can spread easily toward intracranial vessels by way of the facial vein, the cavernous sinus, the petrosal sinus and the internal jugular vein.6)7) In the preantibiotic era, about 65% of the cases of cavernous sinus thrombophlebitis were caused by gram-posi- tive microorganisms including Staphylococcus aureus.8) The development of potent antibiotics has significantly reduced
Fig. 2. T2-weighted magnetic resonance image demonstrating bright signal (empty arrow) within internal carotid artery lumen in right cavernous sinus area.
Fig. 3. T1-weighted magnetic resonance image revealing bri- ght signal along the sigmoid sinus (empty arrow) and lateral sinus (white arrow) in the right side.
Fig. 1. Coronal CT scan showing bony dehiscence (empty arr- ow) in the roof of left sphenoid sinus and mucosal thickening in both sphenoid sinuses.
70 / J Rhinol 4(1), 1997
the incidence, but lateral sinus thrombophlebitis should be included in the differential diagnosis of persistent headaches unresponsive to usual analgesics. In acutely developed lateral sinus thrombophlebitis, high fever and neurologic deficit can develop suddenly with a severe headache. However, our case seems to be a chronic, progressive type with acute exacerbation.
The eyelid swelling and ptosis we witnessed can, however, develop in both acute and chronic cavernous sinus lesions.
In this case, thrombus formation did not advance to the level of vein of Labb and the confluence of sinuses. If, however, the vein of Labb or the confluence of sinuses are obstructed by thrombi, severe complications and sudden death can dev- elop. This is the reason why lateral sinus thrombophlebitis should be treated aggressively and immediately. For the pre- vention of severe complications, early diagnosis by clinical evaluations and radiological examinations such as CT and MRI are needed.9)10) Proper management includes parenteral infu- sion of heparin and the administration of an effectively broad spectrum of antibiotics against gram-positives and anaerobes.11) If there is no response to medical management, surgical inte- rvention should be considered.
In spite of the fact that less than 40% of cases result in co- mplete recovery without residual neurologic deficit, thromb- ophlebitis of the cavernous and lateral sinuses can be managed successfully by immediate and effective medical and surgical
treatment.
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