Cavernous Sinus - Clinical Correlate*

A 45-year-old gourmet chef returns from a hunting trip with high fever and severe headaches. He relates that about five days earlier he developed an infection of the right upper lip which resulted from a cut while shaving. He concedes that, against all childhood advice from his parents, he had vigorously squeezed the sore in an attempt to expel a painful build up of pus. He is seen by his family physician who gives him penicillin injections and keeps him under close observation. The patient does not improve. Instead, he became very restless and rather delirious. He was transferred to the hospital.

On admission the patient is found to be acutely ill with septic temperatures and frequent chills. He vomits at intervals, and from time to time becomes delirious. In his clearer moments he complains of nausea and severe headache, particularly on the right side.

1. Examination
   1. swollen lip with oozing of pus from several sites
   2. swollen eyelids of right side (venous return compromised)
   3. swollen right check (thrombosed facial v.)
   4. right eye ball protrudes (exophthalmos)
      1. compromised venous drainage of orbit
      2. what if there is pulsatile exophthalmos?
   5. loss of voluntary movement of the eye
      1. failure to abduct and look "down and out"
   6. tingling and burning sensations (paresthesia) of the right forehead, nose, upper face
      1. compromised functioning of ophthalmic and maxillary divisions of trigeminal nerve
   7. subsequent examination indicates the left eye is involved
      1. intercavernous sinus through diaphragma sellae
2. Diagnosis
   1. staphylococcic infection of the subcutaneous lip with spread to cavernous sinus
      1. facial vein thrombosis and spread of infection
      2. why is ligating the angular vein ineffective at preventiing cavernous sinus infection?
3. Therapy
   1. I.V. antibiotics, narcotics, and liquid diet
      1. calm the patient and limit movement of facial musculature

*Adapted from Earnest Lachman