Snapshot A 24-year-old female presents with worsening headache, fever, and double vision. Her headache is located in the periorbital region. Medical history is significant for a left-sided mid-facial furuncle which she attempted to squeeze over one week prior. On physical exam, there is bilateral supraorbital edema, lateral gaze palsy, ptosis, mydriasis, and chemosis. Introduction Thombosis of the cavernous sinus Most commonly caused by a continguously spreading infection via valveless venous vessels nose sinuses ears maxillary teeth bacteremia e.g., sinusitis and mid-face furuncle Causative organisms are most commonly Staphylococcus aureus (70%) others Streptococcus pneumoniae gram-negative bacilli anaerobes certain fungi Epidemiology Mortality < 30% with antibiotic administration Complete recovery is rate Can affect all ages Presentation Symptoms fever periorbital edema headache Physical symptoms cranial nerve palsies first involve CN VI as it runs through the middle of the sinus Evaluation Clinical diagnosis Complete blood count polymorphonuclear leukocytosis with left-shift (commonly) Blood culture CT and MRI with contrast get MRI with MR venography (imaging modality of choice) preferred first test in patients with a high pretest probability and in patients in whom radiation should be avoided CT venography is an appropriate alternative if MR venography is not available CT early in disease course may be normal Differential Angle-closure glaucoma Orbital and periorbital infection Subarachnoid hemorrhage Treatment Broad-spectrum intravenous (IV) antibiotics penicillinase-resistant penicillin + 3rd or 4th generation cephalosporin Heparin controversial should be considered contraindicated in intracranial hemorrhage Corticosteroids should be considered if adrenal insufficiency results from cavernous sinus thrombosis, give corticosteroids prevents adrenal crisis Prognosis, Prevention, and Complications Prognosis decreased mortality with antibiotic administration