Review Question - QID 105013

This patient with headache, fever, and a sixth cranial nerve palsy on exam likely has cavernous sinus thrombosis. She is likely to also have loss of sensation over the upper lip due to involvement of cranial nerve V2 in the cavernous sinus.

Recall that the cavernous sinus is a collection of venous sinuses on either side of the pituitary gland. CN III, IV, V1, V2, and VI as well as postganglionic sympathetic fibers all pass through the cavernous sinus. Cavernous sinus thrombosis is most often caused by a contiguous spread of a primary infection in the nose, sinuses, ears, or teeth. The most common causative organisms are Staph and Strep. Patients may present with a low-grade fever, periorbital edema, and headache. Patients may also show signs of cranial nerve palsies, most commonly beginning with CN VI since it runs through the middle of the cavernous sinus. Other cranial nerves that run through the sinuses and may be involved are III-V2.

Clinch review evaluation of acute headaches in adults. Classifying headaches as primary (due to migraine, tension-type, or cluster) or secondary facilitates evaluation and management. Red flags for secondary disorders include the sudden onset of headache, onset after age 50, increased frequency or severity, concomitant systemic illness, papilledema, and focal neurologic signs and symptoms as in this patient.

Desa and Green review current tharpies for cavernous sinus thrombosis. Mainstay of treatment is early antibiotics. These agents must cover the usual suspected microbes such as Staph and Strep but must also have broad coverage to fend off gram negative and anaerobic organisms. Controversy exists on the use of anticoagulation.

Illustration A presents a schematic of the cavernous sinus, note the course and distribution of the cranial nerves that run within the cavernous sinus.

Incorrect Answers:
Answer 1: Hoarseness would be expected with involvement of cranial nerves IX or X. These nerves do not run in the cavernous sinus, and their involvement would not be expected.

Answer 2: Inability to raise the shoulders against resistance would be expected with involvement of cranial nerve XI, the spinal accessory nerve. This nerve does not run in the cavernous sinus, and its involvement would not be expected.

Answer 3: Loss of sensation over the body of the mandible would be expected with involvement of cranial nerve V3e. This nerve does not run in the cavernous sinus, and its involvement would not be expected.

Answer 5: Tongue deviation to one side would be expected with involvement of cranial nerve XII, the hypoglossal nerve. This nerve does not run in the cavernous sinus, and its involvement would not be expected.

Bullet Summary:
Cavernous sinus thrombosis may present with involvement of cranial nerves III, IV, V1, V2 and VI.