What are the symptoms and treatment options for cavernous venous thrombosis?

Symptoms of Cavernous Sinus Thrombosis

Cavernous sinus thrombosis presents with a characteristic triad of fever, headache, and ocular manifestations—with cranial nerve VI palsy causing lateral gaze limitation being the most common neurological finding. 1

Cardinal Clinical Features

Constitutional Symptoms

• Fever is present in nearly all cases and represents a critical diagnostic clue distinguishing septic cavernous sinus thrombosis from other causes of orbital pathology 1, 2
• Headache occurs frequently but may not be as prominent as expected, which can delay diagnosis 2

Ocular Manifestations (Most Diagnostically Important)

• Periorbital edema and chemosis develop in almost all recognized cases, often progressing rapidly over hours to days 1, 2
• Proptosis (bulging eye) is a hallmark finding that distinguishes this from simple orbital cellulitis 1, 2, 3
• Ophthalmoplegia (paralysis of eye movements) occurs due to cranial nerve involvement, with lateral rectus palsy from CN VI being most common 1, 2
• Ptosis (drooping eyelid) may be present due to CN III involvement 1
• Vision changes including blurred vision or vision loss can occur and represent an ophthalmologic emergency 1

Cranial Nerve Involvement Pattern

• CN VI (abducens nerve) is affected first and most frequently, causing inability to move the eye laterally—this is the single most specific early finding 1, 2
• CN III (oculomotor), CN IV (trochlear), and CN V (trigeminal) may subsequently be affected as the thrombosis progresses 1, 2
• Bilateral involvement of the opposite eye typically develops within 48 hours of initial unilateral presentation, which is pathognomonic for cavernous sinus thrombosis 2

Temporal Progression

The disease typically follows a facial infection or sinusitis by several days, with symptoms progressing rapidly once they begin 1. The bilateral progression within 2 days is a critical distinguishing feature—if you see unilateral orbital signs today and bilateral signs 24-48 hours later, cavernous sinus thrombosis must be your primary consideration 2.

Common Pitfalls

• Do not dismiss the diagnosis if headache is mild or absent—approximately 10-20% of cases may not have prominent headache despite the severity of the condition 2
• Do not wait for bilateral involvement to make the diagnosis—treatment must begin with unilateral findings given the high mortality rate (approximately 30% even with treatment) 2, 4
• Recognize that the antecedent infection may be minor—even small forehead abrasions or dental infections can lead to this life-threatening complication 5, 3

Associated Systemic Complications

• Pulmonary involvement may occur through septic emboli 1
• Central nervous system complications including stroke, seizures, and altered mental status can develop as the thrombosis extends 4
• Hypopituitarism may result from involvement of the pituitary gland, which sits adjacent to the cavernous sinus 4

Laboratory and Imaging Findings

• Inflammatory markers are typically elevated (ESR, CRP, WBC) 1
• Blood cultures are positive in up to 70% of cases, most commonly growing Staphylococcus aureus 1, 2
• CT head with IV contrast (delayed phase imaging) is recommended in the emergency setting, though MR venography has the highest sensitivity 1