II. Pathophysiology
- Most common infection of dural sinus thrombosis
- Sources
- Mid-face infections near the eyes and nose (e.g. nasal Furuncle)
- Sphenoid Sinus or Ethmoid Sinus infection
- Dental Infection (uncommon)
III. Symptoms
- Initial (first 1-2 days)
- Headache (most common
- Sharp pain increasing in severity becoming refractory and interferes with sleep
- Unilateral frontal and retroorbital Headache (Trigeminal Nerve ophthalmic and Maxillary branches)
- Headache (most common
- Next
IV. Signs
- Classic, severe presentation
- Eye findings
- Lateral Gaze Palsy (CN 6)
- Eye looks down and laterally (CN 3)
- Eyelid Ptosis
- Mydriasis
- Fundus Exam (abnormal in two thirds of patients)
- Papilledema
- Dilated tortuous Retinal veins
- Other neurologic findings
- Trigeminal Nerve (CN 5) deficits
V. Imaging
- Orbital CT with contrast
- MRI with gadolinium enhancement
VI. Management
- Antibiotics
- MRSA coverage and initial empiric management
- Vancomycin 15-20 mg/kg (up to 2 g) IV every 8-12 hours AND
- Ceftriaxone 2 g IV every 12 hours or Cefepime 2 g IV every 8-12 hours
- Add Metronidazole 500 mg every 8 hours for Dental Infection (or higher dose for Brain Abscess)
- MSSA coverage (if confirmed by culture)
- MRSA coverage and initial empiric management
-
Anticoagulation
- Heparin (still recommended as of 2016)
-
Glucocorticoids
- Dexamethasone 10 mg IV every 6 hours
- Surgery
- Emergent surgical drainage of Sphenoid Sinus should be considered
VII. References
- Southwick (2016) Septic Dural Sinus Thrombosis, UpToDate, accessed online 4/8/2016
- (2016) Sanford Guide, accessed on IPad App 4/8/2016