Emergency Department Care
The mainstay of therapy for cavernous sinus thrombosis (CST) is early and aggressive antibiotic administration. Although S aureus is the usual cause, broad-spectrum coverage for gram-positive, gram-negative, and anaerobic organisms should be instituted pending the outcome of cultures.
Empiric antibiotic therapy should include a penicillinase-resistant penicillin plus a third- or fourth-generation cephalosporin. If dental infection or other anaerobic infection is suspected, an anaerobic coverage should also be added.
IV antibiotics are recommended for a minimum of 3-4 weeks.
Controversy exists on the use of anticoagulation for cavernous sinus thrombosis. Because of the rarity of this syndrome, no prospective trials have been performed on the use of anticoagulation for CST. Some retrospective studies have shown a decrease in mortality and clot propagation by anticoagulation. A Cochrane review found two small trials involving 79 patients who were treated with anticoagulants. Limited evidence suggests anticoagulant drugs are probably safe and may be beneficial for people with sinus thrombosis. [11] Therefore, anticoagulation with heparin should be considered since the goal is to prevent further thrombosis and to reduce the incidence of septic emboli. One review suggests that low-molecular weight heparin (LMWH) is superior to unfractionated heparin (UFH). [12] Heparin is contraindicated in the presence of intracerebral hemorrhage or other bleeding diathesis.
Locally administered thrombolytics have also been used in the treatment of CST. However, use of thrombolytics should be considered experimental and only for severe refractory cases. [1]
Corticosteroids may help to reduce inflammation and edema and should be considered as an adjunctive therapy. They should be instituted after antibiotic coverage. When the course of CST leads to pituitary insufficiency, however, corticosteroids definitely are indicated to prevent adrenal crisis. Dexamethasone or hydrocortisone should be considered.
Surgery on the cavernous sinus is technically difficult and has never been shown to be helpful. The primary source of infection should be drained, if feasible (eg, sphenoid sinusitis, facial abscess). It is important to recognize the infected sphenoid sinus early and to prevent spread of the infection to the cavernous sinus.
Consultations
If drainage is indicated, make arrangements for intensive care and request the appropriate surgical consultation.
An infectious disease consultation should be considered in choosing the proper antibiotic coverage for the CST.
Prevention
Patients should be educated that furuncles or abscesses (pimples) in the central portion of the face should not be manipulated without prior antibiotic coverage.
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Anatomy of cross section of cavernous sinus showing close proximity to cranial nerves and sphenoid sinus.
