The past four weeks or so, I encountered four similar cases which rarely happens. At first, it was just what one would pass off as a simple case of swelling and headache, where you just give a symptomatic relief to the patient to make it go away. The last case I actually did not see, as you would know why later in this article.
The first case involved 14-year-old Jonathan, who had swollen nose three days before consultation and is now having a headache. The second case was LP, 24, male, who initially developed an acne cyst on the left side of the nose and, after a day, had a painful, red lump under the pimple with a swollen left lower eyelid, accompanied by tearing. The third patient was MC, 25, male, with an asymmetrical face due to swelling on the right cheek and the start of erythema (redness), tenderness, and what seems to be also a slight swelling on the left cheek. MC was also complaining of headache and fever.
Then, when I was interviewed over the radio about three days ago, there was this caller who described a relative who was confined in a hospital. According to this caller, the relative was confined due to proptosis (popping of the eyeballs). It started as a sudden swelling of the nose, followed by hematoma (if I remember it right, that is some sort of bleeding pasa-pasa), then puffing of the eyelids and, eventually, protrusion of both eyeballs, or what is probably referred to as chemosis. In general, chemosis is a nonspecific sign of eye irritation. The outer surface covering appears to have fluid in it. The conjunctiva (portion of the eye that becomes red in sore eyes) becomes swollen and gelatinous in appearance. Often, the eye area swells so much that the eyes become difficult or impossible to close fully. The relative also said that the patient had difficulty in following instructions and was not responding properly to questions asked her (that’s probably because the patient had a reduced level of consciousness).
In all three cases, the eventuality of a Cavernous Sinus Thrombosis (CST) should be considered as a possibility (if not treated immediately). However, the fourth patient, the one forwarded to me on the phone, is probably already having CST. This is a rare condition that can result in high mortality and morbidity rates if not attended to as soon as possible.
The diagnosis of CST is challenging due to its mild nonspecific clinical presentation, which includes facial swelling, headache, fever, proptosis, cranial nerve palsies in about 80 to 100 percent of patients (paralysis of the eye muscles, diplopia or seeing double in about 50-80 percent of patients), hemiparesis (weakness of one side of the body), loss of vision, and seizures in less than 20 percent of cases.
The primary source of CVT may be a distant focus of infection (septic CST), with septicemia (a dangerous infection of the blood) preceding thrombosis (clots in the brain) of the cavernous sinus.
The human brain is a highly vascular organ responsible for coordinating a myriad of processes throughout the body. Therefore, it is important that a pathway exists to return blood that enters the skull to systemic circulation. Sitting in the middle of the brain, cavernous sinuses are one of several drainage pathways for the brain that, in addition to receiving venous drainage from the brain, also receive tributaries (something like a stream that flows to a larger stream or another body of water) from parts of the face.
Clot formation within the cavernous sinus may be either septic (infectious) or aseptic (noninfectious) in origin. Infection can spread to the cavernous sinus either as an extension of the clot or by a moving clot (septic emboli). The origin of an aseptic (noninfectious) cavernous sinus thrombosis is usually trauma, injury, or a prothrombotic condition.
Infection may spread from the facial region, via the facial venous plexus or from the sphenoid sinus (two irregular cavities in the body of the sphenoid bone in the skull that communicate with the nasal cavities) directly to the adjacent cavernous. Infection from these sites may easily travel to the cavernous sinus and cause blood clots and occlusion, leading to serious implications involving the brain and eyes. Nasal furuncle (pigsa) is believed to be the most common cause of CST (50 percent), followed by infection of the sinuses (30 percent), and dental infections (10 percent). Less common primary sites of infection include the tonsils, soft palate (ngala-ngala), middle ear, and orbit. The highly branched venous system of the paranasal sinuses (spaces located within the bones) allows retrograde spread of infection to the cavernous sinus (via the superior and inferior ophthalmic veins). The bacterium Staphylococcus aureus is the most common infectious microbe, found in 70 percent of cases. Streptococcus is the second leading cause. This septic form is the most frequent, but in about 4.8-12.5 percent of cases, the etiology remains unclear.
The diagnosis of CST depends on a strong initial suspicion, and Magnetic Resonance Angiography is the gold standard method to identify the filling defect of the cavernous sinus.
The prognosis of CST has improved and its current mortality rate is about 30 percent. Severe irreversible and fatal side effects of this condition can be prevented by early treatment,which can lead to successful management of patients.
Antibiotics should be started immediately because they have the greatest effect on outcome. That is, whether the patient will come out fully recovered or will have some neurological sequelae or whether the patient will not live another day.
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