CAVERNOUS SINUS

Venous sinuses of Dura Mater. Cavernous sinus. Structure. Location. Boundaries. Re ations. !ri"utaries #Inco$in% C&anne s'. Drainin% C&anne s #Co$$unications'. A(( ied Anato$) * Co$( ications. Cavernous Sinus !&ro$"osis.
Introduction Etiology Mortality/Morbidity rate History of the patient Clinical signs & symptoms -Venous -Cranial -Systemic Differential Diagnosis ab Studies Imaging/!adiographic aids "reatment protocol -Emergency department care -Do#s & Don#ts -!ight time to call the doctor

Da$a%e to t&e Interna Carotid Arter). Conc usion. References.

CAVERNOUS SINUS

VENOUS SINUS O+ DURA MA!ER,- "hese are $enous spaces the %alls of %hich are formed by the duramater& "hey ha$e an inner lining of endothelium& "here is no muscle in their %alls& "hey ha$e no $al$es& Venous sinuses recei$e $enous blood from the brain' meninges' and bones of the s(ull& Cerebrospinal fluid is poured into some of them& Cranial $enous sinuses communicate %ith $eins outside the s(ull through emissary veins. "hese communications help to (eep the pressure of the blood in the sinuses constant& "here are about )* $enous sinuses' of %hich some are paired and others are unpaired& Paired Venous Sinuses:"here is one sinus on each side +right or left,& )& Ca$ernous sinus& -& Superior petrosal sinus& .& Inferior petrosal sinus& /& "rans$erse sinus& *& Sigmoid sinus& 0& Sphenoparietal sinus& 1& 2etros3uamous sinus& 4& Middle meningeal sinus& Unpaired venous Sinuses:"hese are median in position& )& Superior sagittal sinus& -& Inferior sagittal sinus& .& Straight sinus& /& 5ccipital sinus&

*& 6nterior interca$ernous sinus& 0& 2osterior interca$ernous sinus& 1& 7asilar ple8us of $eins& CAVERNOUS SINUSES,.&ere is it Located/ Each Ca$ernous sinus +right or left, is a large $enous space situated in the middle cranial fossa' on either side of the body of sphenoid bone& Its interior is di$ided into a number of spaces +ca$erns, by trabeculae& "he trabeculae are much less conspicuous in the li$ing than in the dead& Structure of cavernous sinus,79" E! +):*1,;- asserted that a distended adult sinus contains a fe% trabeculae' mostly in its periphery near the entry of its tributaries& <hen the sinus is collapsed' as in cada$ers' its ca$ity is encroached upon by ner$es and arachnoid granulations in its %all' creating a spurious resemblance to ca$ernous tissue= hence called as the Ca$ernous Sinus& 26!>I?S5? +):0., & 2E!?>52@ +):1.,;- depicted the sinus as a A$enous ple8usB& 7!5<DE! & >62 6? +):10,;- described the sinus as AreticulatedB& It %as not clear %hether they meant ple8iform or ca$ernous&

.&at are its Boundaries/ "he floor of the sinus is formed by endosteal dura mater& "he lateral %all' roof and median %all are formed by the meningeal dura mater& Anteriorly, the sinus e8tends up to the medial end of the superior orbital fissure and posteriorly, up to the ape8 of the petrous temporal bone& It is about -cm long and ) cm %ide& Re ations,A. Structures outside the sinus: Superiorly: a, 5ptic "ract' b, Internal carotid artery and anterior perforated substance& Inferiorly: a, @oramen lacerum and the Cunction of the body and greater %ing of sphenoid bone& Medially: a, Hypophysis cerebri and sphenoidal air sinus& Laterally: a, "emporal bone %ith uncus& Anteriorly: a, Superior orbital fissure and the ape8 of the orbit& . Structures in the lateral !all of the sinus, form a"ove do!n!ards: 5cculomotor ner$e;- In the anterior part of the sinus it di$ides in to superior and inferior di$isions %hich lea$e the sinus by passing through the superior orbital fissure&

"rochlear ner$e;- In the anterior part of the sinus it crosses superficial to the .rd ner$e' and enters the orbit through the superior orbital fissure&

5phthalmic ner$e;- In the anterior part of the sinus it di$ide into the lacrimal' frontal and nasociliary ner$es Ma8illary ner$e;- It lea$es the sinus by passing through the foramen rotundum on its %ay to the pterygopalatine fossa& "rigeminal ganglion;- "he ganglion +and its dural ca$e, proCect Ainto the posterior part of the lateral %all of the sinus& #. Structures passin$ throu$h the centre of the sinus: Internal carotid artery;- %ith the $enous and sympathetic ple8uses around it& 6bducent ner$e;- inferolateral to the internal carotid artery& "hese structures in the lateral %all and in the centre of the sinus are separated from blood by endothelial lining& !ri"utaries #inco$in% c&anne s',A. %rom the or"it: "he superior ophthalmic $ein& 6 branch of inferior ophthalmic $ein +sometimes the $ein itself, "he central $ein of retina;- may drain either into the superior ophthalmic $ein or into the superior ophthalmic $ein or into the ca$ernous sinus& . %rom the "rain: Superficial middle cerebral $ein

 Inferior cerebral $ein from the temporal lobe& #. %rom the menin$es: Sphenoparietal sinus @rontal trun( of the middle meningeal $ein;- may drain either into the pterygoid ple8us +through the foramen o$ale, or into the Sphenoparietal or ca$ernous sinus& Drainin% c&anne s #co$$unications',"he ca$ernous sinus drains; Into the trans$erse sinus through the superior sinus' Into the internal Cugular $ein through the inferior petrosal sinus and through a ple8us around the internal carotid artery' Into the pterygoid ple8us of $eins through the emissary $eins passing through the foramen o$ale' foramen lacerum and the emissary sphenoidal foramen' Into the facial $ein through the superior ophthalmic $ein& "he right and the left ca$ernous sinuses communicate %ith each other through the anterior and posterior interca$ernous sinuses and through the basilar ple8us of $eins& 6ll these communications are $al$e less and blood can flo% in either direction& A(( ied Anato$) and Co$( ications of infections of cavernous sinus,-

"he importance of ca$ernous sinus arises because of the structures %hich lie in and around it& "hey may be in$ol$ed %ith infections %hich can spread to it along the many tributaries& "hrough its communications' it forms a route of communication bet%een the face' chee(' brain and the internal Cugular $ein& @ollo%ing are the complications arising from the infection of the ca$ernous sinus;A&. #avernous sinus throm"osis:Ca$ernous Sinus "hrombosis' as the name states' is the formation of blood clot +thrombus, in the ca$ernous sinus& It is important to (no% that CS" affects cranial ner$es III' IV and VI' %hich are necessary for eye mo$ement' and cranial ner$e V' %hich gi$es sensation to the top and middle portion of the face& "herefore' it is a serious' life-threatening infection that re3uires aggressi$e medical and surgical inter$ention& Etiology;It is not contagious neither infectious& "he cause is usually infections starting in the face' sinuses +esp& sphenoid and ethmoid, or the ears= as the bloodstream drains bac( into the ca$ernous sinus in the s(ull' the infection spreads to this area and results in the disease& "he causati$e agent is generally Staphylococcus aureus, although streptococci' pneumococci and fungi may be implicated in rare cases& 5ther sources of infection are;-

Source ?ose & Danger area of the face Ethmoid sinus Sphenoid sinus @rontal sinus 5rbit 9pper eye lid 2haryn8 Ear

'isease @uruncle' Septal abscess 5rbital cellilitis or abscess& Sinusitis Sinusitis and osteomylitis of frontal bone Cellulitis and abscess 6bscess 6cute tonsillitis or peritonsillar abscess 2etrositis

(oute 2haryngeal 2le8us& 5phthalmic $eins& Direct& Supraorbital and ophthalmic $eins 5phthalmic $eins 6ngular and ophthalmic $eins 2haryngeal ple8us 2etrosal $enous sinuses&

Mortality / Morbidity rates;2rior to the ad$ent of effecti$e antimicrobial agents' the mortality rate from CS" %as effecti$ely bet%een 4D-)DDE& <ith aggressi$e management' the mortality rate has come do%n to -D.DE& Morbidity' ho%e$er' remains high' and complete reco$ery is rare& !oughly' one-si8th of patients are left %ith some degree of $isual impairment' and one half has cranial defects& History of the patient; 2atients generally ha$e sinusitis or a midface infection +most commonly a furuncle, for *-): days& Headache' fe$er and malaise typically precede the de$elopment of ocular findings& 6s the infection tracts posteriorly' patients

complain of orbital pain and fullness accompanied by periorbital edema and $isual disturbances& In some patients' periorbital findings do not de$elop early on' and the clinical picture is subtle& <ithout effecti$e therapy' signs appear in the contra lateral eye by spreading through the communicating $eins to the contra lateral ca$ernous sinus& "his is pathognomonic of CS"& "he patient rapidly de$elops mental status changes from C?S in$ol$ement and/or sepsis& Death follo%s shortly thereafter& Clinical featres;Clinical picture presents the follo%ing systemic'$enous and ner$ous symptoms; ), ?er$ous symptoms; Se$ere pain in the eye and forehead in the area of distribution of 5phthalmic ner$e& In$ol$ement of the third' fourth and si8th cranial ner$es indi$idually and se3uentially resulting in the paralysis of the muscles supplied and e$entually total ophthalmoplegia& 2aralysis of the V cranial ner$e results in the loss of sensation in the top and the middle portion of the face& -, Venous symptoms; Eyelids get s%ollen %ith chemosis and proptosis of the eyeball& 2upils become dilated and fi8ed& 5ptic disc sho%s congestion and oedema %ith diminution of $ision&

 E8ophthalmos and ophthalmoplegia& ., Systemic signs indicati$e of sepsis; Chills' @e$er' Shoc(' Delirium and coma appear as late findings& Differential Diagnosis;CS" needs to be differentiated fromF Cellulitis Epidural Hematoma Epidural and subdural infections Glaucoma' 6cute angle closure cases 5rbital infections 2eriorbital infections Sinusitis Subarachnoid hemorrhage Subdural hematoma 5rbital cellulites +most difficult to distuinguish,&
Distinguishing bet%een CS" and 5rbital Cellulitis;-

Or"ita Ce u itis Source 5nset Cranial ner$e in$ol$ement Commonly ethmoid sinus Slo% In$ol$ed concurrently %ith complete

Cavernous Sinus !&ro$"osis ?ose' sinus' orbit' ear or pharyn8 6brupt In$ol$ed indi$idually and se3uentially&

aterality ab Studies;-

ophthalmoplegia& 5ften in$ol$es eyes&

In$ol$es both eyes&

CS" is a clinical diagnosis and lab studies are seldom specific& Most patients e8hibit a 2M? leucocytosis often mar(ed %ith shift to%ards immature form& 7lood cultures are generally positi$e for the offending organism& Imaging studies;Historically' a number of techni3ues ha$e been used li(e; 2lain Sinus radiography' Carotid angiography 5rbital $enography& In current practice the techni3ues being used are; C" scan M!I M! angiography umber puncture

?euroradiology "reatment; I&V& broad spectrum antibiotic co$erage and attention to the focus of infection& Eg;- 2enicillin' SulfadiaHine' Chlomphenicol and metrinidaHole&

7lood culture should be ta(en prior to starting antibiotic therapy& Surgery of the ca$ernous sinus is technically difficult and ne$er been sho%n to be helpful& "he primary source of infection should be drained if possible +infected Ethmoid or Sphenoid sinus or facial abscess,& Corticosteroids may help to reduce inflammation and edema and should be considered as an adCuncti$e therapy !ole of anticoagulants li(e heparin is not clear but is supported by recent studies& Do#s;a, 7est treatment is pre$ention& !ecognise the primary source of infection and treating this primary source e8peditiously is the best %ay to pre$ent CS" b, 9nderstand that CS" can be a life threatening' rapidly progressing disease %ith high mortality rates despite antibiotic use Don#t s;a, Don#t forget that CS" is a medical emergency and depending on the location of the primary infection' the appropriate specialist should be in$ol$ed& @or E8ample; an ophthalmologist should be consulted if the infection is in the eye& !ight time to call the Doctor; Eye problems; Eye pain

oss/difficulty in $ision

7ulging of the eyeball or drooping of eyelids& Difficulty in mo$ing the eye in a certain direction& Ear problems; Ear pain Hearing loss Drainage from ear& @e$er' headache' nausea' $omiting' stiff nec( Drainage from the sinus& & 'ama$e to the Internal #arotid Artery:"he Internal Carotid 6rtery can be damaged by inCuries to the base of the s(ull' leading to the lea(age of the arterial blood into the sinus& "his increases the pressure in the sinus and the $eins entering it' so that the eyeball may protrude and produce a pulsating e8ophthalmos& C5?C 9SI5?;In our routine practice' %e as dentists' %ould encounter many patients %ho %ould seem to be suffering from other%ise non-threatening and common infections of the eye' ear and nose& It is of paramount importance on our part that %e assume the patient as a suspected case if he presents %ith a clinical picture suggesting that of CS"& "hough the occurrence of CS" is $ery rare due to 5perati$e procedures' the possibility still remains and it is called for that %e employ steriliHation procedures properly and consistently= reduce chances of cross-infection= to (eep the threat of CS" at bay&