A 48-year-old man comes to the hospital after a day of high-grade fever, progressive headache, and double vision. The patient has been having purulent nasal drainage and frontal headache for the past several days. He has a history of type 2 diabetes mellitus. His temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, and pulse is 94/min. Physical examination shows ptosis, mydriasis, mild proptosis, and loss of the corneal reflex of the right eye. Visual acuity is normal in both eyes, but the patient is unable to move the right eye in any direction. There is decreased sensation in the right upper face. Which of the following structures is most likely involved in this patient's presentation?

Question

A 48-year-old man comes to the hospital after a day of high-grade fever, progressive headache, and double vision.  The patient has been having purulent nasal drainage and frontal headache for the past several days.  He has a history of type 2 diabetes mellitus.  His temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, and pulse is 94/min.  Physical examination shows ptosis, mydriasis, mild proptosis, and loss of the corneal reflex of the right eye.  Visual acuity is normal in both eyes, but the patient is unable to move the right eye in any direction.  There is decreased sensation in the right upper face.  Which of the following structures is most likely involved in this patient's presentation?

Quizplus · Accepted Answer

11ec160b_35a2_dd7e_9249_e950e6542048_MD0001_00 Cavernous sinus thrombosis is most commonly due to contiguous spread of an infection from the medial third of the face, sinuses (ethmoidal or sphenoidal), or teeth. The infection can communicate in a retrograde fashion into the cavernous sinus through the valveless facial venous system (via the superior and inferior ophthalmic veins). Common pathogens include Staphylococcus aureus (most common) and streptococci, although fungal organisms (eg, Mucor, Rhizopus) are responsible in rare cases. Patients typically experience headache, fever, and diplopia. Ocular muscle paralysis occurs due to injury of cranial nerves (CNs) III, IV, and VI. CN III palsy may also result in ptosis and mydriasis. Involvement of the ophthalmic and maxillary branches of CN V can cause loss of both upper facial sensation and the afferent limb of the corneal reflex. Proptosis (eye protrusion) and chemosis (conjunctival swelling) may also be evident due to impaired venous drainage through the ophthalmic veins. (Choice A) Brainstem lesions typically result in crossed signs (ipsilateral cranial nerve palsies and contralateral hemiparesis), vertigo, and ataxia. (Choice C) Frontal lobe pathology can cause disinhibition, problems with planning/organizing, and personality changes. CN deficits are not characteristic. (Choice D) The inferior orbital fissure transmits the maxillary division of CN V, infraorbital vessels, and branches from the sphenopalatine ganglion. (Choice E) Lesions of the jugular foramen can result in jugular foramen (Vernet) syndrome, which is characterized by the dysfunction of CNs IX, X, and XI. Findings include dysphagia, hoarseness, loss of gag reflex on the ipsilateral side, and deviation of the uvula toward the normal side. (Choice F) The optic chiasm is superior to the cavernous sinus and is where the optic nerve fibers from the nasal side of each retina cross to the opposite side of the brain. Optic chiasm lesions typically cause bitemporal hemianopia, which is absent in this patient. Educational objective: Infection of the medial face, sinuses (ethmoidal or sphenoidal), or teeth may spread through the valveless facial venous system into the cavernous sinus, resulting in cavernous sinus thrombosis. Patients typically present with headache, fever, proptosis, and ipsilateral deficits in cranial nerves III, IV, VI, and V (ophthalmic and maxillary branches). __________ References: Septic thrombosis of the cavernous sinuses. (http://www.ncbi.nlm.nih.gov/pubmed/11732931) Ocular manifestations of cavernous sinus thrombosis. (http://www.ncbi.nlm.nih.gov/pubmed/22802153)

A 48-Year-Old Man Comes to the Hospital After a Day