- Email: [email protected]
Cavernous sinus thrombosis with generalized septicemia
Cavernous sinus thrombosis with generalized septicemia Report
of a fatal
case following
dental
extraction
C
avernous sinus thrombosis is one of the major complications resulting from infection of the teeth or surrounding structures in the upper or lower jaws. Furunculosis, infected nose hairs, and scratching of pimples on the face are frequent causes. Extraction of mandibular molars and maxillary anterior teeth in the presence of acute infection, usually staphylococcal, can also cause this condition. The infection may be spread by direct extension via the infratemporal space through the cranial wall or by way of the pterygoid plexus and emissary veins from the pterygomaxillary space. The infection ascends in the veins, against the usual venous flow. This is possible because of the anatomic anomaly of the absence of valves in the angular, facial, and ophthalmic veins.“, G REVIEW
OF THE LITERATURE
Abercrombie,l in 1818, was the first to report a case of lateral sinus thrombosis following a mastoid infection. The first complete description of the signs and symptoms of cavernous sinus thrombosis was published by Knapp in 1868.l’ In 1902 Dwight and Germain,* from their collection of eighteen cases of cavernous sinus thrombosis, reported fourteen cases of cavernous sinus thrombosis having their primary focus in the mouth. In 1932 twenty-four cases of fatal infection following dental infection were reported in the literature; among these were four cases of cavernous sinus thrombosis, the remaining being intracranial involvement of other types. Childs and Courville,3 in a review of seventy-four cases of cavernous sinus thrombosis which followed dental infection, stated that the thrombi originated in the pterygoid or pharyngeal plexus in thirty-two cases and in the venous plexus of the face in nine cases. In three cases there was a combination of the *Assistant
Dental
Surgeon,
Christian
Medical
College
Hospital,
Vellore,
South
India.
715
716
‘IIfJh rotrn
O.S., 0.N. c 0.1’. .I ,111f~.l!wJ
Cavernous sinus thrombosis
Volume 19 Number 6
to swallow, hyperpyrexia, and rigors. He also not,iced multiple small body. He had difficulty in walking. The past medical history and family history were noncontributory. Clinical
swellings
717
all over the
examination
The patient was found to bc a well-built man in severe prostration and acute distress. He had a temperature of 103” F., a pulse rate of 110, and a respiration rate of 26. There was a diffuse swelling of the right side of the face, extending from below the lower border of the mandible to the right eye (Fig. 1). The intraoral examination revealed poorly healed hounds from the extraction of the mandibular right first and second molars. There were multiple hemorrhagic areas and erythematous nodules all over the face and body (Fig. 2). The right side of the fact looked red and inflamed. There was pitting on pressure. The pnriorbital region was edematous, and t,he right eye was closed and swollen. Ecchymosis of the conjunctiva, ptosis, and ophtl~almoplegia on the right side were noted. !rhe movements of the eyeball were sluggish, and t,hrre was paresis of the s~onrl, third, fourth, ant1 sixth IIRI’VI’Y. There also was a market1 neck rigidity. Radiographic
examination
An anteroposterior rocntgcnogram region of the right maxillary antrum any fracture. Laboratory
of the mandible as compared \vith
revealed the left.
a marked opacity in the There was no evidence of
examination
Laboratory stud& revcaltxll tlrcl following : Hemoglobin-14.0 Gm. Packed cell volume-44 Platelet count-90,000 per cubic millimctcr White blood count-4,500 per cubic millirn~~ter Neutrophils, 70 per cent Lymphocytes, 2i per cent Monoeytes, 3 per cent Urinalysis-Essentially negative Prothrombin time-17 seconds (control, 15 seconds) Erythrocyte sedimentation rate-first hour, 20 mm.; second hour, 30 mm. Bleeding and clotting time-Within normal limits Blood urea-246 mg. per cent Blood sugar-180 mg. per cent Cerebrospinal fluids-sugar, 75 mg. per cent; protein, 85 mg. prr cent; chlorine, mg. per cent Serum electrolytes-sodium, 135; potassium, 6.0; rhlorinc, 70.0 Treatment
and
620
course
given 10,000,000 units of cryst,alline penicillin intravenously. The patient was immediately Subsequently, 5,000,OOO units was given intravenously every 6 hours. Simultaneously, 5,000 units of heparin (an anticoagulant) was given subcutaneously. I\Iagnesium sulfate compresses were used on the face three times a day to alleviate pain and swelling. Largactil, 100 mg., was given three times a day for sedation. A fluid diet consisting of 3 pints of 5 per cent glucose, 2 pints of 5 per cent glucose saline, and 1 pint of 10 per cent glucose was administered intravenously, together with multivitamins. The very next day the patient’s temperature shot to 105” F., and there was extreme difficulty in breathing. A tracheotomy was performed to create a patent airway. Since there was no visible improvement in the patient’s general condition, it was decided to administer 100 mg. of erythromycin four times a day after the antibiotic-sensitivity test showed resistance to other antibiotics. As a supplement to the fluid diet, 20 mg. of vitamin I*; and 10 C.C. of 10 per cent calcium gluconate were injected intravenously. An intravenous injection
EagletonF diagnostic criteria arc ( 1) known site of infection: (2) bloodstream infection as cvidenccd by chilliness, high I’evcr, and toxicity; (:j) signs of venous obstruction in the retina, conjuuctiva. eyelids, ant1 orbits on one or both sides; (4) paresis of third, -fourth, and sixth ncrv~s; and (*5) scmicomatosc~ condition. Although no autopsy could bc pcrformcd in this cast because of the refusal by the patient’s relatives to grant permission, all signs and symptoms pointed to a clinical diagnosis of cavernous sinus thrombosis, since the foregoing criteria were fulfilled. The fact that the modern “mondcr drugs” could not save the patient’s life shows that cavernous sinus thrombosis is still a dreadful disease. SUMMARY
A case of cavernous sinus thrombosis and septicemia following dental estraction has been reported and discussed. The litcraturc has been rcvicwcd
briefly, and the regional anatomy and routes of infection have been reviewed. Oral infection may contribute to generalized septicemia. Extraction of teeth in the presence of fulminating dental infection is hazardous. REFERENCES
J.: Observations on Chronic Inflammation of the Brain and Its Membranes, Edinburgh M. & Surg. J. 14: 263, 1818. Dwi&t. E. W.. and Germain. 1%. II.: Cavernous Sinus Thrombosis. 1Vith Report of 4 Cases, Bosi;n’YI. S&g. J. 146: 45ij, 1902. Childs, II. G., and Courville, C. B. : Thrombosis of Cavernous Sinus Secondary to Dental Infections, Am. J. Orthodontics & Oral Sure. 28: 367. 402, 515, 1942. Thoma, li: H. : Oral Pathology, ed. 5, St. L&is, 1958,‘Thc e. V: Mosby Company, p. 493. Thoma, K. II.: Oral Surgery, cd. 3, St. Louis, 1958, The C. V. Mosby Company, pp. 966, 967. Shafer, W. G., Hine, M. K., and Levy, B. 11.: A Text Book of Oral Pathology, Philadelphia, 1958, W. B. Saunders Company, pp. 38T, 388. of the Cavernous Oliver, K. S., Diab, A. E., and Abu-Jandah, C. N.: Tl~roml~opl~lebitis Sinus Originating From Acute Dental Infection, Arch. Otolaryng. 48: 36, 1948. Eagleton. \V. P.: Cavernous Sinus ThromboDhlebitis and Allied Reatic and Traumatic, Lesions (;f the Basal Venous Sinuses-S Clinical Study of Blood &earn Infection, Xcw York, 1926, The Macmillan Company. Tl~rombopl~lebitis of Cavernous Sinus FollowWicsenfeld, I. H., and Phillips, Edward: inp Extraction of Teeth. Arch. Otolarvne. 40: 497. 1944. O!L!Cavernous Sinis Thromb;~phlebitis With Heparin and ChcmoLy”ons, C.: Treatment therapy, Ann. Surg. 113: 113, 1941. Schcll. I,. A.: Treatment of Septic Tl~rombopl~ltbitis of C’avernous Sinus. J. A. 11. A. 117: 681. 1941. in a Diabetic, ORAL SURC., Russel, A., and Fearing, 8. J.: Carcrnous Sinus ‘l’hromlwsis ORAL MED. & ORAL PATX 8: 372, 1955. Haymaker, W.: Fatal Infection of the Central X;rrvous Syslcm aud Meninges After Tooth Extraction, Am. J. Orthodontics & Oral Surg. 31: 117, 1943.
1. Abercrombie, 2. 3.
4. 5. 6. 7. 8. 9. IO. 11. 12. 13.
of a fatal
case following
dental
extraction
C
avernous sinus thrombosis is one of the major complications resulting from infection of the teeth or surrounding structures in the upper or lower jaws. Furunculosis, infected nose hairs, and scratching of pimples on the face are frequent causes. Extraction of mandibular molars and maxillary anterior teeth in the presence of acute infection, usually staphylococcal, can also cause this condition. The infection may be spread by direct extension via the infratemporal space through the cranial wall or by way of the pterygoid plexus and emissary veins from the pterygomaxillary space. The infection ascends in the veins, against the usual venous flow. This is possible because of the anatomic anomaly of the absence of valves in the angular, facial, and ophthalmic veins.“, G REVIEW
OF THE LITERATURE
Abercrombie,l in 1818, was the first to report a case of lateral sinus thrombosis following a mastoid infection. The first complete description of the signs and symptoms of cavernous sinus thrombosis was published by Knapp in 1868.l’ In 1902 Dwight and Germain,* from their collection of eighteen cases of cavernous sinus thrombosis, reported fourteen cases of cavernous sinus thrombosis having their primary focus in the mouth. In 1932 twenty-four cases of fatal infection following dental infection were reported in the literature; among these were four cases of cavernous sinus thrombosis, the remaining being intracranial involvement of other types. Childs and Courville,3 in a review of seventy-four cases of cavernous sinus thrombosis which followed dental infection, stated that the thrombi originated in the pterygoid or pharyngeal plexus in thirty-two cases and in the venous plexus of the face in nine cases. In three cases there was a combination of the *Assistant
Dental
Surgeon,
Christian
Medical
College
Hospital,
Vellore,
South
India.
715
716
‘IIfJh rotrn
O.S., 0.N. c 0.1’. .I ,111f~.l!wJ
Cavernous sinus thrombosis
Volume 19 Number 6
to swallow, hyperpyrexia, and rigors. He also not,iced multiple small body. He had difficulty in walking. The past medical history and family history were noncontributory. Clinical
swellings
717
all over the
examination
The patient was found to bc a well-built man in severe prostration and acute distress. He had a temperature of 103” F., a pulse rate of 110, and a respiration rate of 26. There was a diffuse swelling of the right side of the face, extending from below the lower border of the mandible to the right eye (Fig. 1). The intraoral examination revealed poorly healed hounds from the extraction of the mandibular right first and second molars. There were multiple hemorrhagic areas and erythematous nodules all over the face and body (Fig. 2). The right side of the fact looked red and inflamed. There was pitting on pressure. The pnriorbital region was edematous, and t,he right eye was closed and swollen. Ecchymosis of the conjunctiva, ptosis, and ophtl~almoplegia on the right side were noted. !rhe movements of the eyeball were sluggish, and t,hrre was paresis of the s~onrl, third, fourth, ant1 sixth IIRI’VI’Y. There also was a market1 neck rigidity. Radiographic
examination
An anteroposterior rocntgcnogram region of the right maxillary antrum any fracture. Laboratory
of the mandible as compared \vith
revealed the left.
a marked opacity in the There was no evidence of
examination
Laboratory stud& revcaltxll tlrcl following : Hemoglobin-14.0 Gm. Packed cell volume-44 Platelet count-90,000 per cubic millimctcr White blood count-4,500 per cubic millirn~~ter Neutrophils, 70 per cent Lymphocytes, 2i per cent Monoeytes, 3 per cent Urinalysis-Essentially negative Prothrombin time-17 seconds (control, 15 seconds) Erythrocyte sedimentation rate-first hour, 20 mm.; second hour, 30 mm. Bleeding and clotting time-Within normal limits Blood urea-246 mg. per cent Blood sugar-180 mg. per cent Cerebrospinal fluids-sugar, 75 mg. per cent; protein, 85 mg. prr cent; chlorine, mg. per cent Serum electrolytes-sodium, 135; potassium, 6.0; rhlorinc, 70.0 Treatment
and
620
course
given 10,000,000 units of cryst,alline penicillin intravenously. The patient was immediately Subsequently, 5,000,OOO units was given intravenously every 6 hours. Simultaneously, 5,000 units of heparin (an anticoagulant) was given subcutaneously. I\Iagnesium sulfate compresses were used on the face three times a day to alleviate pain and swelling. Largactil, 100 mg., was given three times a day for sedation. A fluid diet consisting of 3 pints of 5 per cent glucose, 2 pints of 5 per cent glucose saline, and 1 pint of 10 per cent glucose was administered intravenously, together with multivitamins. The very next day the patient’s temperature shot to 105” F., and there was extreme difficulty in breathing. A tracheotomy was performed to create a patent airway. Since there was no visible improvement in the patient’s general condition, it was decided to administer 100 mg. of erythromycin four times a day after the antibiotic-sensitivity test showed resistance to other antibiotics. As a supplement to the fluid diet, 20 mg. of vitamin I*; and 10 C.C. of 10 per cent calcium gluconate were injected intravenously. An intravenous injection
EagletonF diagnostic criteria arc ( 1) known site of infection: (2) bloodstream infection as cvidenccd by chilliness, high I’evcr, and toxicity; (:j) signs of venous obstruction in the retina, conjuuctiva. eyelids, ant1 orbits on one or both sides; (4) paresis of third, -fourth, and sixth ncrv~s; and (*5) scmicomatosc~ condition. Although no autopsy could bc pcrformcd in this cast because of the refusal by the patient’s relatives to grant permission, all signs and symptoms pointed to a clinical diagnosis of cavernous sinus thrombosis, since the foregoing criteria were fulfilled. The fact that the modern “mondcr drugs” could not save the patient’s life shows that cavernous sinus thrombosis is still a dreadful disease. SUMMARY
A case of cavernous sinus thrombosis and septicemia following dental estraction has been reported and discussed. The litcraturc has been rcvicwcd
briefly, and the regional anatomy and routes of infection have been reviewed. Oral infection may contribute to generalized septicemia. Extraction of teeth in the presence of fulminating dental infection is hazardous. REFERENCES
J.: Observations on Chronic Inflammation of the Brain and Its Membranes, Edinburgh M. & Surg. J. 14: 263, 1818. Dwi&t. E. W.. and Germain. 1%. II.: Cavernous Sinus Thrombosis. 1Vith Report of 4 Cases, Bosi;n’YI. S&g. J. 146: 45ij, 1902. Childs, II. G., and Courville, C. B. : Thrombosis of Cavernous Sinus Secondary to Dental Infections, Am. J. Orthodontics & Oral Sure. 28: 367. 402, 515, 1942. Thoma, li: H. : Oral Pathology, ed. 5, St. L&is, 1958,‘Thc e. V: Mosby Company, p. 493. Thoma, K. II.: Oral Surgery, cd. 3, St. Louis, 1958, The C. V. Mosby Company, pp. 966, 967. Shafer, W. G., Hine, M. K., and Levy, B. 11.: A Text Book of Oral Pathology, Philadelphia, 1958, W. B. Saunders Company, pp. 38T, 388. of the Cavernous Oliver, K. S., Diab, A. E., and Abu-Jandah, C. N.: Tl~roml~opl~lebitis Sinus Originating From Acute Dental Infection, Arch. Otolaryng. 48: 36, 1948. Eagleton. \V. P.: Cavernous Sinus ThromboDhlebitis and Allied Reatic and Traumatic, Lesions (;f the Basal Venous Sinuses-S Clinical Study of Blood &earn Infection, Xcw York, 1926, The Macmillan Company. Tl~rombopl~lebitis of Cavernous Sinus FollowWicsenfeld, I. H., and Phillips, Edward: inp Extraction of Teeth. Arch. Otolarvne. 40: 497. 1944. O!L!Cavernous Sinis Thromb;~phlebitis With Heparin and ChcmoLy”ons, C.: Treatment therapy, Ann. Surg. 113: 113, 1941. Schcll. I,. A.: Treatment of Septic Tl~rombopl~ltbitis of C’avernous Sinus. J. A. 11. A. 117: 681. 1941. in a Diabetic, ORAL SURC., Russel, A., and Fearing, 8. J.: Carcrnous Sinus ‘l’hromlwsis ORAL MED. & ORAL PATX 8: 372, 1955. Haymaker, W.: Fatal Infection of the Central X;rrvous Syslcm aud Meninges After Tooth Extraction, Am. J. Orthodontics & Oral Surg. 31: 117, 1943.
1. Abercrombie, 2. 3.
4. 5. 6. 7. 8. 9. IO. 11. 12. 13.