From 1940 to 1984, 19 cases of septic dural-
sinus thrombosis have been diagnosed at the Massachusetts General Hospital, and some 136 cases have been reported from other institutions. Septic
thrombosis most frequently involves the cavernous sinuses (96 cases). Facial or sphenoid air
sinus infection often precede cavernous-sinus disease. In addition to the classical signs of
proptosis, chemosis, and
oculomotor paralysis, isolated
sixth-nerve palsy and hypo- or
hyperesthesia of the fifth nerve may be found. The major pathogens associated with cavernous-sinus
infection include Staphylococcus aureus, other gram-positive organisms, and anaerobes. Septic
lateral-sinus thrombosis (64 cases) is almost exclusively a complication of
otitis media and/or mastoid
infection. Organisms causing this
infection include Proteus species, Escherichia coli, S. aureus, and anaerobes. Septic
thrombosis of the superior sagittal sinus (23 cases) most frequently accompanies
bacterial meningitis or air
sinus infection. Causative organisms include Streptococcus pneumoniae, S. aureus, other streptococci, and Klebsiella species. Because septic dural-
sinus thrombosis is rare, this disease is frequently misdiagnosed. Evaluation should include lumbar puncture, air sinus films, and computed tomographic scan with contrast. Other helpful diagnostic tests may include carotid angiography, and dynamic brain scan. Orbital venography is the most definitive study in cases of chronic
cavernous-sinus thrombosis.
Therapy should include intravenous
antibiotics and early surgical drainage of purulent exudate in the air sinuses or mastoid regions. Retrospective analysis suggests that treatment with
heparin may reduce mortality in carefully selected cases of septic
cavernous-sinus thrombosis. Anticoagulation is not recommended in other forms of septic dural-
sinus thrombosis. Mortality in the
antibiotic-era remains high, particularly in patients with septic
thrombosis of the cavernous (30%) and superior sagittal (78%) sinuses.