Case Presentation: A 65-year-old female with a history of sphenoid sinusitis status post recent fiberoptic endoscopic sinus surgery presented with one week of neck stiffness and two days of fever, headache, photosensitivity, and diplopia. Vital signs were: temperature 102.6, heart rate 82, respiratory rate 20, blood pressure 122/45 and 95% room air O2 saturation. Physical exam showed right-sided neck edema with restricted lateral rotation and difficulty performing full neck flexion. Right cranial nerve VI palsy was also noted. The remaining physical exam was unremarkable. Laboratory testing showed WBC 22,000 / mm3 (normal 4000 – 10,000 / mm3) with 88% neutrophils and CRP 18.1 (normal < 0.5 mg/dL). CSF analysis was significant for protein 58 mg/dL (normal 15-45 mg/dL), glucose 66 mg/dL (normal 40-70 mg/dL), and WBC 359 (normal 0-10 mm3) with 87% neutrophils. Empiric vancomycin, ceftriaxone, and ampicillin were administered. Contrast computed tomography (CT) of the head, facial bones and neck showed sphenoid sinusitis and thrombophlebitis of the bilateral internal jugular and cavernous sinus. Admission blood cultures were positive for Streptococcus intermedius. CSF cultures were negative. A trans-thoracic echocardiogram did not show valvular vegetations or thrombus. The patient underwent a repeat endoscopic sinus surgery with image-guided sphenoidectomy and debridement. She was discharged with four-weeks of ceftriaxone and three months of rivaroxaban.

Discussion: While sphenoid sinusitis often presents with facial pain, rhinorrhea, and nasal congestion, headache is sometimes the only reported symptom. If untreated, bacteria may spread hematogenously through afferent veins or via direct extension through mucosa and bone, leading to intracranial complications. Cavernous sinus thrombosis (CST) is one of the rare and life-threatening complications of sinusitis with a mortality rate up to 30%. Potential infectious sources include any anatomical site that drains to the cavernous sinus (face, nose, tonsils, teeth and ears), with paranasal sinusitis being the most common source.
Symptoms of CST vary but may include headache, periorbital edema, photophobia, proptosis, cranial nerve palsies (III, IV, V, VI) and fever. Staphylococcus and streptococcus species are the most common causative etiologies, but gram-negative bacilli, anaerobes and fungal organisms have also been reported. Contrast CT can be used but MR venography is preferred to confirm the diagnosis and evaluate for other intracranial complications. Up to 90% of patients with CST will have multiple other intracranial thromboses.
Intravenous antibiotics and surgical drainage of the source of infection are the mainstays of treatment. Anticoagulation may be considered in infectious head and neck cases with thrombophlebitis, but risk should be weighed against benefit for each individual patient. Because of the rarity of CST, there is not high-level evidence to support anticoagulation use in all cases. Even with treatment, blindness and cranial nerve palsy may persist in survivors.

Conclusions: Hospitalists should recognize the constellation of fever and headache in association with cranial nerve deficits as signs of CST. Urgent imaging with contrast CT or MRI (preferred) should be obtained. Early administration of intravenous antibiotics and surgical drainage of the source of infection can reduce the risk of acute complications and long-term sequelae.