cavernous sinus thrombosis ( cst ) was first reported by bright et al . in 18311 .
cst is an infectious disease that is potentially fatal if it is not treated in its early stage .
furthermore , despite treatment , complications of cst such as cranial nerve dysfunction may remain .
there are very few reports of cst related to periodontal disease or to tooth extraction3 .
the authors present a case in which misdiagnosis and inappropriate treatment of a buccal cheek laceration due to an ill - fitting denture resulted in a buccal space abscess that progressed into cst .
a 65-year - old man with no past medical history presented to the emergency room with facial swelling and fever .
two weeks earlier , he began having trismus and pain on the mandibular left side .
the patient was prescribed prednisolone , cyclobenzaprine , steroids and muscle relaxants and was advised to frequently apply moist hot packs .
the patient 's symptoms persisted and he developed spiking fevers with delirium . in the emergency room ,
his vital signs included blood pressure 151/82 mmhg , pulse 95 beats per minute , temperature 39.3 , and respiratory rate 12/min .
a complete blood count revealed a white blood cell ( wbc ) count of 19,110/l with 92.8% neutrophils , a erythrocyte sedimentation rate ( esr ) of 89 mm / h and c - reactive protein ( crp ) of 279.2 mg / l .
computed tomography ( ct ) showed an abscess in the buccal and pterygomandibular space spreading into the temporal space.(fig .
1 ) the patient 's mental status was assessed with questions about his personal information .
he had three teeth on the right mandibular side , and the left buccal cheek was swollen with a 1 cm laceration .
however , because the patient showed clinical signs of infection associated with buccal , pterygomandibular , and temporal space abscesses , he was admitted to the hospital .
empirical antibiotic treatment was initiated with flomoxef 2 g / day , metronidazole 1.5 g / day , and isepamicin sulfate 400 mg / day . on the day of hospitalization
ofloxacin otic solution was topically applied to the external auditory canal and the occlusive dressing was changed daily . on the second day of hospitalization ,
a spinal tap revealed cerebrospinal fluid turbidity suggestive of central nervous system ( cns ) infection .
as per recommendations from internal medicine , and neurology , the antibiotic regimen was changed to ceftazidime 4 g / day and vancomycin 2.7 g / day to cover the cns infection and potential methicillin - resistance staphylococcus aureus ( mrsa ) . on the third day of hospitalization , an oral and maxillofacial surgeon performed intraoral incision and drainage of the buccal and pterygomandibular spaces .
results of a magnetic resonance image ( mri ) included a dilated superior ophthalmic vein , bulging cavernous sinus contour , and septic thrombi in the cavernous sinus .
2 ) antimicrobial sensitivity testing identified methicillin - sensitive staphylococcus aureus ( mssa ) and therefore the antibiotic regimen was changed to nafcillin 12 g / day .
his buccal swelling decreased , he recovered the ability to open his mouth , and his visual acuity and extremity sensation improved .
wbc , esr , and crp counts also improved.(table 1 ) with reduced swelling , we discovered an ill - fitting denture .
cst is a rare condition in which blood clots form within the cavernous sinus , a large collection of thin - walled veins .
septic cst may be caused by sinusitis , otitis , odontogenic infection , or facial cellulitis .
the most frequent cause of septic cst is sinusitis in the sphenoid or ethmoidal sinuses .
dental infections account for < 10% of septic cst cases , and most of these cases are related to maxillary infection4 .
eagleton5 proposed the following criteria for cst diagnosis : a known site of infection ; blood stream infection ( sepsis ) ; early obstructive signs ( such as retinal vein fullness , proptosis , exophthalmus , and collateral venous circulation ) ; ocular nerve paralysis ( via lesions of cranial nerves iii , iv , v , and iv ) ; surrounding soft tissue abscesses ( of the orbit , occiput , neck or nasopharynx ) ; and symptoms of a complicated disease ( such as headache , papilledema , and meningeal signs ) .
other potential pathogens include pneumococcus , bacteroides , fusobacterium , proteus , haemophilus , pseudomonas , and corynebacterium6 .
venous flow is bidirectional in the cerebral vein , emissary vein , and dural sinus because these vessels do not have valves .
therefore , bacteria or thrombi from another facial region can spread to the cavernous sinus via the facial vein or pterygoid plexus7 .
ophthalmoplegia is extraocular muscle weakness that results ( in cst ) when cranial nerves iii , iv , and/or vi are damaged due to their passage through the cavernous sinus .
other symptoms of lethargy , headache , periorbital swelling , papilledema , and venous engorgement occur in 50%-80% of patients . decreased visual acuity , sluggish / dilated pupil , periorbital sensory loss , and decreased corneal reflex are less frequent symptoms that occur in < 50% of patients .
. early symptoms of orbital cellulitis are similar to those of cst and include periorbital swelling , proptosis , chemosis , fever and impaired vision .
cst is included in the differential diagnosis when the above symptoms present bilaterally or when there is sensory loss in the periocular area , papilledema , and pupillary dilation9 .
coronal ct reveals that the lateral wall of the cavernous sinus is flat or convex instead of its normal concave shape . additionally , irregular filling defects due to thrombi , and superior ophthalmic vein dilation are often observed .
mri is useful when the ct images are not clear or when the infection has spread to surrounding tissues including the brain and pituitary gland10,11 . in the past
these imaging techniques are no longer recommended because they increase the risks of the infection spreading and thrombosis12 .
optimal therapy for cst includes the concomitant administration of nafcillin , metronidazole , and ceftriaxone / cefotaxime .
surgical interventions are indicated when the primary site of infection is sinusitis , or a dental infection . in the case of a serious infection ,
one may consider direct surgical drainage of the cavernous sinus ; however , this approach is difficult and complications are likely to arise7 .
corticosteroid therapy must be considered if adrenal insufficiency occurs due to cranial nerve dysfunction or pituitary necrosis13 .
some studies have reported that anticoagulating with heparin , for example , within seven days after cst reduces the mortality rate14 .
however , anticoagulation increases the risk of intracranial and/or systemic hemorrhage , and therefore should be used with caution15 . in this case , it was difficult to confirm the source of infection because the patient 's buccal cheek swelling and trismus prevented adequate intraoral examination .
the only suspicious finding was a small laceration on left buccal mucosa . generally , odontogenic infections arise from the teeth themselves or from periodontal tissue . therefore , it was difficult to confirm that this severe infection originated from a small laceration in a patient with no medical history .
another dentist who examined the patient two weeks before his presentation had misdiagnosed him with temporomandibular joint symptoms and myofascial pain .
administration of moist hot packs and prednisolone may have actually facilitated the infection 's progression .
cst treatment must include proper management of the primary infection site and empiric antibiotics considering the possible pathogens .
cst presents with inconsistent symptoms , and therefore it is essential to collaborate with various departments including neurology , ophthalmology , otorhinolaryngology , and internal medicine .
it presents with proptosis , chemosis , periorbital swelling and other typical signs of infection including as fever , pain and swelling .
clinicians in oral and maxillofacial surgery should be aware of cst and should consider it in patients with facial swelling .
 cavernous sinus thrombosis not only presents with constitutional symptoms including fever , pain and swelling but also with specific findings such as proptosis , chemosis , periorbital swelling , and cranial nerve palsies . 
 it is known to occur secondary to the spread of paranasal sinus infections in the nose , ethmoidal and sphenoidal sinuses . however , paranasal sinus infection of dental origin is rare . 
 the following is a case of cavernous sinus thrombosis due to the spread of an abscess in the buccal and pterygomandibular spaces via buccal mucosal laceration . 