Bilateral cavernous sinus thrombosis and facial palsy as complications of dental abscess
A 50-year-old, previously healthy, female patient presented with complaints of fever, pain, and pus discharge from right maxillary molars and swelling of right cheek since 15 days. Three days later she developed puffiness of both eyes.\nPatient was drowsy at the time of admission. She was mildly febrile. On examination, there was diffuse inflamed swelling over right maxillary region along with bilateral exophthalmos with chemosis and congestion of conjunctiva. Oral examination revealed right maxillary dental abscess related to molars. Central nervous system examination revealed nuchal rigidity. Bilateral ptosis with external ophthalmoplegia was present along with palsy of lower half of face []. Other neurological examination was normal. Other systems examination did not reveal any abnormality.\nHer baseline investigations revealed the following results: Total leukocyte count: 17000/mm3, Differential leukocyte count: P80L18E1M1, Erythrocyte sedimentation rate: 46 mm/h, serum Na+136 meq/L, serum K+3.4 meq/L, blood urea 20 mg/dL, serum creatinine 0.6 mg/dL, and random blood glucose 106 mg/dL. Her chest X-ray revealed multiple thin-walled abscesses (pneumatoceles) []. HIV Enzyme-linked immunosorbent assay was nonreactive.\nThe patient was first seen by oral and maxillofacial surgeon. Her orthopantomogram was done which showed opacity at the tips of right second and third maxillary molars []. Drainage of the dental abscess and extraction of the right maxillary molars was done immediately. The pus sent for culture grew Staphylococcus aureus. With suspicion of CST, the patient was transferred to neurology department. Her magnetic resonance imaging (MRI) brain was done which showed bilateral mastoiditis along with bilateral CST with abscess in right cerebellar and right cerebellopontine angle region with infarct in right parietooccipital and right high parietal region [Figures and ]. Magnetic resonance (MR) venography did not show involvement of any other major sinuses. The patient was started on intravenous fluids and antibiotics (vancomycin 2 g/day, ceftriaxone 2 g/day, and clindamycin 1200 mg/day). Anticoagulant was added in the form of enoxaparin 0.4 mL s.c. twice a day. Oral anticoagulant (warfarin) was added subsequently.\nThe patient improved during the hospital stay of 4 weeks and was discharged satisfactorily. At follow-up after 3 months, she had complete recovery.