A 57-year-old woman presents to the emergency department for a headache. She was at home when a sudden headache began with greater severity than she had experienced in the past. She presented within 30 minutes of symptom onset. The patient has a medical history of sinusitis, constipation, diabetes, and pelvic inflammatory disease. Her current medications include fexofenadine, oral contraceptive pills, and metformin. She is currently taking amoxicillin for a sinus infection. She smokes 1 pack of cigarettes per day and drinks 2-3 alcoholic beverages daily. Her temperature is 99.5°F (37.5°C), blood pressure is 187/118 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, the patient is noted to be uncomfortable with the appearance shown in Figure A. Neurological exam reveals a confused woman who is now complaining of "seeing double." Cardiopulmonary exam reveals mild bibasilar crackles and tachycardia. Abdominal exam is within normal limits. Which of the following is the most appropriate initial step in management?
MRI of the head
Piperacillin-tazobactam
Dexamethasone
Amoxicillin-clavulinic acid
Piperacillin-tazobactam
This patient is presenting with symptoms suggestive of septic cavernous sinus thrombosis (CST). The most appropriate initial step in management is urgent broad-spectrum antibiotics and surgical drainage.

Cavernous sinus thrombosis is an emergency that requires immediate intervention. It typically occurs in a patient with a history of sinusitis, oral contraceptive pill usage, smoking, or other risk factors that could cause a hypercoagulable state. These patients will often present with severe pain, a sudden headache, and diplopia. A distinct appearance is typically noted with periorbital edema. These patients should be immediately treated with broad-spectrum antibiotics and undergo surgical drainage of the inciting source of infection. In some cases, thrombolytics can be used as well.

Caranfa and Yoon review the evidence regarding the diagnosis and treatment of septic cavernous sinus thrombosis. They discuss how this diagnosis was almost universally fatal in the pre-antibiotic era. They recommend using broad-spectrum antibiotics and debridement to address this disease.

Figure/Illustration A is a clinical photograph demonstrating a face with swelling and periorbital edema (red circles). This appearance is classically seen in patients with CST.

Incorrect Answers:
Answer A: Amoxicillin-clavulanic acid would be appropriate management of acute otitis media or sinusitis; however, it is insufficient coverage for CST. Broad-spectrum antibiotics and surgical intervention are needed to prevent loss of vision.

Answer B: A CT scan of the head could be indicated potentially for surgical planning in a more stable patient; however, in this situation, immediate intervention is more dire. After antibiotics and stabilization, CNS imaging will be needed.

Answer C: Dexamethasone would be appropriate treatment of a relapse of multiple sclerosis, which can also present with visual changes; however, it would not present with sudden headache and periorbital edema.

Answer D: An MRI of the brain would be appropriate for further characterizing neurologic deficits of unclear etiology. In this case, the patient's acute presentation with neurologic changes secondary to CST requires immediate treatment rather than additional imaging.

Bullet Summary:
Cavernous sinus thrombosis should be immediately managed with broad-spectrum antibiotics and neurosurgery.