A 19 year old young girl with previous history of repeated pain over medial canthus and chronic use of nasal decongestants, presented with abrupt onset of fever with chills & rigor, diplopia on lateral gaze, moderate proptosis & chemosis. On examination optic disc is congested. Most likely diagnosis is
Cavernous sinus thrombosis Repeated pain over medial canthus and chronic use of nasal decongestants suggest chronic ethmoidal sinusitis. Patient's other symptoms suggest that she has landed up in complicated sinusitis Now lets see the symptoms one by one ? There is sudden onset of ? - Chills & rigor Systemic symptoms - Diplopia on lateral gaze --> s/o VI C.N. (abducent) involvement leading to lateral rectus palsy - Proptosis & chemosis b/o venous congestion - Optic disc congestion So, among the given options ? Orbital apex syndrome (OAS) can be ruled out as visual loss is often the initial manifestations of an OAS (not seen in this patient). Orbital apex syndrome *Orbital apex syndrome is caused by any etiology (infective, neoplastic,granulomatous inflammation or traumatic) that involves the structures in the orbital apex (posterior orbit). Orbital apex consists of the superior orbital fissure + optic canal. Thus so: Orbital apex syndrome Superior orbital fissure syndrome + optic nerve signs *Superior orbital fissure syndrome is caused by involvement of all extraocular peripheral nerves passing through the superior orbital fissure i.e. III, IV, VI, & VI. *Orbital apex syndrome is characterized by: - Ophthalmoplegia (due to paresis of III, IV, VI, & VI cranial nerves), - Ptosis, - Anaesthesia in the region supplied by ophthalmic division of Vth nerve (decreased corneal sensation and -Early visual loss and afferent papillary defect (caused by optic nerve involvement). The remaining two options; cavernous sinus thrombosis & orbital cellulitis can impose adignostic difficulty. Both of these have almost similar presentation with some differences. Abrupt onset of chills & rigor, mod. proptosis and lateral gaze palsy our cavernous sinus thrombosis (CST). In orbital cellulitis onset is slow & systemic features are mild & there is restricted ocular movement in all directions from the beginning. Optic disc congestion & vision loss in late stages are found both in CST & orbital cellulitis. Differences in CST, Orbital cellulitis & OAS Clinical features CST Orbital Cellulitis OAS Onset Abrupt Slow Slow Systemic features Marked Mild Mild Laterality Initially unilateral, but can become bilateral in more than 50% cases Unilateral Unilateral Proptosis Moderate Marked Mild to moderate Chemosis Moderate Marked Mild Vision Not affected in early stages Not affected in early stages Lost in early stages Ophthalmo- plegia Sequential & complete -4 lateral gaze palsy to sta with ,as 6th C.N. is involved first* Concurrent & complete Concurrent & complete Edema in mastoid region Present (Diagnostic sign) Absent Absent *6th cranial nerve passes through the cavernous sinus (separated only by endothelial lining), so is involved first in CST.
Cavernous sinus thrombosis
Orbital cell ulitis
Acute Ethmoidal sinusitis
Orbital apex syndrome