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 \' VA^>3Lua . ^" ' to' 
 
 THROMBOSIS OF CAVERNOUS SINUSES FROM SUP- 
 PURATION IN NASAL CAVITIES. 
 
 uy 
 F. (r. FIN LEV, M.I). 
 
 Assistant Professor of Mt'dicine find Associate Professor of Clinical Medicine' 
 McGill University ; Attending Physician, Montreal General Hospital. 
 
 (lieprinlfd from the Montreal Medical Journal, l^otemher, 1808.) 
 
 ■'■^.. 
 
 1 MEDICAL FACULry, 
 
 ^.<-'- 
 
 ^Vx,;.-,Brv5.- 
 
THROMBOSIS OF CAVERNOUS SINUSES FROM 
 SUPPURATION IN NASAL CAVITIES.' 
 
 BV 
 
 F. G. FiNLKY, M.D., 
 
 Assistant Professor of Medicine, and Associate Professor of Clinical Medicine. 
 
 McGill University ; Attending Physician, Montreal General Hospital. 
 
 The patient, a girl of 15, was admitteJ to oho Montreal General 
 Hospital on October 1st, 189S, complainincr of headache and weakness 
 
 Two years previously she was laid up for two weeks with rheuma- 
 tism in the ankle. Enquiry revealed that there had been a purulent 
 discharge from tlu^ nose some weeks previously, l)ut there had been 
 no aural affection. 
 
 About two weeks previous to admission, the patient began to suffer 
 from headache. She kept at her work for a week, when she took 
 to bed with .severe headache, weaknjss, and, during tlie ensuing days, 
 diarrhoea. 
 
 State on admisnon. — She is a moderately nourished girl, inclined 
 to be emotional and cries readily. There is intense headache and on 
 moving she holds her hands to her head. The skin is hot and dry 
 the temperature 101|° on admission. The pupils are moderately 
 dilated and equal. The teeth are irregular, the month open, and the 
 palate much arched, conditions suggesting adenoids. The tongue is 
 moderately coated. The abdomen gives gurgling in the right iliac 
 and left lumbar region, but there is no tenderness, no splenic tumour 
 or rose spots. The heart and lungs are normal, the pulse 120 small 
 and compressible. 
 
 Oct. 2. The temperature has varied from 102 ° to 105''. In the 
 afternoon the ho;',se physician. Dr. Schwartz, noticed that the left eye 
 was somewhat swollen. 
 
 Oct. 3. There is marked cedema of both upper and lower lids, more 
 marked on the right side, with distinct proptosis of both eyes. The 
 temperature continues high, and a rigor took place this afternoon, the 
 temperature rising to lOG^. 
 
 Oct. 4. Proptosis increased in both eyes since yesterday. Eyelids are 
 closed, and on the left side they bulge forward to the level of the fore- 
 head, and rather beyond it on the right. The conjunctiva of the right 
 is markedly swollen and (jedematous, projecting forward through the 
 
 ' Read before the Montreal Medico-Chirurgical Society, November 7th, 1898^ 
 
closed lids. On the left side there is sli<^ht (udenia of the conjunctiva 
 with a sub-conjunctival liseniorrhage. The eyeballs are immobile, the 
 left pupil dilated as befon, the riit;ht pupil not seen, owing to swell- 
 ing and inability to open the eyelids. The left optic disc is slightly 
 swollen, its edges blurred and the veins are full. Slight (edema of the 
 forehead between the eyes is present. There is slight fulness of the 
 side of the neck. Imt no tenderness of the mastoid, and the middle 
 ears are normal. A second rigor occurred during the previous night. 
 
 Oct. 5. A third rigor occurred this morning. (Edema over the right 
 tetnple and right side of face. 
 
 Oct. G. Occasional delirium occurred during the night. Swelling 
 of the I'ight side of the face and neck is well marked, and there are 
 red lines on the forehead along the course of tlie veins (purulent 
 phlebitis). Before death the temperature rose to 108". 
 
 Anatomical d'uifino-iis. — Septic thrombo-phlebitis of cavernous 
 sinus; suppuration and necrosis of ethmoidal cells, orbits and scalp; 
 acute purulent meningitis ; old sni)pui!ition in left antrum ; small 
 infarct of spleen ; cloudy swelling ami fatty degeneration of all organs. 
 
 Body of a slightly built young girl, with ^moderate rigoi-. Marked 
 buh'inc of ritdit oi-bit. Veins of forehead above root of nose are 
 prominent and have a varicose appearance. 
 
 On j-emoval of scalp, small pockets of dirty grayish pus are found 
 aliout tht^ right orl»it and in the centre of the forehead ; another 
 i)ocket just behind riglit ear. Kacli of these contains- about a thimble- 
 ful of trreenish fetid pus, which on examination shows <liplococci and 
 a few short l»acilli. 
 
 Skull cap thin, diplococci scanty ; no signs of suppuration about 
 bone or periosteum. Longitudinal sinus free, 'i'lie pia on convexity 
 is a little aujeniatous, but not opaque. 
 
 Vessels moderately injected. No lymph. 
 
 In the left frontal and orbital regions there is a layer of lympho- 
 pus extending from the Sylvian fissure to the anterior extremity of 
 lobe, the pia being niucli matted. Small ha^morrhagic areas are 
 seen in the cortex beneath. Another pocket of lympho-pus, size of 
 thumb nail, lies on left side of the pons, the adjoining vein being 
 plucrged with firm thromVa. Sylvian arteries free. Right Sylvian 
 fissure free from intiannnation. At the l)ase of cerebellum is a collec- 
 tion of pus beneath the arachnoid and covering the middle lobe. 
 Ventricles appear free, but on section at level of island of Reil some 
 ])urulent infiltration is seen to extend along the deeper convolutions- 
 Medulla intact. (}rayish-red soft clots seen in lateral sinus, non- 
 adherent, but speckled with whitish points. Tn the sella tur.sica, to 
 the right of the pituitary body, is an area of puruilent ntiltration, 
 
extending in the direction of the cavernous sinus, which ia plugged. 
 A similar condition exists on left side, hut this is less umrked. No 
 signs 6f old suppuration in frontal sinus. The ethmoid sinus is full 
 of pus and the bones on each side are necrosed. The necrosis also 
 involves the sphenoid winj^s and the occipital naso-pharynx shows 
 thickening and granulation of mucosa. No adenoids. Turbinated 
 bones show very little change. Left antrum full of pus and a gelatin- 
 ous looking pulp with some caseous master. Tis.sue of both orbits 
 shows purulent infiltration around po.steriof half of the globe. The 
 right optic nerve is considerably swollen near ♦^lie point of entrance 
 into eyeball. 
 
 Gums and teeth show nothing abnormal. 
 
 Heart muscle somewhat pale and opaque. Pericardium h oz. clear 
 light-coloured fluid. Valves and coronary ves.sels healthy. Lungs 
 healthy »ind crepitant thi'oughout. Colour pale gray. Liver some- 
 what enlarged, fatty and nutmeg. Inte.stines and stomach healthy. 
 Cystic ducts patent. Spleen pale, soft and small infarct about the 
 size of a split pea on surface. Pancreas normal. Kidney .soft, flabby 
 and pale. ('apsule peels readily, surface smooth. VenfB stellatie 
 prominent. Cortex pale, almost yellowish and swollen Medulla and 
 pelvis look healthy. Suprarenals healthy. Pelvic organs healthy, 
 except for slight cystic condition of ovaries. 
 
 When first admitted the graflual onset of the illness with diai-rhnea 
 and headache suggested typhoid ; the headache was, 1 owever, much 
 more severe than is usually .seen in this disease, and the positive evi- 
 dences of typhoid, rose spots and Widal's tests, were absent. 
 
 The appearance of proptosis and redema of the lids appearing first 
 on the left, and a few hours later on the right, led to a diagnosis of 
 thrombosis of the cavernous sinuses, beginning on the left side and 
 spreading to the right through the circular sinus, and that its origin 
 was septic, was indicated b^' the rigors and high temperature. 
 
 The origin of the disease was somewhat obscure. The history of 
 nasal discharge suggested some purulent condition in the nasal fossa, 
 although nothing was observed in the anterior nares to confirm such 
 a view. 
 
 This case bears a close resemblance^ to thrombosis of the lateral 
 .sinuses, from middle ear disease. 
 
 The autopsy showed that the infection had spread from the sphe- 
 noidal and ethmoidal sinu.ses, which were filled with pus, and the 
 analogy is still fui"ther borne out by the purulent meningitis at the 
 base of the brain. 
 
 The symptoms are very striking — the great cedema of the lids, and 
 
the proptosia of Inith eyes could only result from this cause. Whilst 
 paralysis of the ocular muscles is usually present in such cases it 
 seemed uupossihle to me to state whether th.,' immol)ility of the eyes 
 was due to this cause or to fixation of the protruded eyehalls by 
 .swelhn^r at the hack of tiic orbits. 
 
 Th..' u'dema of th.- fac, which is absent in pure ca.ses of sinus 
 thrombosis, i.s .sati.sfactorily explained by the purulent phlebitis of the 
 veins of the face. 
 
 MacEwan, in his work on Pyogenic Infective Diseases of the Brain 
 relates the history of five cases of thrombosis of the cavernous sinuses 
 one of wliich was due to infecti.)n from an old .standing syphilitic 
 oztema. " ^ 
 
 Coupland (Trans, of Ophth. Soc, Vol. IH., 1887) in reporting a ca.se 
 ot cavernous sinus thrombosis, has tdded twenty-eicrht others Of 
 these only one ha«i a distinctly nasal origin, being due to oziena' pro- 
 bably of syphilitic origin. Pus was fo.und in the sphenoidal sinuses 
 
 It would thus .seem that suppuration in the no.se is a rather rare 
 cause ot cavernous sinus thrombosis. The origin is much commoner in 
 suppuration of the middle ear, with thrombosis of the cavernous sinus 
 extending forward. It is occasionally due to suppuration extending, 
 from the orbit and from necrosis about the pharynx in scarlatina and 
 diphtheria.