IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)

e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 17, Issue 7 Ver. 11 (July. 2018), PP 44-47
www.iosrjournals.org

Cavernous sinus thrombosis caused by Wisdom tooth extraction:

a case report.
DrKanishkaNavin Guru1, Dr. Rashmi Guru2, DrKapil Malviya3,
Dr. Pramod Sharma4,Dr Ajay Pillai5,DrShreshth Sharma6.
1
Associate Professor, Dept. of Dentistry, Chirayu Medical College & Hospital
2
Consultant ophthalmologist, Guru’s Eye and Dental Surgical Centre
3
Consultant dental surgeon, Dr. Guru’s Eye & Dental Surgical Center
4
Professor & Head ,Department of Dentistry, Chirayu Medical College & Hospital
5
Professor & Head ,Department of Oral and Maxillo-Facial Surgery,PDA
6
Post graduate resident. Department of Oral and Maxillo-facial Surgery,PDA
Corresponding Author: DrKanishkaNavin Guru

Abstract: Cavernous sinus thrombosis (CST) secondary related to maxillofacial infection is a rare clinical
squeale.The CST is a rare disease which is reported to how high rate of morbidity and mortality.Cavernous
sinus thrombosis not only presents with symptoms of infections which includes fever, pain and swelling but
also with specific findings such as proptosis, chemosis, periorbital swelling, and cranial nerve palsies. The
prompt diagnosis and timelytreatment of CST is very important for successful outcome. The infectionin
maxillofacial region shouldbe given due attention, as to prevent CST. In this case report, we highlighted the role
of Odontogenic abscess leads to CST, facial palsy, and loss of vision. The Odontogenic infection should never
be neglectedas in rare instances it may cause serious intracranial complication like CST.
Key words: Cavernous sinus thrombosis, Cavernous sinus, Sepsis, Dental focal infection
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Date of Submission: 10-07-2018 Date of acceptance: 27-07-2018
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I. Introduction
The Cavernous sinus is bilaterally symmetrical sinus located laterally to sellaturcica of the sphenoid
bone. Many important anatomical structures are related to cavernous sinus such as internal carotid artery,
trigeminal ganglion, occulomotor nerve, ophthalmic nerve and abducent nerve 1.
It’s an important sinus for drainage of the brain and communicates with facial veins via angular and
ophthalmic veins.1 As the veins of maxillofacial region and cerebral veins don’t have valves, hence any
odontogenic or non odontogenic infection in the maxillofacial region can essence to the cavernous sinus.
Cavernous sinus thrombosis was first described by Bright al in 1831. If not treated in the early stage
cavernous sinus thrombosis can potentially be fatal. 2,3 As cavernous sinus thrombosis is fatal disease and if not
aggressively managed, the mortality rate of cavernous sinus thrombosis is less than 30%. As per the literature
review, many pathological conditions like sinusitis, orbital cellulites, para pharyngeal abscess are the main
causes of cavernous sinus thrombosis. Odontogenic cause of cavernous sinus thrombosis has been reported low3
in the literature. In this article, we present an unusual and rare case of cavernous sinus thrombosis after surgical
disimpaction of the maxillary third molar3.

Clinical Case
21 year old male, reported with chief complaint of swelling and pain over left side of face, orbit and
submandibular region. (Fig.1)

Figure 1 : Facial palsy

DOI: 10.9790/0853-1707114447 www.iosrjournals.org 44 | Page
 Cavernous sinus thrombosis caused by Wisdom tooth extraction: a case report.

Circum orbital edema was to a extend that the patient was not even able to open the left eye. Patient gives
history of surgically extracted left impacted maxillary third molar in a local clinic one week ago. Preoperative
OPG was available with the patient which was showing left impacted maxillary third molar.(Fig 2)

Figure 2 : showing impacted left maxillary third molar

On clinical examination the swelling was hard, generalized in the left check region and was febrile.On intraoral
examination purulent discharge was present from the surgical socket and mucosal necrosis was present at the
posterior region of hard palatal .(Fig. 3)with foul smell.

Figure 3 : palatal necrosis

As per our surgical center protocol we have taken a sample of pus discharge for culture and antibiotic
sensitivity and sample was immediately sent. Post-operative OPG was taken where we noticed that the impacted
maxillary third molar was indeed surgically removed(Fig 4).

Figure 4 :Post-operative OPG

Empirical antibiotics, analgesics, antipyretic medications and i.v fluids were started and a reference
was made to the ophthalmologist for opinion.Ophthalmologist inspected the patientand vision was found to be
6/6, chemosis,proptosis,with unilateral periorbital edema and ophthalmoplegia was present. Later on the patient
presented with left sidedfacial palsy. Ophthalmologist reviewed the patient and she noted that the patient

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 Cavernous sinus thrombosis caused by Wisdom tooth extraction: a case report.

developed diplopia, IOP was raised and vision was decreased as 4/6 in left eye. (Fig 5).Soon we concluded that
patient developed secondary complication as CST.A call was made to neurologist who took a CT SCAN
showing elevated Intra-cranial pressure and upon co related with other symptoms,he confirmedthat patient has
developed CST.Awaited culture and antibiotic sensitivity report reveals presence ofPseudomonas Klebsiella.
RoutineBlood lab findings revealed the following results: CBC, Total leukocyte count: 20,000/mm3,
Differential Leukocyte Count P80L18E1M1, ESR:46 mm/h and Complete Metabolic Panel with serum sodium
136 meq/l, serum potassium 3.4 meq/l, BUN20 mg/dl, serum creatinine 1.6 mg/dl,andrandom blood glucose 106
mg/dl. This report parameterreveals that patient going into septic shock.

Figure 5 Figure 6
Figure 5 Diplopia, Dilated pupil, proptosis, periorbital ecchymosis, and diplopia of the left eye.
Figure 6: CT SCAN showing elevated Intra-cranial pressure

As the disease was diagnosed, the patient was immediately taken up for debridement and curettage of
the infected socket under general anesthesia. Postoperatively patient was admitted under intensive care unit
under the the emergency medicine department. Unfortunately, latter on the patient died due to complications of
the disease, which included meningitis, sepsis, and shock.

II. Discussion
Septic cavernous sinus thrombosis can be defined as thrombophlebitis involving the cavernous sinus
which is secondary to Odontogenic and non Odontogenic infection origin. 4The primary source of infection can
be odontogenic or non odontogenic origin in the maxillofacial region. It has been reported that to the average of
7% of cavernous sinus thrombosis is of Odontogenic origin 1, as there is direct communication with facial veins
and pterygoid plexus of vein to the cavernous sinus. As these veins don’t have any valves, hence any infection
in the maxilla facial region can easily ascends towards the cavernous sinuous. Hence the Dentist or maxillofacial
surgeon or any surgeons operating in the maxillofacial region should be very careful, not to cause any trauma
during the procedure in maxilla or giving posterior superior alveolar nerve block. 1Any use of contaminated
needle or any instrument can cause secondary infection in this region. The surgeons must use extreme care to
manage a open wound of road traffic accident in this region. In our study the primary source of infection was
surgical removal of left impacted maxillary third molar.1The patient develops swelling following second day of
the extraction. The signs of cavernous sinus thrombosis usually is a result of congestion in venous drainage and
usually the mode of onset is acute, proptosis, headache and unilateral periorbitaledema. All signs of
inflammation can also be noticed in this disease. The diagnosis of cavernous sinus thrombosis is usually done on
clinical symptoms, pus culture and radio graphical investigations. Compared to CT scan, MRI and MR
venography are more sensitive for proper diagnosis of Cavernous sinus thrombosis.4 Usually the patient with
cavernous sinus thrombosis, have leucocytosis and in this present case leukocyte count: 20,000 cub/mm3. As
soon as we achieve diagnosis, under empirical antibiotics coverage, surgery to remove primary source of
infection should be initiated.
To conclude, after the breakthrough of antibiotics and imaging techniques still the mortality rate of
cavernous sinus thrombosis remains high and when prompt management is not initiated can lead severe life
threatening complications.

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 Cavernous sinus thrombosis caused by Wisdom tooth extraction: a case report.

As soon as the disease is diagnosed the primary step of management is to immediately initiate aerobic
and anaerobic antibiotics and to identify the primary source of infection. Surgery should immediately be
performed to remove the primary source of infection.

Take home message:

1. Cavernous sinus thrombosis is a rare disease.
2. The morbidity and mortality rate remains high.
3. Unethical practices or not following proper principles of sterilisation and wound management by
practitioners and a lack of awareness of dental health in rural areas can lead to severe life threatening.
4. Empirical antibiotictherapy and emergency surgical management must be considered as soon as the disease
is diagnosed.

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DrKanishkaNavin Guru " Cavernous sinus thrombosis caused by Wisdom tooth extraction: a
case report. "IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), vol. 17, no. 7,
2018, pp 44-47.

DOI: 10.9790/0853-1707114447 www.iosrjournals.org 47 | Page