Cavernous sinus thrombosis physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Physical Examination

Physical examination of patients with cavernous sinus thrombosis is usually remarkable for high fever, altered mental status, unilateral or bilateral exophthalmos, periorbital edema (initially unilateral but typically bilateral), lid erythema, chemosis, ptosis, proptosis (due to impaired venous drainage of orbit), restricted or painful eye movement, and less commonly papilledema, retinal hemorrhages, decreased visual acuity, photophobia, diminished pupillary reflex, and pulsating conjunctiva.

Appearance of the Patient

• Patients with cavernous sinus thrombosis usually appear very ill and toxic.

Vital Signs

• High-grade fever
• Tachycardia with regular pulse
• Tachypnea
• Low blood pressure with normal pulse pressure

Skin

• Cyanosis
• Jaundice
• Pallor
• Bruises

HEENT

• Periorbital edema (initially unilateral but typically bilateral)
• Unilateral or bilateral exophthalmos
• Extra-ocular movements may be abnormal from third, fourth and sixth cranial neuropathy
  • Sixth cranial neuropathy is the most common neuropathy (resulting in partial ophthalmoplegia with limited eye abduction).
• Pupils non-reactive to neither light nor accommodation (from paralysis of the iris and ciliary body)
• Lid erythema
• Horner syndrome (ptosis, miosis, and anhidrosis)
• Chemosis
• Ptosis
• Proptosis (due to impaired venous drainage of orbit)
• Painful eye movement
• Papilledema
• Retinal hemorrhages
• Decreased visual acuity
• Photophobia
• Pulsating conjunctiva
• Facial tenderness
• Impaired corneal reflex.
• Blindness

Neck

• Stiff neck may be present.

Lungs

• Pulmonary examination of patients with cavernous sinus thrombosis is usually normal.

Heart

• Cardiovascular examination of patients with cavernous sinus thrombosis is usually normal.

Abdomen

• Abdominal examination of patients with cavernous sinus thrombosis is usually normal.

Back

• Back examination of patients with cavernous sinus thrombosis is usually normal.

Genitourinary

• Genitourinary examination of patients with cavernous sinus thrombosis is usually normal.

Neuromuscular

• Altered mental status
• Extra-ocular movements may be abnormal from third, fourth and sixth cranial neuropathy
  • Sixth cranial neuropathy is the most common neuropathy (resulting in partial ophthalmoplegia with limited eye abduction).
• Photophobia
• Horner syndrome (ptosis, miosis, and anhidrosis)
• Hyperreflexia
• Generalised weakness
• Abnormal gait
• Decreased visual acuity
• Downgoing plantar reflex
• Ptosis
• Hemiparesis

Extremities

• Extremities examination of patients with cavernous sinus thrombosis is usually normal.