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Last reviewed: 19 Sep 2025
Last updated: 09 Sep 2025

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • rapid onset of signs and symptoms (acute septic cavernous sinus thrombosis)
  • headache
  • fever
  • peri-orbital oedema
  • chemosis and proptosis
  • lateral gaze palsy
  • ophthalmoplegia
  • profound sepsis (acute septic cavernous sinus thrombosis [CST])

Other diagnostic factors

  • ptosis and mydriasis
  • papilloedema and/or retinal-vein dilatation
  • decreased corneal reflex
  • hypo- or hyper-aesthesia in the distribution of the ophthalmic and maxillary nerves
  • mental state changes (e.g., confusion, drowsiness, coma)
  • clinically detectable primary infection site
  • meningismus (nuchal rigidity, photophobia, and headache)
  • positive Kernig's or Brudzinski's signs
  • seizures
  • loss of visual acuity

Risk factors

  • recent history of acute sinusitis
  • history of facial infections
  • history of peri-orbital infection
  • history of otitis media, mastoiditis, or petrositis
  • history of dental or oral infection
  • history of sepsis
  • immunosuppression
  • genetic prothrombotic condition
  • acquired and other prothrombotic states
  • history of head and neck trauma
  • use of oral contraceptives
  • pregnant or postpartum
  • history of malignancy
  • history of recent head or neck surgery
  • vascular abnormalities
  • ulcerative colitis
  • volume depletion
  • heroin overdose

Diagnostic investigations

1st investigations to order

  • FBC
  • contrast-enhanced high-resolution CT of head
  • contrast-enhanced MRI of head
  • blood culture
  • microscopy and culture of suppurative fluid or tissue from primary infective source
  • antiphospholid and anticardiolipin antibodies
  • protein S and protein C
  • antithrombin III
  • factor V Leiden
  • haemoglobin electrophoresis
  • D-dimer level

Investigations to consider

  • lumbar puncture with cerebrospinal fluid analysis

Treatment algorithm

Contributors

Authors

Jayant Pinto, MD

Associate Professor of Surgery

Section of Otolaryngology-Head and Neck Surgery

University of Chicago

IL

Disclosures

JMP has received funds from Regeneron, Sanofi, and Optinose for speaker's bureau and advisory boards. He served as a site investigator for Regeneron, Sanofi, and Upstream Bio.

Mohamad R. Chaaban, MD, MSCR, MBA

Associate Professor

Cleveland Clinic

Lerner College of Medicine at Case Western Reserve University

Cleveland

OH

Disclosures

MRC has no competing interests.

Peer reviewers

David Rowed, MD

Division of Neurosurgery

University of Toronto

Toronto

Ontario

Canada

Disclosures

DR declares that he has no competing interests.

Louis R. Caplan, MD

Lecturer in Neurology

Hospital Chief

Cerebrovascular/Stroke Division

Beth Israel Deaconess Medical Center

Division of Cerebrovascular/Stroke

Boston

MA

Disclosures

LRC declares that he has no competing interests.

Sorabh Khandelwal, MD

Clinical Associate Professor of Emergency Medicine

Ohio State University

Columbus

OH

Disclosures

SK declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Ebright JR, Pace MT, Niazi AF. Septic thrombosis of the cavernous sinuses. Arch Intern Med. 2001 Dec 10-24;161(22):2671-6.Full text  Abstract

Caranfa JT, Yoon MK. Septic cavernous sinus thrombosis: a review. Surv Ophthalmol. 2021 Nov-Dec;66(6):1021-30. Abstract

Bhatia K, Jones NS. Septic cavernous sinus thrombosis secondary to sinusitis: are anticoagulants indicated? A review of the literature. J Laryngol Otol. 2002 Sep;116(9):667-76. Abstract

American College of Radiology. ACR appropriateness criteria: headache. 2022 [internet publication].Full text

American College of Radiology. ACR appropriateness criteria: orbits, vision, and visual loss. 2017 [internet publication].Full text

Reference articles

A full list of sources referenced in this topic is available here.

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