ʻO Septic Cavernous Sinus Thrombosis: "Ka Triangle Pōʻino o ka Maka" ʻO nā paila, Sphenoid/Ethmoid Sinusitis, Early Sixth-Nerve Palsy, a me Bilateral Proptosis¶

Septic cavernous sinus thrombosis (CST) he pōʻino neurovascular pōʻino e hoʻoweliweli ana i ke ola kahi e puka ai ke koko koko i maʻi ʻia (septic thrombus) i loko o ka cavernous sinuses, he mau keʻena venous trabeculated, piha i ke koko e noho pololei ana ma ke kumu o ka lolo ma kēlā ʻaoʻao kēia ʻaoʻao o ka pituitary gland (sella turcica) a me ka sinus sphenoid. No ka mea, o ka facial vein (angular vein) a ʻo nā ʻaʻa ophthalmic kiʻekiʻe a haʻahaʻa** e kahe ana i waena o ka maka o ke kanaka a me nā kumu o ka maka he 100 pākēneka valveless (loaʻa ʻole nā ʻaʻa venous ala hoʻokahi), bacteria mai kahi ʻōpala i ʻoki ʻia a i ʻole pimple i loko o ka "Danger Triangle of the Face"** (mai nā kihi o ka waha a hiki i ke alahaka ʻole o ka waha a hiki i ke alahaka ʻaʻole o ka sinus? ʻO ka maʻi**, ka cellulitis orbital, a i ʻole ka ** ʻōpū niho mua o luna** hiki ke kahe i hope (retrograde) pololei i ka iwi poʻo. Inā loaʻa i kekahi kanaka i loaʻa i ka maʻi sinus hou, ka ʻūhā ihu, a i ʻole ka cellulitis o ka maka, ua ulu ʻo ** i ke poʻo nui ma hope o nā maka, ke kuni nui, ka pehu a i ʻole ka huʻi ʻana o ka maka (proptosis), hiki ole ke hoohuli i ka maka iwaho i ka pepeiao (sixth cranial nerve palsy ka ʻike makalua), hāʻule ka lihilihi (ptosis), a i ʻole ka pehu o ka maka e lele ana mai kekahi maka a i ʻelua mau maka i loko o 24 a 48 hola**, e kelepona i kou wahi. helu pilikia (911 ma ʻAmelika Hui Pū ʻIa a me Kanada, 112 ma waena o ka European Union, 999 ma United Kingdom, a i ʻole 000 ma Australia) koke. ʻOiai e kali ana i ka lawe ʻana i ka haukapila, e nānā i kā mākou hoa alakaʻi ma nā maʻi orbital cellulitis a me nā maʻi triangle pilikia maka, ʻO ka mastoiditis coalescent a me ka thrombosis sinus sigmoid, a maningitis a me ka maningococcal septicemia triage.

No ke aha i ʻike kūʻokoʻa ʻia ai ka septic cavernous sinus thrombosis ma ka ʻaoʻao moe inā ʻike ʻoe i ka mea e hoʻāʻo ai? No ka mea, ʻaʻole like me nā hale ʻē aʻe i loko o ke kino o ke kanaka, he ʻaʻa ko ka cavernous sinus (the internal carotid artery) a me ke aʻalolo cranial (Cranial Nerve VI, the abducens nerve) e holo pololei ana ma waena o kona kahe koko venous, aʻo ʻehā mau aʻalolo cranial ʻē aʻe (CN III, CN IV, CN \(\text{V}_1\), a me CN \(\text{V}_2\)) e holo ana i loko o kona paia ʻaoʻao waho. Eia kekahi, ua hoʻopili ʻia nā sinuses cavernous hema a me ka ʻākau ma waena o ka laina waena e intercavernous venous sinuses. No laila, hoʻopuka ka CST septic i kahi inoa maʻamau ** ʻelua-step clinical signature **: 1. Ka mua (Early Hours): Isolated Ipsilateral Lateral Gaze Palsy (Cranial Nerve VI Palsy: hiki ʻole ke hoʻohuli i ka maka i hoʻopilikia ʻia i waho i ka luakini) hele pū ʻia me ke poʻo orbital retro-orbital hohonu a me ka helu ʻana o ka lae/corneal (CN V1). 2. Ka lua (Within 24 to 48 Hours: Hōʻailona Pathognomonic): Laha ʻia ka pehu ʻana o ka lihilihi maka, ka baluna conjunctival (chemosis), maka puʻu (proptosis), a me ka neʻe ʻana o ka maka hau (ophthalmoplegia) i ka KUE (contralateral) maka, e hoʻololi ana i ka pilikia maka ʻaoʻao hoʻokahi i ka pōʻino bilateral.

E hana i kēia i kēia manawa¶

1. ** Hana i ka 30-Second "Horizontal Finger-Tracking Eye Test" (Testing Cranial Nerve VI) a me ka "Both-Eyes Symmetry Check".
2. Hae Ula mua (CN VI Abducens Palsy): ʻAʻole huli ka maka hoʻokahi i waho i ka pepeiao (abduction deficit), e ike ana ka mea ma'i i na kii aoao elua (horizontal diplopia) ke nana aku i kela aoao?
3. Hae ʻulaʻula kiʻekiʻe (CN III & IV + Bilateral Spread): Ke hāʻule nei ka lihilihi maka (ptosis), ʻo ka haʻahaʻa a lohi, ua maloʻo ka maka ma waena o ke kūlana (ophthalmoplegia waho piha), a i ʻole ua hoʻomaka ka ʻike ʻia ʻana o ka pehu/ʻulaʻula ma ka **lua (ma ke alo) **?
4. Kahea 911 / 112 / 999 inā loaʻa koke ʻia kekahi maʻi pala, sinusitis, a ʻulaʻula o ka lihilihi paha me ANY Cavernous Sinus a i ʻole Orbital Red Flag:
5. ** ʻIke pālua (diplopia), ʻeha a kaohi ʻia ka neʻe ʻana o ka maka, a i ʻole ka lihilihi hāʻule.**
6. Proptosis (poʻe maka ʻōpuʻu) a i ʻole chemosis (ka pehu translucent e like me ka jelly o ka conjunctiva keʻokeʻo e paʻi ana ma luna o ka lihilihi lalo).
7. Holo ka ʻike maka, ʻike pohihihi, a i ʻole ka nalowale o ka saturation kala ʻulaʻula (afferent pupillary defect).
8. ** ʻO ka ʻeha, ʻeha, a ʻeha paha ma ka lae, ka lihilihi luna, ka ihu, a i ʻole ka papalina luna** (Cranial Nerve V1 / V2 trigeminal sensory deficit).
9. ** ʻO ke poʻo poʻo retro-orbital a mua paha, ʻāʻī ʻoʻoleʻa, photophobia, huikau, lethargy, a i ʻole nā ​​maʻi "picket-fence" kiʻekiʻe (39.5°C+ / 103°F+) me ka haalulu (rigors)**
10. AOLE e komi, pop, ihe, a i ole e hana i ka pimple, furuncle (boil), a i ole i ka lauoho ihu i ulu i loko o ka "Danger Triangle of the Face."glabella) iho i nā kihi hema a me ka ʻākau o ka lehelehe luna (oral commissures), me ka nasal vestibule (i loko o nā puka ihu) a me ka philtrum. Ke kaomi ʻana i kahi maʻi Staphylococcus aureus paila i loko o kēia wahi e hoʻoneʻe ʻia i ka maʻi bacteria a me ka micro-thrombi maʻi i hope ma o nā ʻaʻa ophthalmic ʻaʻohe valve a me nā aʻa ophthalmic pololei i ka sinus cavernous.
11. Inā he maʻi ʻeha a i ʻole ka maʻi ihu ihu (nasal furunculosis) aia i loko o ka Triangle Danger me ka ʻole o nā hōʻailona neurological: e hoʻopili i kahi puʻu wai maʻemaʻe mehana me ka mālie no 15 minutes 3 to 4 times daily me ke kaomi ʻole a ʻomi ʻole, holoi lima me ke kopa, a ʻike koke i ke kauka no ** topical Intranasal Mupirocin (2%) ʻaila** a me nā lāʻau anti-staphylococcal waha (cephalexin, dicloxacillin, doxycycline, or TMP-SMX).
12. E mālama pono i ka mea maʻi e hele ana i ke Keʻena Emergency Hospital NPO (ʻaʻohe mea ma ka waha: ʻaʻohe meaʻai, ʻaʻohe wai). ʻO nā poʻe maʻi me ka septic cavernous sinus thrombosis ma muli o ka acute sphenoid/thmoid sinusitis, abscess dental, a i ʻole orbital subperiosteal abscess e koi pinepine i emergent endoscopic sphenoidotomy / ethmoidectomy surgical drainage ma lalo o ka anesthesia whānui i loko o nā hola o ka hiki ʻana mai.
13. E hoʻokiʻekiʻe i ke poʻo o ka moena a i ʻole ke kau ʻana i 30 to 45 degrees i ka wā o ka lawe ʻana e hōʻemi i ka hoʻopaʻa ʻana o ka ʻāʻī intracranial a me ka intra-orbital venous oiai e mālama ana i ka ʻāʻī i kahi kū ʻole, ʻaʻohe kūlana ʻole no laila ʻaʻole keakea ʻia ke kahe ʻana o ka venous jugular kūloko.

Ka lāʻau hoʻoholo: Ke hoʻāʻo ʻana i ka maka i nā maʻi Triangle Triangle, sinusitis, a me ka pehu ʻana o ka maka¶

flowchart TD
    Trigger["ʻO ka maʻi me ka Midface/Nasal Pimple or Boil ('Danger Triangle'), Acute Ethmoid/Sphenoid Sinusitis, Eyelid Cellulitis, a i ʻole ka maʻi niho luna."] --> NeuroCheck{"KaʻAnuʻu Hana 1: Kiʻi no ka Cavernous Sinus & Orbital Ula Hae: Kāohi ʻia/Eha ʻEha Neʻe (ʻOiaʻiʻo Outward Gaze CN VI), ʻIke Palua, ʻAi Pua (Proptosis), Lae/Palina Numbness (CN V1/V2), Severe Retro-Orbital Headache, High Fever, a i ʻole Pehu ma nā maka ʻelua?"}

    NeuroCheck -->|"ʻAe i kēlā me kēia Hae ʻulaʻula (Maikaʻi loa i nā hōʻailona maka bilateral a i ʻole Cranial Nerve Palsy)"| CSTCode["KAHIKI ʻia ʻo SEPTIC CAVERNOUS SINUS THROMBOSIS (OR ORBITAL APEX SYNDROME): E kelepona iā 911 / 112 / 999 koke -> E hoʻokiʻekiʻe i ke poʻo 30-45 Degere -> NPO koʻikoʻi no ka ʻoki ʻana."]

    NeuroCheck -->|"ʻAʻohe Cranial Nerve Palsy a i ʻole Bilateral Spread, aka, he ʻulaʻula ka pehu o ka maka o kekahi maka."| CheckOrbital{"KaʻAnuʻu Hana 2: E hoʻokaʻawale i ka Post-Septal (Orbital) Cellulitis vs. Pre-Septal (Periorbital) Cellulitis: Aia He ʻeha ma ka Neʻe ʻana o ka Maka, Proptosis, Chemosis, a i ʻole ʻIke Hoʻemi?"}

    CheckOrbital -->|"ʻAe: ʻeha me ka neʻe ʻana o ka maka, proptosis, a i ʻole ka hoʻololi ʻike"| OrbitalCell["POST-SEPTAL (ORBITAL) CELLULITIS (Hoʻomaka koke i ka Cavernous Sinus Thrombosis): E hele koke i ka 'Oihana Hoʻopiʻi Haukapila no IV Antibiotic & Contrast Orbit / Sinus CT"]

    CheckOrbital -->|"ʻAʻole: ʻO ka ʻulaʻula o ka lihilihi maka wale nō; ʻO ka ʻeha ʻole o ka maka piha, ʻike maʻamau, ʻaʻohe kuni/ ʻeha poʻo"| PreSeptal["Pre-Septal (Periorbital) Cellulitis a i ʻole Localized Facial Furuncle: E ʻimi i ka lāʻau lapaʻau o ka lā hoʻokahi no nā lāʻau Antibiotic Oral/IV; AOLE E Komi ka paila; E nānā hou i nā neʻe ʻana o ka maka i kēlā me kēia 4 hola"]

    CSTCode --> HospitalCST["ʻO ka Haukapila Neurovascular & ENT Bundle: 1. Nā Moʻomeheu Koko + STAT Meningeal-Dose IV Vancomycin + IV Ceftriaxone/Cefepime + IV Metronidazole, 2. ʻO ka MRI Brain Hoʻonui Kūʻokoʻa me MR Venography (MRV) + Thin-Slice Contrast CT o Orbits / Sinuses. (Ke wehe ʻia ka Hemorrhage), 4. Emergent Endoscopic Sphenoid/Ethmoid Sinus a i ʻole Abscess Drainage"]

Mahele 1: Anatomy o ka "Tia Triangle" a me ka Hoʻolālā Kūloko o ka Cavernous Sinus¶

ʻO ka hoʻomaopopo ʻana i ʻelua kiʻi anatomical, (1) ʻo ka valveless venous highway mai ka ihu a hiki i ke kumu iwipoʻo a me (2) ka cross-sectional map o nā aʻalolo cranial i loko o ka cavernous sinus, e wehewehe i kēlā me kēia hōʻailona e ulu ai ka mea maʻi.

1. Na Alanui Komo 3 Venous Iloko o ka Sinus Cavernous¶

No ke aha ka cavernous sinus ke ala waena o ka maka luna, ka maka, ka pepeiao, a me ka lolo? 1. Ala Mamua (Mai ka "Der Triangle of the Face" & Eye Socket): - E kaha i ka huinakolu mai na ** kihi o ka waha (labial commissures)** a hiki i ** alahaka o ka ihu (nasion/glabella)**. - Hoʻokaʻa ʻia ke koko venous mai ka lehelehe luna, philtrum, nasal tip, a me nasal vestibule i loko o ka facial vein -> angular vein (ma ka ʻaoʻao o loko o ka maka), e hoʻopili pololei ana me ka superior ophthalmic vein (SOV) a me ʻaʻa ophthalmic inferior (IOV). - No ka loaʻa ʻana o kēia mau aʻa i ka ʻaʻohe kīwī **, hoʻolaha pololei ka thrombophlebitis septic i hope ma o kmāwae orbital kiʻekiʻe i mua o ka sinus cavernous. 2. Medial PathwayMai ka Sphenoid and Ethmoid Sinuses: The #1 Modern Cuuse): - I kēia alāʻau antibiotic hou, ʻo acute sphenoid sinusitis me posterior ethmoid sinusitis helu no **over 50 to 60 percent** o na hihia thrombosis septic cavernousinus. - Hoʻopili pololei ʻia nā sinuses cavernous hema a me ka ʻākau ma luna o nā paia iwi ʻaoʻao lahilahi pepa o ka sphenoid sinus** (klzzh:0048). Hele pololei mai ka ma'i ma ka iwi lahilahi a ma o ka li'ili'i valveless diploic and emissary veins**. 3. **Nāla Haʻahaʻa & Ma hope (Mai nā niho luna a me ka iwi mastoid): - Nā ʻōpū niho o ka iwi ā luna (kzwxh:0049) hele i luna ma o ka pterygoid venous plexus ma o ka foramen ovale/lacerum i lalo o ka cavernous sinus, aʻo nā maʻi pepeiao/mastoid (petrous apicitis / Gradenigo syndrome) hele i mua ma ka superior and inferior petrosal sinuses.

2. Cross-Sectional Anatomy o ka Cavernous Sinus: No ke aha Cranial Nerve VI Hāʻule mua¶

========================================================================
       CORONAL CROSS-SECTION OF THE CAVERNOUS SINUS (SKULL BASE)
========================================================================

                 [ OPTIC CHIASM & PITUITARY GLAND ]
                                 ||
        +------------------------++------------------------+
        |  LATERAL WALL          ||                        |
        |  (Dura Mater):         ||                        |
        |                        ||                        |
        |  * [ CN III ]          ||                        |
        |    (Oculomotor)        ||    [ SPHENOID ]        |
        |  * [ CN IV ]           ||    [  SINUS   ]        |
        |    (Trochlear)         ||    (Separated by       |
        |                        ||     <0.5 mm bone)     |
        |         [ INTERNAL ]   ||                        |
        |         [ CAROTID  ]   ||                        |
        |         [ ARTERY   ]   ||                        |
        |              |         ||                        |
        |  * [ CN V1 ] v         ||                        |
        |    (Ophthalmic)  ===> [ CN VI (ABDUCENS) ]       |
        |  * [ CN V2 ]          (Runs FREE inside the      |
        |    (Maxillary)         center of the venous      |
        |                        blood pool -> HIT FIRST) |
        +--------------------------------------------------+
             ||                                      ||
             ++===[ INTERCAVERNOUS VENOUS SINUSES ]==++
             (Connects Left & Right Cavernous Sinuses ->
              Causes BILATERAL Eye Spread in 24 to 48 Hours)
========================================================================

E nānā pono i ke kiʻi anatomical ma luna. - Paʻa ʻia i loko o ka pā ma waho o waho o ka paia (mai luna a lalo) noho ʻehā mau aʻalolo: 1. ** ʻAʻalolo Cranial III (Oculomotor Nerve):** Hoʻokiʻekiʻe i ka lihilihi luna (levator palpebrae), kaohi i ka haumana (parasympathetic fibers), a hoʻoneʻe i ka maka i luna, lalo, a i loko. 2. ** ʻAʻalolo Cranial IV (Trochlear Nerve):** Hoʻoneʻe i ka maka i lalo a i loko (superior oblique muscle). 3. Puʻupuʻu Cranial \(\text{V}_1\) (Ophthalmic Division of Trigeminal Nerve): Hāʻawi i ka manaʻo i ka cornea, ka lihilihi luna, ka lae, a me ke alahaka o ka ihu. 4. ** ʻAʻalolo Cranial \(\text{V}_2\) (Maxillary Division of Trigeminal Nerve):** Hāʻawi i ka manaʻo i ka lihilihi lalo, ka papalina, ka ʻaoʻao o ka ihu, a me ka lehelehe luna/niho. - ** E lana ana me ka pale ʻole ʻia i waenakonu o ke keʻena koko venous** (ma ka ʻaoʻao o ka ** ʻaʻaʻa carotid i loko ** a me kona ʻāʻī aʻalolo aloha) noho ** Cranial Nerve VI (Abducens Nerve)**, ka mea e hoomalu ana i ka lateral rectus muscle (ka io e hoohuli i ka pōpō maka i waho i ka pepeiao). - Ka hopena o ke kino: I ka wa e komo mua ai ka pus a me ke koko septic i loko o ka sinus cavernous, Cranial Nerve VI (Abducens) ʻauʻau ʻia ʻo ia i loko o ka thrombus i maʻi ʻia ma mua, e hana ana i kahi maʻi maʻi maʻi ʻaoʻao ʻaoʻao (lateral rectus palsy).inability to turn the eye outward) mau hola ma mua o ka hoʻonui ʻia ʻana o ka ʻāʻī e hiki ai ke kōmi i ka CN III, IV, \(\text{V}_1\), a me \(\text{V}_2\) ma ka paia o waho (no laila ke kumu o ka maka maloʻo piha [total ophthalmoplegia], poʻi hāʻule [ptosis], haumāna hoʻonui [mydriasis] mai CN III parasympathetics a i ʻole haumāna hoʻopaʻa ʻia [miosis] inā paʻi mua ʻia nā carotid sympathetics, a ʻo **ka lae/pālina **).

3. No ke aha e lele ai ka ma'i i ka maka ku e i 24 a 48 mau hola (The Intercavernous Bridge)¶

I ka orbital cellulitis maʻalahi (he maʻi i hoʻopaʻa ʻia i loko o ka puka maka hoʻokahi), noho paʻa nā hōʻailona ma kahi maka (unilateral) no ka mea, ua hoʻokaʻawale ʻia nā iwi iwi ʻelua e ka ihu ethmoid. - ʻO ka ʻokoʻa, ʻo ka ʻaoʻao hema a me ka ʻākau cavernous sinuses ua hui pololei ʻia ma waena o ke kumu pituitary e like me nā ʻanuʻu o kahi alapiʻi e nā ** mua a me hope intercavernous (circular) sinuses**. - I loko o 24 a 48 hola o ka hoʻopaʻa ʻia ʻana o hoʻokahi sinus cavernous, hoʻolaha pololei ʻia ka thrombus septic ma kēlā ʻaoʻao o ke alahaka intercavernous a i ka ** kū'ē (contralateral) cavernous sinus**, e hoʻomaka koke ana ka maka ʻē aʻe o ka mea maʻi i ** periorbital edema, chemosis, proptosis, a me nā aʻalolo cranial III/IV/VI palsies. ** ʻO ka piʻi ʻana mai ka unilateral a hiki i ka bilateral proptosis a me ka ophthalmoplegia i loko o ka mea maʻi febrile he pathognomonic ia no ka septic cavernous sinus thrombosis a hiki i ka hōʻike ʻia ʻana.*

Māhele 2: Ka hoʻokaʻawale ʻana i ka Cavernous Sinus Thrombosis mai Orbital Cellulitis, Pre-Septal Cellulitis, a me Carotid-Cavernous Fistula¶

E hoʻohana i kēia papa hoʻohālikelike lapaʻau e hoʻokaʻawale i ka CST septic mai kāna mau mimic kokoke loa ʻekolu:

Mahele 3: ʻO nā Microbes Ke kumu a me ke kumu e hiki ai ke hōʻeha ʻana i ke aʻaʻa carotid kūloko¶

1. ʻO wai ka maʻi bacteria i hoʻokumu i ka Septic Cavernous Sinus Thrombosis?¶

No ka mea, puka mai ka septic CST mai ka ʻili o ka nasal vestibule/lehelehe luna (Danger Triangle), nā paranasal sinuses, a i ʻole nā ​​niho, pono e hoʻopaʻa koke ʻia ka lāʻau lapaʻau empirical i ʻehā mau pūʻulu pathogen: - Staphylococcus aureus (60% to 70% ʻO nā hihia a pau: #1 ʻO ka maʻi maʻi holoʻokoʻa): Ua helu ʻia e ka aneane 100% ʻO nā hihia e puka mai ana mai nā furuncles ihu, nā pimples maka, a me ka ʻeha ʻili, a me ka hapa nui o nā hihia sphenoid/thmoid sinusitis acute. Methicillin-Resistant i loaʻa i ke kaiāulu a me ka mālama ola kino Staphylococcus aureus (MRSA) ka mea maʻamau, e koi ana i empiric intravenous Vancomycin (a i ʻole Linezolid/Daptomycin) mai ka Minute 1. - Streptococcus ʻAno (15% to 20%: Streptococcus pneumoniae, S. pyogenes, a me ka hui Streptococcus anginosus/milleri): Maʻa mau i nā hihia sinusogenic a me otogenic. - Oral & Sinus Strict Anaerobes (10% to 15%: Fusobacterium necrophorum, Bacteroides, Prevotella, Peptostreptococcus): He mea maʻamau i ka wā e puka mai ai ka maʻi mai kahi ʻōpū odontogenic (niho), sinusitis sphenoid mau loa, a i ʻole thrombophlebitis like me Lemierre. - Angioinvasive Fungi i ka maʻi diabetic / Immunocompromised (Mucor / Rhizopus [Mucormycosis] a me Aspergillus fumigatus): - ** CRITICAL CLINICAL RED FLAG:** I kēlā me kēia mea maʻi me ka maʻi diabetes mellitus maikaʻi ʻole (especially Diabetic Ketoacidosis / DKA), neutropenia, ma'i leukemia, ho'ololi o ke kino pa'a, corticosteroids ki'eki'e, a i 'ole deferoxamine therapy ka mea e loa'a me ka sinusitis, eschar necrotic 'ele'ele ma ka nasal turbinates a i 'ole ka palapala pa'a, a me ka thrombosis sinus cavernous, ke kuhi nei ** Rhino-Orbital-Cerebral Mucormycosis (ROCM)**, kahi e koi koke ai intravenous Liposomal Amphotericin B (5 to 10 mg/kg/day) a me ka hoʻomaʻemaʻe ʻana i ka ʻokiʻoki.

2. ʻO ka hoʻopiʻi ʻana o ke aʻa carotid kūloko (Mycotic Aneurysm and Ischemic Stroke)¶

E hoʻomanaʻo ʻo ** ke aʻa carotid kūloko (ICA), ke aʻa nui e hoʻolako ana i ke koko i mua o ʻelua hapakolu o ka lolo, e hele pololei ana ma waena o ka sinus cavernous i ʻauʻau ʻia i ka naʻau a me ke koko. - ʻO ka hoʻouka ʻana o ka bacteria a me ka mumū nui o ka paia arterial carotid (infectious arteritis) hiki ke hoʻoulu i ka vasospasm, ka hōʻemi ʻana o ka carotid (stenosis), ka occlusion septic carotid, a i ʻole ka carotid mycotic aneurysm cavernous, e hoʻoulu ai i ka ** ʻāʻī ʻāʻī hemispheric hemispheric (ka maʻi maʻi o ka lima contralateral a me ka aphasia) a hiki i 10 to 15 percent o na ma'i. - Eia kekahi, necrosis o ka pituitary gland kokoke (sella turcica) hiki ke hoʻohāiki i ke kino, weliweli i ke ola ** ʻaʻole lawa ka adrenal lua (pituitary apoplexy / hypocortisolism), e hoʻoulu ana i ka hypotension refractory e pane wale ana i ka ** hydrocortisone intravenous i loko o ke kaumaha (100 mg IV STAT).

Mahele 4: Hale Hōʻikeʻike gula maʻamau (MRI/MRV + Contrast CT) a me ka Lapaau Paa¶

Ke hōʻea ka mea maʻi i ke Keʻena Emergency me ka mea i manaʻo ʻia he septic cavernous sinus thrombosis, ʻo ke ola ʻana me ka ʻole o ka makapō mau a i ʻole ka hahau ʻana e hilinaʻi ʻia i ka hoʻokō ʻana i ʻehā mau hōʻaiʻē haukapila e like me ka hola mua:

1. ʻO nā lāʻau antibiotic intravenous i loko o ka Meningeal-Dose Broad-Spectrum. < 60 Minutes)¶

Ma hope o ke kahakiʻi ʻana i ʻelua pūʻulu o nā moʻomeheu koko aerobic a me anaerobic (he mea maikaʻi i 70% ʻO nā maʻi CST septic acute), hāʻawi koke nā kauka lapaʻau ** i nā lāʻau antibiotic intravenous intravenous-nervous-system-penetrating (meningeal-dose): - Mahele 1 (Ka uhi ʻana i ka Anti-MRSA / Anti-Staphylococcal): Vancomycin Intravenous (15 to 20 mg/kg IV every 8 to 12 hours, me kahi 25-30 mg/kg ka hoʻouka ʻana i ka hoʻopaʻa ʻana no ka pā 15-20 mcg/mL) A I ʻole Linezolid Intravenous (600 mg IV every 12 hours) (ʻo ia ka mea e hoʻokō ai i ka CSF kiʻekiʻe a me ka ʻiʻo o ka lolo inā ʻae ʻia ka vancomycin). (Inā hōʻoia nā moʻomeheu i ka methicillin-susceptible S. aureus [MSSA], haiki i ka helu nui IV Nafcillin a i ʻole Oxacillin 2 g IV every 4 hours) - Mahele 2 (Cephalosporin ʻEkolu a ʻEhā paha no ka Pneumococcus & Gram-Negatives): ** Ceftriaxone Intravenous (2 grams IV every 12 hours: hoʻopaʻa paʻa pālua maningeal piha) A i ʻole ** Intravenous Cefepime (2 grams IV every 8 hours)** (inā kānalua ʻia ʻo Pseudomonas a i ʻole ka mālama ola kino). - Mahele 3 (Anaerobic Brain/Sinus Penetration): Intravenous Metronidazole (500 mg IV every 6 to 8 hours). (ʻO kahi ʻē aʻe, Meropenem Intravenous 2 grams IV every 8 hours + Hoʻopili ʻo Vancomycin i nā papa bacteria ʻekolu i loko o kahi hoʻoponopono lāʻau ʻelua). - Ka lōʻihi o ka IV Therapy: ʻO ka liʻiliʻi o 3 a 4 pule o nā lāʻau antibiotic intravenous (hoʻonui ʻia i 6 a hiki i 8 pule inā pili ʻia me ka osteomyelitis iwi mua/sphenoid a i ʻole intracranial brain/epidural abscess).

2. ʻO Neuroimaging Hoʻoholo Kiʻekiʻe (Contrast Brain MRI with MR Venography + Thin-Slice Sinus/Orbit CT)¶

ʻAʻole nalo ka nānā ʻana o ke poʻo ʻokoʻa ʻole CT a hiki i 30% to 50% o nā thromboses mua o ka sinus cavernous. - MRI Brain Hoʻonui Kūʻokoʻa me MR Venography (MRV) ka maʻamau gula diagnostic koʻikoʻi loa: ʻike ʻo ia i ka ka hoʻonui a me ka convex lateral bulging o nā paia sinus cavernous, ʻaʻole i loaʻa ka hōʻailona venous flow / fill defects in the cavernous sinus, dilation and thrombosis of the superior ophthalmic vein (SOV), hoʻonui lōʻihi, a me ka hōʻemi ʻana o ke aʻa carotid kūloko intracavernous. - Kiʻekiʻe-Resolution Thin-Slice (1 mm) Hoʻohālikelike CT o nā Orbits a me Paranasal Sinuses (CT Venography / CTV): Hana koke ʻia ma ka ʻaoʻao o MRI no ka palapala ʻana i ka hoʻoheheʻe ʻana i nā iwi o ka sphenoid a me ethmoid sinuses a alakaʻi i ka hoʻoheheʻe ʻana i ka ʻauʻau endoscopic.

3. Anticoagulation (Intravenous Unfractionated Heparin a i ʻole LMWH)¶

Pono ʻoe e hāʻawi i nā mea ʻoki koko (anticoagulation) i ka mea maʻi me ka maʻi maʻi i loko o ka sinus cavernous? - Ka Manaʻo Kūkākūkā o kēia manawa (AHA/ASA Cerebral Venous Thrombosis Guidelines & Cochrane Nā Manaʻo): I kekahi manawa neuroimaging (CT/MRI) wehe ʻole i ka hemorrhage intracranial nui a i ʻole kahi carotid mycotic aneurysm ruptured, ** anticoagulation hoʻohui mua me Intravenous Unfractionated Heparin (UFH: makemake mua ʻia no ka mea hiki ke hoʻopau ʻia a hoʻohuli ʻia me ka protamine i loko o nā minuke ma mua o ka hana sinus) a i ʻole Low-Molecular-Weight Heparin (Enoxaparin 1 mg/kg SC every 12 hours)** hoʻopau i ka hoʻolaha ʻana o ka clot ma waena o ka sinus intercavernous i ka ʻaoʻao o ka maka a hoʻomaikaʻi i ke komo ʻana o nā lāʻau antibiotic i loko o ka thrombus, e hōʻemi nui ana i ka make (from -30% down to < 10-15%) a me ka makapō aʻalolo cranial mau loa. Hoʻomau pinepine ʻia ka anticoagulation no 6 pule a hiki i 3 mahina a hiki i ka hoʻihoʻi hou ʻana o ka venous.

4. Hoʻoholo ʻia i ke kumu o ka ʻoki ʻana (Endoscopic Sphenoidotomy / Ethmoidectomy a i ʻole ka hoʻoheheʻe ʻana o ka ʻōpū)¶

ʻAʻole hiki i nā lāʻau lapaʻau a me ka heparin ke hoʻomaʻemaʻe i kahi iwi sphenoid sinus i paʻa i hoʻopiha ʻia me ka pus. Inā ʻike ʻia ka CT imaging ** acute sphenoid/ethmoid sinusitis, kahi orbital subperiosteal abscess, a i ʻole he niho/facial abscess**, kahi Otolaryngologist (ENT surgeon) a i ʻole Oral & Maxillofacial Surgeon lawe koke i ka mea maʻi i ka lumi hana no Functional Endoscopic Sinus SurgeryFESS: sphenoidotomy endoscopic ākea a me ka ethmoidectomy) a i ʻole ka hoʻokahe ʻana i ka ʻōpū. (E hoʻomanaʻo: Hoʻokahe ka poʻe ʻoki i ka sinus mua a i ʻole ke kumu maka; ʻAʻole lākou e ʻoki pololei i loko o ke keʻena sinus cavernous pono'ī).

Nā helu ulia pōpilikia a me ka hoʻāʻo neurovascular¶

ʻO ka mea i manaʻoʻia he septic cavernous sinus thrombosis e koi koke i ka lawe kaʻa kaʻa i kahi ** Comprehensive Stroke / Tertiary Hospital Emergency Department i lako me 24-hour MRI / MRV, Neurosurgery, Neurology, Ophthalmology, a me Otolaryngology (ENT) ʻO ka Opehana **:

• ** ʻAmelika Hui Pū ʻIa a me Kanada:** Kāhea koke i ka 911. Mālama ʻia ma lalo o Ahahui Puʻuwai ʻAmelika / ʻAhahui Stroke ʻAmelika (AHA/ASA) ʻŌlelo ʻepekema e pili ana i ka ʻike a me ka mālama ʻana i ka Cerebral Venous Thrombosis (CVT), Ka Hui Ma'i Infectious Society of America (IDSA), a me AAO-HNS alakai.
• United Kingdom: Kāhea i ka 999 a i ʻole e hele koke i kahi haukapila koʻikoʻi nui Keʻena ulia pōpilikia (A&E) me ke kelepona ENT, Ophthalmology, a me Neurology/Neurosurgery. Mālama ʻia ma lalo o European Stroke Organization (ESO) / NICE Cerebral Venous Sinus Thrombosis Guidelines a me ENT UK protocols.
• Uni ʻEulopa: Kāhea 112. Mālama ʻia ma lalo o European Stroke Organization (ESO) Nā alakaʻi no ka ʻike ʻana a me ka mālama ʻana i ka Cerebral Venous Thrombosis.
• Australia a me New Zealand: Kāhea i ka 000 ma Australia a i ʻole 111 ma New Zealand. Mālama ʻia ma lalo o Stroke Foundation / ANZAN a me Therapeutic Guidelines: Antibiotic (Septic Venous Sinus Thrombosis).
• Asia-Pākīpika: Kāhea i ka 119 (Iapana, South Korea), 995 (Singapore), a i ʻole 112 / 108 (India). E noi e hoʻololi koke i kahi neurosurgical a me ke kikowaena ENT.

Nīnau pinepine¶

He aha ka "Triangle Triangle of the Face," a no ke aha e hiki ai i ka ʻomi ʻana i kahi pimple ma laila ke kumu o ka lolo koko?¶

ʻO ka "Danger Triangle of the Face" ka ʻāpana triangular e holo ana mai ke alahaka o kou ihu a hiki i nā kihi hema a ʻākau o kou waha, me kou ihu, nā puka ihu, a me ka lehelehe luna. ʻAʻole like me nā veins i ke koena o kou kino i loaʻa nā kiwi hoʻokahi ala e hoʻomau i ke kahe ʻana o ke koko i kou puʻuwai wale nō, ʻo ka vein facial (angular vein) a me nā veins ophthalmic kiʻekiʻe a haʻahaʻa a puni kou mau maka, ʻaʻohe kīpē. Ke ʻomi a pahū ʻoe i kahi ʻeha hohonu a i ʻole pimple (i maʻi pinepine ʻia me Staphylococcus aureus) i loko o ka puka ihu a i ʻole ka lehelehe luna, e hoʻopuni ana ka pehu a puni i ka wai maʻamau i lalo, a ʻo ke kaomi ʻana e hoʻokuʻu i ke koko a me ka bacteria i hope ma o nā aʻa o ka maka i loko o ka sinus cavernous ma ke kumu o ka lolo.

No ke aha i hiki ʻole ai ke hoʻohuli i kekahi maka i waho ("sixth-nerve palsy") ka hōʻailona mua loa o ka thrombosis sinus cavernous?¶

ʻElima mau aʻalolo cranial e hele i loko o ka cavernous sinus a hiki i ka maka a me ka maka: Cranial Nerves III, IV, V1, a me V2 ua hoʻopaʻa pono ʻia i loko o ka pā paʻa paʻa o waho o ka sinus, aʻo Cranial Nerve VI (ke aʻalolo abducens, nāna e hoʻokele i ka ʻiʻo e hoʻohuli i kou maka i waho i kou pepeiao waena) e lana pono ana ma ka ʻaoʻao o ke kaʻa o loko. aʻaʻa. Ke komo mua ka hua bacteria a me ke koko i loko o ka sinus cavernous, ʻo Cranial Nerve VI ke aʻalolo mua loa i ʻauʻau ʻia i ka pus a me ke kaomi. ʻO ka mea maʻi i loaʻa i ka maʻi maʻi a i ʻole ka maʻi maʻi o ka maka a ʻike koke i ka ʻike pālua no ka mea ʻaʻole hiki i ka maka hoʻokahi ke huli i waho e pono i kahi lāʻau lapaʻau MRI / MRV a me IV koke.

Pehea e haʻi ai nā kauka i ka ʻokoʻa ma waena o ka orbital cellulitis a me ka thrombosis sinus cavernous?¶

ʻOiai hiki i nā kūlana ʻelua ke kumu i ka maka ʻulaʻula, pehu, pehu (proptosis), ke kuni, a me ka ʻeha a i ʻole ke kāohi ʻia o ka neʻe ʻana o ka maka, ʻekolu mau hōʻailona e kuhikuhi pono ana i ka thrombosis sinus cavernous: (1) Laha ʻelua: no ka mea ua hoʻopili ʻia nā sinuses cavernous hema a me ka ʻākau ma waena o nā veins intercavernous, pehu a pehu ka maka i loko o ka opposite a i ka maka 8 hola; (2) ʻO ke aʻalolo trigeminal numbness: ke kuʻi ʻana a i ʻole ka hoʻopā māmā ʻana i ka lae o ka mea maʻi (CN V1) a i ʻole ka papalina luna (CN V2) e hōʻike ana i ka helu ʻana a i ʻole ka nalo ʻana o ka corneal blink reflex; a me (3) ʻO nā mea ʻawaʻawa koʻikoʻi, e like me ke poʻo ʻehaʻeha ma hope o nā maka, ka ʻāʻī ʻoʻoleʻa, ka haʻahaʻa haʻahaʻa/palaulehu, a me ka neʻe ʻana o ka maka paʻa ma waho o ka like me ka pehu ʻana o ka lihilihi.

He aha ke kumu #1 o ka septic cavernous sinus thrombosis i kēia lā inā ʻaʻole ia e ʻoki i nā pimples?¶

Ma mua o ka ʻike ʻia ʻana o nā lāʻau lapaʻau, ʻo ke kuʻi ʻana i nā ʻūhā o ka maka a me ka ihu ("furuncles") i loko o ka Triangle Danger ke kumu nui o ka thrombosis sinus cavernous. I kēia mau lā, ʻoiai ʻo ka nasal boils ke kumu o ka 15 a 25 ka nui o nā hihia, ʻo ka #1 kumu hou (ke kuleana no ka ʻoi aku o 50 a 60 ka nui o nā hihia) he maʻi bacterial sphenoid sinusitis a me ethmoid sinusitis. Ma muli o ka noho hohonu ʻana o ka sinus sphenoid ma hope o ka ihu i hoʻokaʻawale ʻia mai ka sinus cavernous e ka paia iwi ma lalo o 0.5 millimeters lahilahi (ʻo ia ka mea i loaʻa pinepine nā āwaha microscopic maoli), hiki i ka maʻi kino hohonu ke hoʻopau ʻole ʻia i loko o ka sinus cavernous.

No ke aha e hāʻawi ai nā kauka i nā mea hoʻokahe koko (Heparin) no ka maʻi maʻi i loko o ka sinus cavernous?¶

I ka nānā mua ʻana, ʻo ka hāʻawi ʻana i kahi mea ʻoki koko i ka wā o ka maʻi he mea weliweli, ʻo ia ke kumu e hana mua ai nā kauka i kahi CT a me MRI no ka ʻike ʻana ʻaʻohe kahe o ka lolo. Ke hoʻopau ʻia ke koko, ʻo ka heparin unfractionated intravenous (a i ʻole heparin haʻahaʻa-molecular-weight) me nā lāʻau antibiotic intravenous kiʻekiʻe he hana koʻikoʻi koʻikoʻi e hoʻopakele ola: hoʻopaʻa ia i ke koko septic mai ka laha ʻana ma waena o nā veins intercavernous i loko o ka maka ʻē aʻe o ka mea maʻi a i hope paha i ke koena o ke koena o ka lolo mai ka venous sinuses a pale aku i ka maʻi ʻana o ka lolo, a pale aku i ka maʻi ʻana o ka lolo a me ka hoʻopuʻi ʻana. wehe ʻia nā awāwa venous i hiki i nā lāʻau antibiotic intravenous ke komo i ka maʻi.

He aha kaʻu e hana ai inā loaʻa iaʻu kahi ʻeha ʻeha i loko o koʻu puka ihu a i ʻole ma koʻu lehelehe luna i kēia manawa?¶

ʻO ka mua, e hoʻokaʻawale i kou mau lima: mai ʻomi, ʻimi, ʻohi, a paʻi paha me ka nila. E noi i kahi lole holoi maʻemaʻe, mahana, ʻoluʻolu ma luna o ia wahi no 15 mau minuke ʻekolu a ʻehā mau manawa i ka lā e hoʻoikaika i ka hoʻoheheʻe ʻana i waho me ke kaomi ʻole. E ʻike i ke kauka i ka lā hoʻokahi no ka mupirocin topical (2%) ʻaila hinu a me nā lāʻau antibiotic waha e uhi ana iā Staphylococcus aureus (a me MRSA inā laʻa i kou kaiāulu). Inā loaʻa ʻoe i ke kuni, hoʻolaha ʻia ka ʻulaʻula ma ke kihi o ka maka o loko, ke poʻo ma hope o kou mau maka, ka pehu o ka ʻili, a i ʻole ka ʻike pālua, e hele pololei i kahi keʻena pilikia o ka haukapila.

Nā kumu a me ke alakaʻi kūhelu¶

• Ahahui Puʻuwai ʻAmelika / ʻAhahui ʻAmelika Hui Pū ʻIa (AHA/ASA, ʻAmelika Hui Pū ʻIa): * ʻŌlelo ʻepekema: ʻIke a me ka mālama ʻana i ka Cerebral Venous Thrombosis (CVT) a me Septic Cavernous Sinus Thrombosis* (Stroke, hoʻohālikelike i ke kūlana gula diagnostic MRI/MRV, nā lāʻau lapaʻau CNS-dose ākea, a me ka anticoagulation mua o ka unfractionated/LMWH).
• Infectious Diseases Society of America (IDSA, United States): Clinical Practice Guidelines for Intracranial Suppurative Complications of Sinusitis and Facial Infections (empiric intravenous vancomycin me ke kolu/hā-hanauna cephalosporin a me metronidazole regimens).
• European Stroke Organization (ESO) & National Institute for Health and Care Excellence (NICE, Europe / UK): Nā alakaʻi no ka ʻike a me ka mālama ʻana i ka Cerebral Venous Thrombosis (palekana anticoagulation a me ka hoʻomalu kumu hoʻokele).
• American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS, United States) & ENT UK: Complications of Acute Rhinosinusitis (Sphenoid/Ethmoid Sinusitis, Chandler Classification of Orbital Complications Stage V Cavernous Sinus Thrombosis, and Urgent Endoscopic Sphenoidotomy).
• American Academy of Ophthalmology (AAO): Neuro-Ophthalmic Triage of Cavernous Sinus Syndrome (Isolated Early Cranial Nerve VI Abducens Palsy, Trigeminal V1/V2 Hypoesthesia, and Contralateral Intercavernous Spread).

Nā alakaʻi pili¶

• ʻO ka cellulitis orbital, cavernous sinus thrombosis, a me nā maʻi maka triangle pilikia
• ʻO ka mastoiditis koʻikoʻi koʻikoʻi: ka puka ʻana o ka pinna pepeiao a me ka thrombosis sinus sigmoid
• ʻO ka maʻi maʻi a me ka maningococcal septicemia non-blanching rash triage
• ʻO ka cellulitis, ka erysipelas, ka ʻulaʻula lymphangitis, a me ka holomua o ka abscess sepsis
• ʻO Bell's palsy vs. stroke ka hāʻule ʻana o ka maka, ka mālama ʻana i ka lae, a me ka paʻi ʻana o ka maka