Septic Cavernosis Sinus Thrombosis: "Fakatu'utamaki 'o e tafa'aki tolu 'o e fofonga" 'Oku vela, Sphenoid / Ethmoid Sinusitis, Mu'omu'a 'o e ono-Neave Palsy, mo e Proptosis 'o e ongo tafa'aki¶

Ko e thrombosis 'o e sinus 'o e 'ana 'o e sepi (CST) ko ha fakatu‘utāmaki fakatu‘utāmaki, fakatu‘utāmaki ki he mo‘uí ‘a ia ‘oku fa‘u ai ha fo‘i toto ‘oku ma‘u (septic thrombus) ‘i loto ‘i he cavernous sinuses, ko ha hoa ‘o e ngaahi loki veini ‘oku trabeculated, ‘oku fonu ‘i he totó ‘oku nau tangutu hangatonu ‘i he tefito ‘o e ‘utó ‘i he ongo tafa‘aki ‘o e pitu g.sella turcica) mo e sinusi sfenoid. Koe'uhi ko e veini 'o e fofonga (angular vein) mo e ma'olunga mo e ma'ulalo ange 'a e ngaahi veini 'o e mata 'oku ne fakatafe 'a e lotolotonga 'o e fofonga 'o e tangata mo e ngaahi sote 'o e mata 'oku 100 peseti valveless ('oku 'i ai 'a e zero 'o e ngaahi valve veini 'o e founga 'e taha), 'a e pekitilia mei ha squeezed vela pe pimple 'i loto 'i he "Fakatu'utamaki 'o e Tafa'aki Tolu 'o e mo 'a e fotunga". ihu), ko ha sphenoid pe ethmoid sinus 'oku te'eki ke faito'o, ko ha selula 'o e 'atakai, pe ko ha nifo 'i 'olunga 'i mu'a 'e lava ke tafe ki mui (retrograde) hangatonu ki he ʻuluʻi ʻutó. Kapau ko ha taha na'e toki 'i ai ha'ane mahaki sinus, vela 'a e ihu, pe cellulitis 'i he fofonga 'oku ne ma'u mamahi 'ulu lahi 'i mui 'i he mata, mofi spiking, fula pe bulging 'o e mata (proptosis), ta‘emalava ke tafoki ‘a e matá ki tu‘a ki he telingá ( ).sixth cranial nerve palsy fakatupunga ‘a e sio lōua), tō hifo ‘a e fo‘i mata (ptosis), pe fula ‘a e mata ‘oku puna mei he mata ‘e taha ki he ongo mata ‘I loto ‘i he houa ‘e 24 ki he 48, telefoni ki ho’o feitu’u . ngaahi fika fakavavevave (911 ‘i he ‘Iunaite Seteté mo Kānatá, . 112 ‘i he kotoa ‘o e ‘Iunioni ‘Iulopé, . 999 ‘i he Pule‘anga Fakatahatahá, pe . 000 ‘i ‘Aositelēlia) ‘i he taimi pē ko iá. Lolotonga hoʻo tatali ki he fefonongaʻaki ki he falemahakí, vakaiʻi ʻetau ngaahi fakahinohino hoá ʻi he . orbital cellulitis mo e ngaahi mahaki tapatolu fakatu'utamaki 'o e fofonga ., ko e mastoiditis fakatu'utamaki mo e thrombosis 'o e sinus sigmoid, mo e . 'a e mahaki 'o e meningitis mo e sivi 'o e septicemia 'o e meningokoka.

Ko e hā ʻoku makehe ai hono ʻiloʻi ʻo e thrombosis ʻo e septic cavernous sinus ʻi he tafaʻaki mohengá kapau ʻokú ke ʻiloʻi ʻa e meʻa ke siví? He ‘oku ‘ikai ke hangē ia ha toe fa‘unga kehe ‘i he sino ‘o e tangatá, ko e cavernous sinus ‘oku ‘i ai hono ‘alati (the internal carotid artery) mo ha neave ‘o e ‘ulú (Cranial Nerve VI, the abducens nerve) 'oku lele hangatonu 'i he lotolotonga 'o hono tafe'anga toto 'o e veini, lolotonga ia 'oku lele 'a e ngaahi neave kehe 'e fa 'o e 'ulu (CN III, CN IV, CN \(\text{V}_1\), mo e CN \(\text{V}_2\)) 'oku fakahu 'i hono 'ā tafa'aki 'i tu'a. 'Ikai ngata ai, 'oku fehokotaki 'a e ngaahi sinus cavernous to'ohema mo e to'omata'u 'i he tafa'aki 'o e laine lotoloto 'e he sinus venous intercavernous. Ko hono ola, 'oku fakatupu 'e he septic CST ha kalasi, ta'e-fehalaaki fakamo'oni hingoa fakakiliniki sitepu 'e ua: 1. 'Uluakí (Early Hours): Fakamavahe'i Palsy 'o e Sio 'i he tafa'aki 'o e Ipsilateral (Cranial Nerve VI Palsy: ta'emalava ke tafoki 'a e mata 'oku uesia ki tu'a ki he temipale) 'o 'alu fakataha mo e mamahi 'ulu loloto retro-orbital mo e la'e/corneal numbness (CN V1). 2. Ua (Within 24 to 48 Hours: Faka'ilonga Pathognomonic): Mafola 'a e fula 'o e 'aofinima, 'a e 'uhiki'i mata (chemosis), mata ‘oku pupula (proptosis), mo e ngaahi ngaue ‘aisi ‘a e matá ( ).ophthalmoplegia) ki he FEPAKI ( ).contralateral) mata, liliu ha palopalema mata tafa'aki taha ki ha fakatamaki bilateral.

Fai ʻeni he taimí ni .¶

1. Fakahoko 'a e 30-Sekoni "Sivi 'o e mata 'o e tuhu-muimui fakahosite" (Testing Cranial Nerve VI) mo e "Both-Eyes Symmetry Check" 'i he taimi pe ko ia. Kole ki he mahaki ke ne puke ma'u honau 'ulu pea muimui māmālie ki ho louhi'i nima ki he to'ohema mama'o mo e to'omata'u mama'o:
2. Fuka Kulokula Mu'omu'a (CN VI Abducens Palsy): 'Oku 'ikai ke tafoki 'a e mata 'e taha 'o a'u ki tu'a 'o fakahangatonu ki he telinga (abduction deficit), ‘o fakatupunga ai ke sio ‘a e tokotaha mahakí ki ha ongo ‘ata ‘oku tafa‘aki-ki-he-taha (horizontal diplopia) ‘i he‘ene sio ki he tafa‘aki ko iá?
3. Fuka Kulokula Fakalakalaka (CN III & IV + Bilateral Spread): 'Oku 'alu hifo 'a e mata (ptosis), 'oku fakalahi mo 'ikai ke ngaue 'a e mata, 'oku 'aisi 'a e mata 'i he tu'unga lotoloto (ophthalmoplegia kakato 'i tu'a), pe kuo kamata ke 'asi mai 'a e puffiness/kulokula 'i he mata hono ua (fehangahangai)?
4. Ta mai 911 / 112 / 999 'i he taimi pe ko ia kapau 'oku 'i ai ha vela 'o e fofonga, sinusitis, pe kulokula 'o e mata 'oku 'alu fakataha mo ha Fa'ahinga Sinus Cavernous pe Fuka Kulokula 'o e Orbital:
5. Visone 'e ua (diplopia), mamahi pe fakangatangata ‘a e ngaue ‘a e matá, pe tō ‘a e ‘uhiki‘i matá.
6. Proptosis (puna 'a e mata) pe chemosis (fula 'o e mata hinehina 'oku 'asi mai 'o hange ha jeli 'oku 'asi mai 'i he 'olunga 'o e mata 'i lalo).
7. Mole 'a e sio, sio 'oku 'ikai ke mahino, pe mole 'a e saturation lanu kulokula (afferent pupillary defect).
8. Ko e ngingila, ngingila, pe vela ‘a e mamahi ‘i he tafa‘aki ‘o e la‘é, ‘ulu‘i mata ‘i ‘olungá, ihú, pe kou‘ahe ‘i ‘olungá (Cranial Nerve V1 / V2 trigeminal sensory deficit).
9. Mamahi 'ulu lahi 'i he retro-orbital pe 'i mu'a, fefeka 'a e kia, photophobia, puputu'u, vaivai, pe ma'olunga 'a e spiking "picket-pa" mofi (39.5°C+ / 103°F+) mo e tetetete ‘a e momoko (rigors).
10. 'OUA 'E TEITEI 'ai ke 'omi, pop, lance, pe manipulate ha pimple, furuncle (boil), pe ingrown 'a e fulufulu'i ihu 'i loto 'i he "Tafa'aki Tolu Fakatu'utamaki 'o e Fofonga." 'Oku lele 'a e Tafa'aki Tolu Fakatu'utamaki mei he bridge 'o e ihu (glabella) hifo ki he tuliki to‘ohema mo e to‘omata‘u ‘o e loungutu ‘i ‘olungá ( ).oral commissures), kau ai 'a e vestibule 'o e ihu ('i loto 'i he ngaahi ava 'o e ihu) mo e philtrum. Ko hono lomi'i 'o ha Staphylococcus aureus vela 'oku ma'u 'i he sone ko 'eni 'oku ne fakamālohi'i fakamisini 'a e pekitilia mo e micro-thrombi ma'u ki mui 'o fakafou 'i he ngaahi veini angular mo e mata 'oku 'ikai ha valve 'o hangatonu ki he sinus 'o e cavernous.
11. Kapau ko ha vela pe crusted 'a e mahaki 'o e vestibule 'o e ihu (nasal furunculosis) 'oku 'i loto 'i he Tafa'aki Tolu Fakatu'utamaki 'o 'ikai ha ngaahi faka'ilonga neurological: faka'aonga'i ha ma'a, mafana moist compress malimali ki he . 15 minutes 3 to 4 times daily ‘o ‘ikai ke lomi‘i pe lomi‘i, fufulu nima ‘aki ‘a e sopú, pea sio vave ki ha toketā ki he topical Intranasal Mupirocin (2%) lolo mo e ngaahi faito‘o fakafepaki ki he sitafilokoká (cephalexin, dicloxacillin, doxycycline, or TMP-SMX).
12. Tauhi ha mahaki 'oku 'alu ki he Potungaue Fakavavevave 'a e falemahaki ke fefeka NPO ('ikai ha me'a 'i he ngutu: 'ikai ha me'akai, 'ikai ha vai). Ko e kau mahaki 'oku nau ma'u 'a e thrombosis 'o e sinus 'o e septic cavernous 'oku tupu mei he sinusitis 'o e sphenoid/ethmoid, 'a e nifo 'o e 'uto, pe 'a e 'uto 'o e subperiosteal 'o e 'atakai 'oku fa'a fie ma'u **'i he 'atakai 'o e endoscopic 'oku 'asi hake 'i he lalo 'o e ethmoidectomy sur.
13. Hiki hake 'a e 'ulu 'o e mohenga pe 'o e me'alele ki he . 30 to 45 degrees lolotonga 'a e fefononga'aki ke fakasi'isi'i 'a e intracranial mo e intra-orbital 'o e ngaahi veini lolotonga hono tauhi 'o e kia 'i ha tu'unga tu'u-ki-mu'a, unbent ko ia 'oku 'ikai ke fakalavea'i 'a e tafe 'a e veini jugular 'i loto.

'Akau 'o e tu'utu'uni: Triaging 'a e fofonga Fakatu'utamaki Ngaahi mahaki 'o e tafa'aki tolu, sinusitis, mo e fula 'o e mata¶

flowchart TD
    Trigger["Ko e Mahaki ‘oku ‘I ai ‘a e Pimple ‘i he Fofonga Lotolotó/Ihu pe Vela (‘Tafa‘aki Tolu Fakatu‘utāmaki’), Sinusitis ‘o e Ethmoid/Sphenoid, Seluli ‘o e ‘uhiki‘i matá, pe ko e nifo ‘i ‘olungá"] --> NeuroCheck{"Sitepu 1: Sikini ki he Cavernous Sinus & Orbital Ngaahi Fuka Kulokula: Fakangatangata/Mamahi 'a e Ngaue 'a e Mata (Tautefito ki he Sio ki Tu'a CN VI), Sio 'e ua, Mata 'oku 'asi (Proptosis), 'Ulu/Kou'ahe 'o e 'Ulu (CN V1/V2), Mamahi 'ulu 'o e Retro-Orbital pe SBOTH Ma'olunga?"}

    NeuroCheck -->|"'IO ki ha Fa'ahinga Fuka Kulokula (Tautautefito ki he Ngaahi Faka'ilonga 'o e Mata 'i he ongo tafa'aki pe Cranial Nerve Palsy)"| CSTCode["'OKU MAMAHA'I 'OKU 'I AI 'A E THROMBOSIS 'O E SINUS 'O E 'OTU (PE SYNDROME 'O E 'OTU): Ta mai ki he 911 / 112 / 999 'i he taimi pe ko ia -> Tauhi 'a e 'ulu ke ma'olunga 'i he Tikili 'e 30-45 -> NPO fefeka ki he tafa"]

    NeuroCheck -->|"'IKAI 'I AI 'a e Cranial Nerve Palsy pe Mafola 'i he ongo tafa'aki, KA 'oku 'i ai 'a e mata 'e taha 'oku fula kulokula"| CheckOrbital{"Sitepu 2: Fakafaikehekehe'i 'a e Post-Septal (Orbital) Selulitis vs."}

    CheckOrbital -->|"'IO: Mamahi 'i he Ngaue 'a e Mata, Proptosis, pe Liliu 'o e Sio"| OrbitalCell["POST-SEPTAL (ORBITAL) CELLULITIS (Ko e meʻa ʻoku muʻomuʻa vave ki he thrombosis ʻo e sinus ʻo e ʻaá): ʻAlu vave ki he Potungāue Fakavavevave ʻo e Falemahakí ki he IV ʻEnitipaiōtiki & Fakafehoanaki ʻo e ʻOta/Sinus CT"]

    CheckOrbital -->|"NO: Kulokula 'o e Mata 'i 'olunga Pe; Ngaue Kakato 'a e Mata 'oku 'ikai ha mamahi, Sio Angamaheni, 'Ikai ha Mofi/Mamahi 'Ulu"| PreSeptal["Ko e Selulitis kimuʻa ʻi he Septal (Periorbital) pe ko e Furuncle ʻo e Fofonga Fakalotofonuá: Kumi ha Tokangaʻi Fakafaitoʻo ʻi he ʻAho Tatau ki he Ngaahi Faitoʻo ʻEnitipaiōtiki ʻo e Ngutu/IV; 'OUA 'E TEITEI Faka'ai'ai 'a e Boil; Toe Siviʻi ʻa e Ngaue ʻa e Matá ʻi he Houa ʻe 4 Kotoa pē"]

    CSTCode --> HospitalCST["Falemahaki vave Neurovascular & ENT Fu'u: 1. Ngaahi anga fakafonua 'o e toto + STAT Meningeal-Tu'unga IV Vancomycin + IV Seftriaxone/Cefepime + IV Metronidazole, 2. Fakafehoanaki-Fakalahi 'a e 'uto MRI mo e MR Venography (MRV) + Fakafehoanaki 'o e OrbitSi/Fakafehoanaki. Heparin / LMWH Fakafepaki'i 'o e toto ('I he taimi 'oku 'ikai kau ai 'a e toto), 4. 'Oku 'asi hake 'a e endoscopic Sphenoid/Ethmoid Sinus pe Abscess Drainage"]

Konga 1: Anatomy 'o e "Tafa'aki Tolu Fakatu'utamaki" mo e 'Akiteki 'i loto 'o e Cavernous Sinus .¶

Ko e mahino ki he ongo palani faka'anatomi, (1) 'a e hala lahi 'o e ngaahi veini 'oku 'ikai ha valve mei he ihu ki he tu'unga 'o e 'ulu mo e (2) 'a e mape fakakolosi 'o e ngaahi neave 'o e 'ulu 'i loto 'i he cavernous sinus, 'oku ne fakamatala'i 'a e faka'ilonga takitaha kotoa pe 'oku fakatupulaki 'e ha mahaki.

1. Ko e Ngaahi Hala Lahi 'o e Hu 'a e Veini 'e 3 Ki he Sinus 'o e Cavernous .¶

Ko e ha 'oku hoko ai 'a e cavernous sinus ko e kolosi'anga veini lotoloto 'o e fofonga 'i 'olunga, mata, telinga, mo e 'uto? 1. Hala ki Mu'a (Mei he "Tafa'aki Tolu Fakatu'utamaki 'o e Fofonga" & Sote Mata): - Tā ha tafaʻaki tolu mei he ngaahi tuliki ʻo e ngutú (labial commissures) a'u ki he bridge 'o e ihu ( ).nasion/glabella). - Ko e toto veini mei he ngutu ‘i ‘olungá, philtrum, tumu‘aki ‘o e ihú, mo e vestibule ‘o e ihú ‘oku tafe ia ki he veini ‘o e fofongá -> veini angular (‘i he tuliki ‘i loto ‘o e matá), ‘a ia ‘oku anastomoses hangatonu mo e veini mata ‘i ‘olungá (SOV) mo e veini mata ma'ulalo (IOV). - Koe'uhi ko e ngaahi veini ko 'eni 'oku 'i ai 'a e valves 'ikai ha me'a, 'oku mafola hangatonu 'a e septic thrombophlebitis ki mui 'o fakafou 'i he fissure 'o e 'atakai ma'olunga ange ki he mu'a 'o e sinus cavernous. 2. Hala Fakalotofonua (Mei he Sphenoid mo e Ethmoid Sinus: Ko e #1 Tupunga Fakaonopooni): - 'I he kuonga 'o e 'enitipaiotikí fakaonopooni, ko e sinusitis sphenoid 'oku 'ikai ke 'i ai ha 'uhinga mo e sinusitis ethmoid 'i mui 'oku 'uhinga ia ki he over 50 to 60 percent 'o e ngaahi keisi kotoa pe 'o e thrombosis 'o e sinus 'o e septic. - Ko e ngaahi sinus cavernous to'ohema mo e to'omata'u 'oku nau tangutu palasitaa'i hangatonu ki he ngaahi 'a 'o e hui 'o e tafa'aki pepa-manifinifi 'o e sphenoid sinus (often less than 0.5 mm thick, with natural bony dehiscent gaps). 'Oku kolosi hangatonu 'a e mahaki 'i he hui manifinifi pe 'i he fanga ki'i valveless diploic mo e emissary veini. 3. Ngaahi Hala Ma'ulalo & Mui (Mei he Nifo 'i 'Olunga mo e Hui Mastoid): - Ko e ngaahi fo‘i nifo ‘o e kauvae ‘i ‘olungá (maxillary molars/incisors) fononga hake 'o fakafou 'i he pterygoid venous plexus 'o fou 'i he foramen ovale/lacerum ki he lalo 'o e sinus cavernous, lolotonga ia 'oku fononga ki mu'a 'a e ngaahi mahaki telinga/mastoid (apicitis petrous / Gradenigo syndrome) 'i he sinus petrosal ma'olunga mo ma'ulalo.

2. Kolosi-Vahe 'o e 'Anatomi 'o e Cavernous Sinus: Ko e hā . Cranial Nerve VI Fail 'Uluaki¶

========================================================================
       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)
========================================================================

Sio fakalelei ki he fakatātā fakaʻanatomi ʻi ʻolungá: - Malu'i 'i loto 'i he fibrous 'i tu'a Lateral Wall (mei 'olunga ki lalo) tangutu 'a e ngaahi neave 'e fa: 1. Neave ʻo e ʻUlú III (Oculomotor Nerve): Hiki hake 'a e mata 'i 'olunga (levator palpebrae), ‘okú ne fakangatangata ‘a e tamasi‘i akó ( ).parasympathetic fibers), pea ‘okú ne ‘unuaki‘i ‘a e matá ki ‘olunga, ki lalo, pea ki loto. 2. Neave 'o e 'Ulu IV (Trochlear Nerve): 'Oku ne hiki 'a e mata ki lalo pea ki loto (superior oblique muscle). 3. Neave 'o e 'ulu \(\ tohi{V}_1\) (Ophthalmic Division of Trigeminal Nerve): 'Oku ne 'omi 'a e ongo ki he cornea, 'olunga 'o e mata, la'e, mo e bridge 'o e ihu. 4. Neave 'o e 'ulu \(\ tohi{V}_2\) (Maxillary Division of Trigeminal Nerve): 'Oku ne 'omai 'a e ongo ki he 'aofi mata 'i lalo, kou'ahe, tafa'aki 'o e ihu, mo e ngutu/nifo 'i 'olunga. - 'Oku 'alu ta'e malu'i tonu 'i he lotolotonga 'o e loki toto 'o e veini ('i he tafa'aki hangatonu 'o e 'alati 'o e carotid 'i loto mo hono plexus neave kaungāongo'i) 'oku tangutu 'a e Cranial Nerve VI (Abducens Nerve), 'a ia 'oku ne pule'i 'a e uoua rectus lateral (ko e uoua 'oku ne fakatafoki 'a e fo'i mata ki tu'a 'o fakahangatonu ki he telinga). - Ola Fakafaito'o: 'I he taimi 'oku fuofua hu ai 'a e pus mo e ngaahi fo'i toto septic ki he sinus 'o e cavernous, Neave 'o e 'Ulu VI (Abducens) 'oku kaukau hangatonu 'i he thrombus 'oku ma'u 'uluaki, 'o fakatupu ai ha mavahe'i 'o e rectus palsy (inability to turn the eye outward) houa kimuʻa pea toki fakalahi feʻunga ʻa e foʻi huhuʻá ke ne fakamālohiʻi ʻa e CN III, IV, \(\text{V}_1\), mo e \(\text{V}_2\) ʻi he ʻā ʻi tuʻá (ʻa ia ʻoku ne fakatupu kimui ange ʻa e mata ʻaisi kakato [ 1 ].total ophthalmoplegia], 'ufi'ufi 'oku tō [ .ptosis], fakalahi ʻa e tamasiʻi akó [ 1 ].mydriasis] mei he CN III parasympathetics pe fakapuliki 'a e tamasi'i ako [ 1 ].miosis] kapau 'oku 'uluaki taa'i 'a e ngaahi sympathetics 'o e carotid, pea 'oku 'ikai ke 'i ai ha la'e/kou'ahe).

3. Ko e Ha 'oku Puna ai 'a e Mahaki ki he Mata Fehangahangai 'i he Houa 'e 24 ki he 48 (The Intercavernous Bridge)¶

'I he faingofua 'o e orbital cellulitis (ko ha mahaki 'oku fakangatangata 'i loto 'i he sote 'o e mata 'e taha), 'oku nofo pau 'a e ngaahi faka'ilonga 'i he mata 'e taha (unilateral) koe'uhi ko e ongo mata hui 'oku fakamavahe'i ia 'e he ava 'o e ihu ethmoid. - 'I hono fakafehoanaki, 'oku fakataha'i hangatonu 'a e sinus cavernous to'ohema mo e to'omata'u 'i he tafa'aki 'o e 'akau 'o e pituitary 'o hange ko e ngaahi 'otu 'o ha 'a'ake 'e he sinus intercavernous (takai) 'i mu'a mo mui. - 'I loto 'i he houa 'e 24 ki he 48 'o e clotting 'o e sinus cavernous 'e taha, 'oku mafola hangatonu 'a e septic thrombus 'i he tafa'aki 'o e halafakakavakava intercavernous ki he fehangahangai (contralateral) cavernous sinus, 'o fakatupu ai 'a e mata kehe 'o e mahaki ke fakafokifā 'a e 'edema 'i he tafa'aki 'o e mata, kemikale, proptosis, mo e neave 'o e 'ulu III/IV/VI 'o e 'uto. Ko e fakalakalaka hokohoko mei he tafa'aki 'e taha ki he tafa'aki 'e ua 'o e proptosis mo e ophthalmoplegia 'i ha mahaki mofi 'oku pathognomonic ki he thrombosis 'o e sinus 'o e septic cavernous kae 'oua kuo fakamo'oni'i 'oku kehe.

Konga 2: Fakafaikehekehe'i 'o e thrombosis 'o e sinus 'o e 'ana mei he seluliti 'o e 'atakai, seluliti kimu'a 'i he septal, mo e carotid-kavernous fistula¶

Faka'aonga'i 'a e tepile fakafehoanaki fakakiliniki ko 'eni ke fakafaikehekehe'i 'a e septic CST mei hono mimics ofi taha 'e tolu:

Konga 3: Ko e Ngaahi Me'amo'ui Fakatupu mo e 'Uhinga 'e Lava ke Hoko ai 'a e Stroke 'o e Carotid Artery 'i Loto¶

1. Ko e hā ‘a e Pekitilia ‘okú Ne Fakatupu ‘a e Thrombosis ‘o e Sinus Septic Cavernous?¶

Koe'uhi 'oku tupu 'a e septic CST mei he kili 'o e vestibule 'o e ihu/ngutu 'i 'olunga (Danger Triangle), ko e ngaahi sinus paranasal, pe ko e nifó, kuo pau ke fakataumu‘a vave ‘a e faito‘o faka‘empirical ki he ngaahi kulupu ‘e fā ‘o e ngaahi mahakí: - Ko e Sitafilokoka ʻAulosi (60% to 70% 'o e ngaahi keisi kotoa pe: #1 Fakakatoa 'o e Pathogen): 'Oku 'akauni 'e he meimei . 100% 'o e ngaahi keisi 'oku tupu mei he furuncles 'o e ihu, squeezed 'a e ngaahi 'uto 'o e fofonga, mo e lavea 'o e kili, pea mo ha vahevahe lahi 'o e ngaahi keisi 'o e sphenoid/ethmoid sinusitis 'oku 'ikai ke 'i ai ha 'uhinga. Ko e me'a 'oku ma'u 'e he komiuniti pea 'oku fekau'aki mo e tokanga'i 'o e mo'ui lelei Staphylococcus aureus (MRSA) 'oku fakautuutu 'a e angamaheni, 'o 'ai ke **Vancomycin (pe Linezolid/Daptomycin) 'i he veini 'o e empiric 'oku fakangatangata mei he Miniti 1. - Streptokoka Fa'ahinga (15% to 20%: Ko e niumonia 'o e 'uto, S. pyogenes, mo e kulupu Streptococcus 'o e 'uto/milleri): 'Oku angamaheni 'i he ngaahi keisi 'o e sinusoseni mo e 'otoseni. - Anaerobes 'o e ngutu & Sinus (10% to 15%: Fusobacterium necrophorum, Bacteroides, Prevotella, Peptostreptococcus): 'Oku angamaheni 'i he taimi 'oku tupu ai 'a e mahaki mei ha 'uto 'o e nifo (nifo), 'o e nifo 'o e 'uto, pe 'o e thrombophlebitis hange ko Lemierre. - Fungi 'o e 'uto 'i he suka / kau mahaki 'oku 'ikai ke nau lava 'o malu'i (Mucor / Rhizopus [Mucormycosis] mo e Asipekili fumigatus): - FUKA KULOKULA FAKAKILINIKI MAHU'INGA: 'I ha taha pe 'o e kau mahaki 'oku kovi hono mapule'i 'o e suka mellitus (especially Diabetic Ketoacidosis / DKA).ROCM), 'a ia 'oku fie ma'u vave 'i he 'uto 'o e Liposomal Amphotericin B (5 to 10 mg/kg/day) mo e tafa ‘oku ‘asi hake ‘i he debridement.

2. Ko e Faingata'a'ia 'o e 'Ateli 'o e Carotid 'i Loto (Mycotic Aneurysm and Ischemic Stroke)¶

Manatu'i ko e 'alati 'o e carotid 'i loto (ICA), ko e halanga toto tefito ‘okú ne ‘omai ‘a e totó ki he vahe tolu ‘e ua ‘i mu‘a ‘o e ‘utó, ‘oku fou hangatonu ia ‘i he lotolotonga ‘o e sinus cavernous ‘oku kaukau ‘i he pus mo e clot. - Ko e ‘ohofi ‘e he pekitiliá mo e vela lahi ‘o e ‘ā ‘o e ngaahi halanga totó (infectious arteritis) 'e lava ke ne fakatupu 'a e vasospasm, fakapuliki 'o e carotid (stenosis), ko ha septic carotid occlusion, pe ko ha aneurysm ‘o e ‘uto ‘oku ‘i he ‘ana, ‘o fakatupunga ai ‘a e stroke hemispheric ischemic ‘oku ‘ikai ke fu‘u lahi (fakafokifā ‘a e palalisia ‘o e nima/va‘e ‘o e contralateral mo e aphasia) ‘o a‘u ki he 100.000. 10 to 15 percent ‘o e kau mahakí. - 'Ikai ngata ai, necrosis 'o e kaunga'api kēleni 'o e pituitary (sella turcica) 'e lava ke precipitate 'a e 'uto, fakatu'utamaki ki he mo'ui ta'efe'unga 'o e adrenal hono ua (pituitary apoplexy / hypocortisolism), fakatupu 'a e ma'ulalo 'o e toto 'oku tali pe ki he mafasia-tu'unga 'o e hydrocortisone 'i he veini (100 mg IV STAT).

Konga 4: Tuʻunga Koula ʻo e Fakatotoloʻi ʻo e Falemahakí (MRI/MRV + . Contrast CT) mo e Faito‘o Pau .¶

‘I he taimi ‘oku a‘u atu ai ha mahaki ki he Potungāue Fakavavevavé ‘o mahalo‘i ‘oku ‘i ai ‘ene septic cavernous sinus thrombosis, ‘oku makatu‘unga ‘a e mo‘ui ‘o ‘ikai ha kui tu‘uloa pe stroke ‘i hono fakahoko ‘a e ngaahi ngāue fakafalemahaki ‘e fā ‘i he taimi tatau ‘i loto ‘i he ‘uluaki houá:

1. Meningeal-Tu'unga vave 'o e ngaahi faito'o faka'auha 'o e ngaahi 'enitipaiōtiki 'i he 'uto ('I loto < 60 Minutes)¶

Hili hono tā ha ongo seti ʻo e ngaahi anga fakafonua toto ʻo e aerobic mo e anaerobic (ʻa ia ʻoku lelei ʻi he 2010). 70% 'o e ngaahi keisi 'o e CST septic 'o e 'uto), 'oku fakahoko leva 'e he kau toketaa lotoloto-neave-sisitemi-hū (meningeal-tu'unga) 'enitipaiōtiki 'i he veini: - Konga 1 (Fakafepaki'i 'o e MRSA / Fakafepaki'i 'o e 'Ufi'ufi 'o e Staphylococcal): Vancomycin 'i he veini (15 to 20 mg/kg IV every 8 to 12 hours, mo ha . 25-30 mg/kg uta 'a e faito'o 'oku fakataumu'a ki he trough 15-20 mcg/mL) PE Linezolid 'i he veini (600 mg IV every 12 hours) ('a ia 'oku ne a'usia 'a e CSF ma'olunga ange mo e ngaahi tisiuu 'o e 'uto kapau 'oku fakafepaki'i 'a e vancomycin). (Kapau ʻe fakapapauʻi ʻe he ngaahi anga fakafonuá kimui ange ʻa e S. aureus ʻoku faingataʻaʻia ʻi he methicillin [1].MSSA], fakapuliki ki he tu'unga ma'olunga IV Nafsilini pe Okisasilini 2 g IV every 4 hours). - Konga 2 (To'utangata Tolu pe Fa 'o e Cephalosporin ki he Niumokoka & Gram-Negatives): Seftriaxone 'i he veini (2 grams IV every 12 hours: faito'o 'e ua 'o e meningeal kakato) PE Cefepime 'i he veini (2 grams IV every 8 hours) (kapau ‘oku mahalo’i ‘oku ‘i ai ‘a e Pseudomonas pe ko e faka’ali’ali ki he mo’ui). - Konga 3 ('Uto/Sina 'oku 'ikai ha 'ea): Metronidazole 'i he veini (500 mg IV every 6 to 8 hours). (Ko e me'a kehe, Meropenem 'i he veini 2 grams IV every 8 hours + Vancomycin 'oku ne 'ufi'ufi 'a e kalasi pekitilia kotoa pe 'e tolu 'i ha founga faito'o 'e ua). - Loloa ‘o e Faito’o IV: Si’isi’i taha ‘o e uike ‘e 3 ki he 4 ‘o e faito’o ‘enitipaiōtiki ‘i he ngaahi uoua (fakalahi ki he uike ‘e 6 ki he 8 kapau ‘oku ‘alu fakataha ia mo e osteomyelitis ‘o e hui ‘i mu’a/sphenoid pe ko e ‘uto/epidural abscess).

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

'Oku 'ikai ke kehekehe 'a e 'ulu CT scans 'oku misi 'o a'u ki he 30% to 50% 'o e ngaahi thromboses 'o e sinus 'o e 'ana 'i he kamata'anga. - Fakafehoanaki-Fakalahi 'o e 'uto MRI mo e MR Venography (MRV) ko e tu'unga koula fakatotolo 'oku ongo'ingofua taha: 'oku ne fakakaukau'i 'a e fakahangatonu fakalahi mo e convex lateral bulging 'o e ngaahi 'a 'o e sinus 'o e cavernous, 'ikai ha faka'ilonga 'o e tafe 'a e veini / fakafonu 'a e ngaahi kovi 'i loto 'i he sinus 'o e cavernous, dilation mo e thrombosis 'o e ve mata ma'olunga ange (SOV), fakalahi 'o e dural, mo e fakapuliki 'o e intracavernous 'i loto 'o e 'alati 'o e carotid. - Ma'olunga-Resolution Manifinifi-Slice (1 mm) Fakafehoanaki CT 'o e ngaahi 'Opiti mo e ngaahi Sinus 'o e Paranasal (CT Venography / CTV): Fakahoko vave 'i he tafa'aki 'o e MRI ke mape'i 'a e 'auha 'o e hui 'o e sphenoid mo e ethmoid sinus pea tataki 'a e endoscopic tafa 'o e vai.

3. Fakafepaki‘i ‘o e toto (Intravenous Unfractionated Heparin pē LMWH)¶

‘Oku totonu ke ke ‘oange ‘a e ngaahi faito‘o fakasi‘isi‘i ‘o e totó (anticoagulation) ki ha taha mahaki 'oku ma'u 'a e clot 'i he cavernous sinus? - Ko e Fakatahataha Fakakiliniki Lolotonga (AHA/ASA Cerebral Venous Thrombosis Guidelines & Ngaahi vakai'i 'o e Cochrane): 'I he taimi 'e taha 'a e neuroimaging (CT/MRI) 'oku 'ikai kau ai 'a e toto lahi 'i loto 'i he 'ulu pe ko ha ruptured 'a e mycotic aneurysm 'o e carotid, vave 'a e anticoagulation fakalahi mo e Heparin 'oku 'ikai ke vahevahe 'i he 'uto (UFH: ‘oku sai‘ia ange ‘i he ‘uluaki taimí koe‘uhi ‘e lava ke tāmate‘i ia pea fakafoki ‘aki ‘a e protamine ‘i ha ngaahi miniti ki mu‘a ‘i he tafa ‘o e sinus) pe ko e Heparin ‘oku Ma‘ulalo-Molekula-Mamafa (Enoxaparin 1 mg/kg SC every 12 hours) ta'ofi 'a e mafola 'o e clot 'i he tafa'aki 'o e intercavernous sinus ki he mata 'e taha pea fakalelei'i 'a e hū 'a e 'enitipaiotikí ki he thrombus, 'o fakasi'isi'i lahi 'a e mate (from -30% down to < 10-15%) mo e kui tu‘uloa ‘a e neave ‘o e ‘ulú. 'Oku angamaheni 'aki hono hokohoko atu 'o e anticoagulation 'i he uike 'e 6 ki he mahina 'e 3 kae 'oua kuo toe fakafoki 'a e ngaahi veini.

4. Pule'i 'o e Ma'u'anga Tokoni Fakavavevave 'o e Tafa (Endoscopic Sphenoidotomy / Ethmoidectomy pe ko e Fakatafe ʻo e ʻAbcess)¶

He ʻikai lava ʻe he faitoʻo ʻenitipaiōtikí mo e heparin ʻo fakaʻauha ha sinus sphenoid hui tāpuni ʻoku fonu ʻi he pus ʻoku fakamālohiʻí. Kapau 'oku 'ilo'i 'e he 'ata CT 'a e sinusitis 'o e sphenoid/ethmoid, ha 'uto 'o e 'atakai, pe ko ha 'uto 'o e nifo/fofonga, 'e 'ave fakavavevave 'e ha Otolaryngologist (toketā tafa ENT) pe Toketā tafa 'o e ngutu & 'o e fofonga 'a e mahaki ki he loki tafa ki he ScoFFESS: faka'auha 'o e sfenoidotomi mo e ethmoidectomy) pe ko e faka'auha 'o e 'uto. (Fakatokanga'i ange: 'Oku fakatafe 'e he kau toketā tafa 'a e sinus tefito pe ma'u'anga tokoni 'o e fofonga; 'Oku 'IKAI ke nau motuhi hangatonu ki he loki sinus cavernous 'iate ia pe).

Ngaahi fika fakavavevave fakavahefonua mo e triage neurovascular¶

Ko e mahalo'i 'o e septic cavernous sinus thrombosis 'oku fie ma'u ke 'ave vave 'a e me'alele fakahaofi mo'ui ki ha Potungaue Fakavavevave 'o e Falemahaki Stroke / Tertiary 'oku fakanaunau'i 'aki 'a e MRI/MRV houa 'e 24, tafa 'o e 'uto, tafa 'o e 'uto, tafa 'o e mata, mo e tafa 'o e telinga:

• 'Amelika mo Kanata: Taila ki he 911 he taimi pe ko ia. Pule'i 'i he malumalu 'o e Kautaha Fatu 'Amelika / Kautaha Stroke 'Amelika (AHA/ASA) Fakamatala Fakasaienisi ki hono Fakatotolo‘i mo hono Tokanga‘i ‘o e Thrombosis ‘o e Veini ‘o e ‘Utó (CVT), Sosaieti 'o e Ngaahi Mahaki Piki 'o 'Amelika (IDSA), mo e ngaahi fakahinohino AAO-HNS.
• United Kingdom: Taila ki he 999 pe 'alu leva ki ha falemahaki lahi 'o e kau mahaki faka'auha Potungaue Fakavavevave (A&E) mo e on-call ENT, Mata, mo e Neu/Tafa 'o e Neu. Pule'i 'i he malumalu 'o e Kautaha Stroke 'a 'Iulope (ESO) / NICE Ngaahi Fakahinohino ki he Thrombosis 'o e Veini 'o e 'Uto mo e ngaahi polokalama ENT UK.
• Iunioni 'Iulope: Tai 112. Pule'i 'i he malumalu 'o e Kautaha Stroke 'a 'Iulope (ESO) Ngaahi Fakahinohino ki hono Fakatotolo'i mo Faito'o 'o e Thrombosis 'o e Veini 'o e 'Uto.
• Aositelelia mo Nu'usila: Taila ki he 000 'i 'Aositelelia pe 111 'i Nu'usila. Pule'i 'i he malumalu 'o e Fakava'e 'o e Stroke / ANZAN mo e Ngaahi Fakahinohino Fakafaito'o: 'Enitipaiōtiki (Thrombosis 'o e Sinus 'o e Veini Sepitiki).
• Esia-Pasifiki: Taila ki he 119 (Siapani, Kōlea Tonga), 995 (Singapoa), pe 112 / 108 (ʻInitia). Kole ke hiki vave ki ha senitā tafa neave mo e ENT ʻi he akoʻanga māʻolungá.

Ngaahi fehu'i 'oku toutou 'eke .¶

Ko e hā ʻa e "Tafaʻaki Tolu Fakatuʻutāmaki ʻo e Fofongá," pea ko e hā ʻe lava ai ʻe hono lomiʻi ha pimple ʻi aí ʻo fakatupu ha foʻi toto ʻi he ʻutó?¶

Ko e "Danger Triangle of the Face" ko e sone tapatolu ia 'oku lele mei he bridge 'o ho ihu 'o hifo ki he tuliki to'ohema mo e to'omata'u 'o ho ngutu, kau ai ho ihu, ngaahi ava 'o e ihu, mo e ngutu 'i 'olunga. ‘I he ‘ikai hangē ko e ngaahi veini ‘i he toenga ‘o ho sinó ‘a ia ‘oku ‘i ai ‘enau ngaahi valve ‘oku ‘i ai ‘a e ngaahi valve ‘e taha ke tauhi ‘a e totó ke tafe pē ki ho lotó, ko e veini ‘o e fofongá (vein angular) mo e ngaahi veini mata ‘i ‘olunga mo mā‘ulalo ‘oku takatakai ‘i ho matá ‘oku ‘ikai ha‘anau valve. 'I he taimi 'oku ke squeeze pe pop ha vela loloto pe pimple ('oku angamaheni 'aki 'a e ma'u 'e he Staphylococcus aureus) 'i loto 'i he ngaahi ava 'o e ihu pe ngutu 'i 'olunga, 'oku takatakai 'a e fula 'oku ne ta'ofi 'a e tafe angamaheni ki lalo, pea 'oku teke 'e he squeezing 'a e toto mo e pekitilia 'oku ma'u ki mui 'o fakafou 'i he ngaahi veini 'o e mata 'o e cavernous 'a e brainus.

Ko e hā ʻoku hoko ai ha taʻemalava ke tafoki ʻa e mata ʻe taha ki tuʻá ("palasi ʻo e neave hono ono") ko e fakaʻilonga fakatokanga vave taha ia ʻo e thrombosis ʻo e sinus cavernous?¶

'Oku fakalaka 'a e ngaahi neave 'o e 'ulu 'e nima 'i he sinus cavernous 'i honau hala ki he mata mo e fofonga: 'Oku tucked malu 'a e ngaahi neave 'o e 'ulu III, IV, V1, mo e V2 'i loto 'i he 'ā 'i tu'a fibrous fefeka 'o e sinus, ka ko e neave 'o e 'ulu VI ('a e neave abducens floward unwardly ki tu'a eproat completly) ‘o fou tonu ‘i he lotolotonga ‘o e vaitupu totó ‘i he tafa‘aki ‘o e ‘alati ‘i loto ‘o e ‘utó. ‘I he taimi ‘oku fuofua hū ai ‘a e fanga ki‘i pekitilia mo e ngaahi fo‘i toto ki he sinus cavernous, ko e Cranial Nerve VI ‘a e fuofua neave ‘oku kaukau ‘i he pus mo e tenge. Ko ha mahaki ‘oku ‘i ai ‘ene mahaki ‘i he sinus pe ko e vela ‘a e fofongá pea fakafokifā pē ‘ene sio fakahosite koe‘uhi ‘oku ‘ikai lava ke tafoki ‘a e mata ‘e tahá ki tu‘a ‘oku fiema‘u ki ai ha faito‘o fakavavevave MRI/MRV mo e IV ‘enitipaiōtiki ‘i he taimi pē ko iá.

‘Oku anga-fēfē hono tala ‘e he kau toketaá ‘a e faikehekehe ‘i he vaha‘a ‘o e mahaki selula ‘o e ‘ōlitá mo e thrombosis ‘o e sinus cavernous?¶

Lolotonga ‘oku lava ke fakatupu ‘e he ongo tu‘ungá fakatou‘osi ha mata kulokula, fula, puna (proptosis), mofi, mo e mamahi pe fakangatangata ‘a e ngaue ‘a e matá, ‘oku tuhu ‘a e ngaahi faka‘ilonga ‘e tolu ki he thrombosis ‘o e sinus cavernous: (1) Mafola ‘i he ongo tafa‘akí: koe‘uhi ‘oku fehokotaki ‘a e sinus cavernous to‘ohema mo e to‘omata‘ú ‘i he tafa‘aki ‘o e midline, . mei he ‘uluaki matá ki he mata ‘e tahá ‘i loto ‘i he houa ‘e 24 ki he 48; (2) Ko e ngingila ‘a e neave ‘o e trigeminal: ko hono fō pe ala ma‘ama‘a ki he la‘e ‘o e tokotaha mahakí (CN V1) pe kou‘ahe ‘i ‘olunga (CN V2) ‘oku fakahaa‘i ai ‘a e ngingila pe mole ‘a e reflex ‘o e kuikui ‘a e mata‘itofé; pea (3) Toxicity neurological lahi, kau ai 'a e mamahi 'ulu agonising 'i mui 'i he mata, fefeka 'a e kia, dilated/sluggish pupil, mo e ngaue 'aisi kakato 'o e mata 'o 'ikai ke fe'unga mo e fula 'o e mata.

Ko e ha mo'oni 'a e tupu'anga #1 'o e thrombosis 'o e sinus septic cavernous he 'aho ni kapau 'oku 'ikai ke ne 'omi 'a e ngaahi 'uto?¶

Kimu'a pea toki 'ilo'i 'a e ngaahi faito'o faka'auha, ko hono 'omi 'o e fofonga mo e ihu ("furuncles") 'i loto 'i he Tafa'aki Tolu Fakatu'utamaki ko e tupu'anga tefito ia 'o e cavernous sinus thrombosis. ‘I he ‘ahó ni, neongo ‘oku kei fakatupunga ‘e he ngaahi vela ‘o e ihú ‘a e peseti ‘e 15 ki he 25 ‘o e ngaahi keisi, ko e tupu‘anga fakaeonopooni #1 (‘oku fatongia‘aki ‘a e peseti ‘e 50 ki he 60 ‘o e ngaahi keisi) ko e sphenoid sinusitis mo e ethmoid sinusitis ‘oku fakatupu ‘e he pekitilia fakatu‘utāmakí. Koe'uhi 'oku tangutu loloto 'a e sinus sphenoid 'i mui 'i he ihu 'oku mavahe mei he sinus cavernous 'e ha puipui hui 'oku si'i hifo 'i he 0.5 milimita manifinifi ('a ia 'oku fa'a 'i ai ha ngaahi ava fakanatula 'o e microscopic), 'e lava ke erode hangatonu ha mahaki sinus loloto 'oku 'ikai faito'o 'o fakafou 'i he sinus cavernous.

Ko e hā ‘oku ‘oange ai ‘e he kau toketaá ‘a e ngaahi faito‘o fakasi‘isi‘i ‘o e totó (Heparin) ki ha fo‘i huhu‘a ‘oku puke ‘i loto ‘i he cavernous sinus?¶

‘I he ‘uluaki vakaí, ‘oku ongo fakatu‘utāmaki ‘a hono ‘oange ha me‘a fakamānifi toto lolotonga ha mahaki, ko e ‘uhinga ia ‘oku ‘uluaki fakahoko ai ‘e he kau toketaá ha CT mo e MRI ke fakapapau‘i ‘oku ‘ikai ha tafe toto ‘i he ‘utó ‘oku ngāue. Ko e taimi pē ʻoku fakaʻehiʻehi ai ʻa e tafe toto, ʻoku fakahoko ʻe he heparin ʻoku ʻikai ke vahevahe ʻi he uoua (pe heparin ʻoku maʻulalo-molekula-mamafa) ʻi he tafaʻaki ʻo e ngaahi faitoʻo ʻenitipaiōtiki ʻi he uoua ʻo e tuʻunga maʻolunga ha fatongia mahuʻinga fakahaofi moʻui: ʻokú ne taʻofi ʻa e toto septic mei he mafola ʻi he ngaahi uoua intercavernous ki he branous ʻo e mata ʻe taha ʻo e sin ‘okú ne ta‘ofi ‘a e ‘alati ‘i loto ‘o e carotid mei he‘ene tō pea fakatupunga ai ha fu‘u stroke lahi, pea ‘okú ne tauhi ‘a e ngaahi halanga ‘o e ngaahi uoua ke fakaava koe‘uhi ke lava ‘a e ngaahi faito‘o ‘enitipaiōtiki ‘i he uoua ‘o hū ki he mahakí.

Ko e hā ʻoku totonu ke u fai kapau ʻoku ʻi ai haʻaku vela mamahi ʻi loto ʻi hoku avaʻi ihú pe ʻi hoku loungutu ʻi ʻolungá he taimí ni?¶

ʻUluakí, taʻofi ho nimá mei ai: ʻoua naʻá ke teitei lomiʻi, fī, toʻo, pe pop ia ʻaki ha tuitui. Fakaʻaongaʻi ha tupenu fufulu maʻa, māfana, mo sūsū ʻo ʻai māmālie ki he feituʻú ʻi ha miniti ʻe 15 tuʻo tolu ki he tuʻo fā he ʻaho ke fakalotolahiʻi ʻa e tafe fakanatula ki tuʻa ʻo ʻikai ha fakamālohi. Vakai ki ha toketā ‘i he ‘aho tatau pē ki ha faito‘o fakafaito‘o ‘oku faka‘aonga‘i ki ai ‘a e mupirocin (2%) mo e ngaahi faito‘o ‘enitipaiōtiki ngutu ‘oku nau ‘ufi‘ufi ‘a e Staphylococcus aureus (pea mo e MRSA kapau ‘oku mafola ‘i ho komiunitií). Kapau te ke maʻu ha mofi, ʻo mafola ʻa e kulokula ki ho tuliki ʻi loto ʻo e matá, mamahi ʻulu ʻi mui ʻi ho matá, fula ʻa e ʻuhikiʻi matá, pe sio lōua, ʻalu hangatonu ki ha potungāue fakavavevave ʻi he falemahakí.

Ngaahi ma'u'anga fakamatala mo e fakahinohino faka'ofisiale .¶

• Kautaha Loto 'Amelika / Kautaha 'Amelika 'o e Stroke (AHA/ASA, 'Iunaiteti Siteiti): Malanga fakasaienisi: Fakatotolo mo e Pule'i 'o e Thrombosis 'o e 'Uto (CVT) mo e Septic Cavernous Sinus Thrombosis (* Stroke *, fakafehoanaki 'a e MRI / MRV fakatotolo'i koula CNS tu'unga, e-spect- 'oku 'ikai ke vahevahe/LMWH heparin fakafepaki'i 'o e toto).
• Sosaieti Mahaki Piki 'o 'Amelika (IDSA, 'Iunaiteti Siteiti): Ngaahi Fakahinohino ki he Ngaue Fakafaito'o ki he Ngaahi Faingata'a'ia'anga 'o e Suppurative 'o e Sinusitis mo e Ngaahi Mahaki 'o e Fofonga (empiric 'i he 'uto 'o e vancomycin fakataha mo e to'utangata hono tolu/fa 'o e cephalosporin mo e metronidazole).
• Kautaha Stroke 'a 'Iulope (ESO) & 'Inisititiuti Fakafonua ki he Mo'ui Lelei mo e Tokanga'i Lelei (NICE, 'Iulope / Pilitania): Ngaahi Fakahinohino ki hono Fakatotolo'i mo e Faito'o 'o e Thrombosis 'o e Veini 'o e 'Uto (malu 'o e anticoagulation mo e pule'i 'o e ma'u'anga tokoni tafa).
• Ako'anga 'Amelika 'o e Otolaryngology-Tafa 'o e 'ulu mo e kia (AAO-HNS, 'Iunaiteti Siteiti) & ENT UK: Ngaahi faingata'a 'o e 'uto 'o e 'uto (Sphenoid/Ethmoid 'o e 'uto, Chandler 'o e ngaahi faingata'a 'o e 'uto Siteisi V Thrombosis 'o e 'uto 'o e 'uto. Thrombosis 'o e 'uto 'o e 'uto)
• Akatemi 'Amelika 'o e Mata (AAO): Neuro-Mata Triage 'o e Cavernous Sinus Syndrome (Na'e fakamavahe'i 'a e neave 'o e 'ulu 'o e 'ulu VI Abducens Palsy, Trigeminal V1/V2 Hypoesthesia, mo e mafola 'o e 'uto 'o e 'uto).

Ngaahi fakahinohino fekau'aki¶

• Ko e mahaki selula ‘o e ‘ōlitá, thrombosis ‘o e sinus cavernous, mo e ngaahi mahaki fakatu‘utāmaki ‘o e fofongá ‘i he tafa‘aki tolu
• Ko e mastoiditis fakatu'utamaki: 'oku 'asi mai 'a e pinna 'o e telinga mo e thrombosis 'o e sinus sigmoid
• Ko e mahaki meningitis mo e septicemia meningococcal 'oku 'ikai ke faka'uli 'a e 'uto
• Ko e mahaki selula, elisipela, lymphangitis kulokula streaking, mo e fakalakalaka 'o e sepsis 'o e 'uto
• Ko e palsy 'a Bell vs. stroke 'a e fofonga 'o e droop, la'e sparing, mo e mata taping