We may also have exophthalmos on one side or both, with conjunctival injection, edema of the lids, and disturbances of vision, due to thrombosis of the cavernous sinus and stasis in the ophthalmic vein. In thrombosis of one transverse sinus only the internal jugular on that side will carry less blood. So long as that on the other side is free it will take that which cannot pass through the obstructed one. Consequently the jugular on the other side will carry more. But if the contained clot extend so far that direct communication with the internal jugular is interfered with then the internal jugular of the affected side will be almost empty, while the external of the same side will be the more distended. When the eye is protruded and the frontal vein distended it is evident that the cavernous sinus on that side is involved. If the superficial veins of the scalp be distended it is the superior longitudinal sinus which is at fault. When the veins of the mastoid region are involved, we may locate the thrombus in the transverse sinus; when there are no localizing symptoms, it can only be said in a general way that thrombosis has occurred.
Prognosis.
—Prognosis is always unfavorable, though recovery is not impossible. The therapeutics are in the main prophylactic. By actual physiological rest the possibility of pulmonary complications can be diminished. The treatment, aside from this, is purely operative, and will be discussed elsewhere.
C. Sinus Phlebitis.
—This may be the result—
- (a) Of thrombosis; or,
- (b) The continuation of suppurative processes from neighboring tissues.
Symptoms.
—The symptoms are seldom diagnostic. Sinus phlebitis is often accompanied by meningitis, even encephalitis. The first symptom is usually severe headache, often localized, made worse by pressure. Anorexia with early mental disturbance and often delirium follows, with vomiting, restlessness, and mania, changing to stupor and coma. Rigidity or spasm of cervical muscles, or of those of the extremities, followed by paralyses, is often seen. Evidences of irritation of special nerves, particularly the oculomotor or the vagus, are not rare. When pyemic symptoms occur they are vague and are most conspicuous in the lungs and liver. Taken in conjunction with aggravating brain symptoms they make prognosis unfavorable.
Symptoms will in large measure depend upon the sinus most involved. They are characteristic if this be the cavernous sinus. There are disturbances in the eye on the same side, congestion of orbital veins, pain and photophobia, and, later, cloudiness of the cornea and edema with exophthalmos. Finally the pupil becomes paralyzed and dilated, the cornea loses its polish, the upper lid cannot be raised, and, if the case persists, the cornea ulcerates. Along with these local evidences there will be complaint of frontal pain, usually with paralysis of the hypoglossal nerve and consequent thickness of speech. When the transverse sinus is involved there are, first, vagus irritation, then paralysis with paralytic sequences in the muscles of the jaw, the tongue, palate, pharynx, etc. Diaphragmatic motions are interfered with and the character of the respiration altered. As the trouble extends to the internal jugular we have further paralysis of accompanying nerves, especially of the hypoglossal. As the irritation extends down the vein there will be tenderness, rigidity, and often swelling. The local signs and symptoms vary obviously as the lesion extends from one sinus to the other, for when one cavernous sinus is involved the trouble nearly always extends to the other, and local symptoms are repeated upon the opposite side.