Infratentorial subdural empyema, pituitary abscess, and septic cavernous sinus thrombophlebitis secondary to paranasal sinusitis: Case report

OBJECTIVE AND IMPORTANCE: Infratentorial empyema, pituitary abscess, and se ptic cavernous sinus thrombophlebitis are all rare and potentially lethal c onditions. The occurrence of all three in a single patient has not previous ly been described. We present such a case occurring in a young, otherwise h ealthy man. CLINICAL PRESENTATION: A 26-year-oId man with a remote history of sinusitis develope d rapidly progressive headache, fever, right eye pain, swelling, proptosis, and visual impairment. Magnetic resonance imaging demonstrated diffuse pan sinusitis, including sphenoid sinusitis, and extension of inflammation and infection into the adjacent cavernous sinuses, pituitary gland, and posteri or fossa. INTERVENTION: Urgent drainage of the ethmoid and maxillary sinuses was perf ormed; pus was not identified. The patient continued to deteriorate clinica lly with worsening of visual acuity. Computed tomography of the head perfor med the next day revealed worsening hydrocephalus and an enlarging posterio r fossa subdural empyema. Urgent ventricular drainage and evacuation of the empyema was performed, and subsequently, the patient's clinical course imp roved. The microbiology results revealed alpha hemolytic streptococcus and coagulase-negative staphylococcus species. The patient survived but during the follow-up period had a blind right eye and pituitary insufficiency. CONCLUSION: Paranasal sinusitis can have devastating intracranial sequelae. Involvement of the adjacent pituitary gland and cavernous sinuses can resu lt in serious neurological morbidity or mortality, and retrograde spread of infection through the basal Venous system can result in subdural or parenc hymal brain involvement. A high index of suspicion and aggressive medical a nd surgical treatment are crucial for patient survival, but the morbidity r ate remains high. Our patient survived but lost anterior pituitary function and vision in his right eye.