Pediatr Radiol DOI 10.1007/s00247-014-3272-x
Facial vein thrombophlebitis: an uncommon complication of sinusitis Claudia Cotes & Roy Riascos & Leonard E. Swischuk
Received: 12 September 2014 / Revised: 11 November 2014 / Accepted: 26 December 2014 # Springer-Verlag Berlin Heidelberg 2015
Abstract Facial vein thrombophlebitis is an uncommon complication of sinusitis. In cases where periorbital swelling complicating sinusitis is diagnosed, clinical findings of swelling and erythema extending beyond the orbital region into the cheek should alert the physician about this unusual complication and the need for further contrast-enhanced imaging and venography. The radiologist must be particularly careful in the evaluation of vascular structures of the face and neck in these children. CT and MRI with contrast material and MR venography are studies that clearly demonstrate the vascular anatomy and possible complications. However, MR venography confirms flow abnormalities within the venous system with the advantage of avoiding radiation exposure to the pediatric patient.
Keywords Child . Computed tomography . Facial vein . Magnetic resonance venography . Preseptal cellulitis . Superior ophthalmic vein . Sinusitis . Thrombophlebitis
Introduction Facial vein thrombophlebitis is a rare complication of sinusitis that may arise from secondary preseptal cellulitis in children. Cases of sinusitis with preseptal cellulitis in which swelling and erythema extend beyond the orbital region into the cheek and face should alert the physician about this unusual complication and the need for further contrast-enhanced imaging and venography to evaluate the vascular structures of the face and neck. We report a case of a 10-year-old girl with frontal, ethmoidal and maxillary sinusitis complicated by an unusual course of preseptal cellulitis in which inflammatory changes involved not only the preseptal region but also the right cheek and face. Imaging findings included right superior ophthalmic and facial vein thrombophlebitis, with thrombi extending into the right internal jugular vein. It is important for the radiologist to be particularly careful in the evaluation of vascular structures of the face and neck in these children in order to obtain an early diagnosis and avoid a fatal outcome.
C. Cotes (*) Department of Radiology, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0709, USA e-mail: [email protected]
R. Riascos Department of Diagnostic and Interventional Imaging, The University of Texas Medical School, Houston, TX, USA L. E. Swischuk Department of Pediatrics and Pediatric Radiology, The University of Texas Medical Branch, Galveston, TX 77555-0709, USA
A 10-year-old girl presented to the emergency department with a swollen right eyelid, watery eyes with purulent discharge and fever up to 103°F. She also complained of sore throat and nasal congestion for approximately 1 week. She had visited the emergency department the day before and was discharged on clindamycin with a diagnosis of preseptal cellulitis. However she continued to worsen clinically and returned. No visual symptoms such as blurry vision, proptosis or pain were reported and she did not recall any bug bites to the face. Her medical history was positive for allergic rhinitis and asthma. Physical examination revealed tachycardia with a heart rate of 118 beats per minute. The right upper and lower eyelids
were edematous and erythematous, with extension of swelling over the right nasal ridge and forehead. The area was not painful to palpation and no secretions were seen. No eye pain or double-vision was documented. The diagnosis of preseptal cellulitis was again considered and the girl was admitted to the pediatric ward on intravenous ceftriaxone. However, the girl’s status continued to deteriorate, with increasing tachycardia, poor oral intake and increased swelling. She was unable to open her eyes, and edema along the right forehead worsened. The facial erythema extended along the right cheek. Trace injection of the right sclera was observed in the ophthalmological exam. A CT of the face was requested and broadspectrum antibiotics were started. Contrast-enhanced CT of the face demonstrated fat stranding and edema affecting the right preseptal periorbital region. Inflammation extended into the right lower eyelid, cheek, lateral face and forehead. A minimal amount of stranding was visualized adjacent to the right frontal sinus in the intraorbital region. The right sclera and lacrimal gland showed increased enhancement suggesting conjunctivitis. Near-complete opacification of the right frontal sinus and mucosal thickening of the right anterior ethmoidal air cells and maxillary sinus were seen as well as an occluded right osteomeatal complex (Fig. 1). In addition, the superior ophthalmic and angular veins did not show contrast opacification (Fig. 2). The right facial vein was engorged, did not opacify after contrast administration and demonstrated surrounding inflammatory changes along its course (not illustrated). A hypodense filling defect was observed prior to its drainage into the internal jugular vein, with extension into the latter. A diagnosis of right preseptal cellulitis, possibly originating from frontal sinusitis and complicated by facial and superior ophthalmic vein thrombophlebitis, was made. No cavernous sinus involvement was observed. Further evaluation with contrast-enhanced MRI and timeof-flight MR venography demonstrated inflammatory
Fig. 1 Axial contrast-enhanced CT of the face with contrast at the level of the frontal bones demonstrates opacification of the right frontal sinus (arrow) along with fat stranding and swelling of the soft tissues of the right forehead (arrowheads)
Fig. 2 Axial contrast-enhanced CT of the face with contrast at the level of the orbit demonstrates opacification of the right ethmoid sinus (*). Focal fat stranding can be seen in the soft tissues adjacent to the medial and inferior walls of the ethmoid and frontal sinuses, respectively (white arrowhead). The right superior ophthalmic vein shows no opacification compared to the opposite side (black arrow). Similar lack of enhancement affects the right angular vein (white arrow). Note swelling and mild fat stranding of the preseptal soft tissues
changes in the soft tissues of the right orbit without abscess formation. Lack of opacification of the facial and superior ophthalmic veins was again documented (Fig. 3), as well as acute right maxillary and frontal sinusitis. Marked inflammatory changes were seen along the right preseptal region (Fig. 3). The right facial vein was thickened and demonstrated a hypointense filling defect throughout its course as well as surrounding increased T2 signal and enhancement along the right cheek compatible with cellulitis (Fig. 4). Extension of the filling defect from the distal right facial vein into the right internal jugular vein was clearly depicted (Figs. 5 and 6). No dural venous sinus or cavernous sinus thrombosis was seen (Fig. 7). MR venography demonstrated lack of signal within the right facial vein up to its drainage into the internal jugular vein.
Fig. 3 Axial T1-W fat-saturated post-contrast MR of the face at the level of the orbit demonstrates lack of enhancement of the right superior ophthalmic vein (black arrow) and right angular vein (white arrow). Mucosal enhancement and fluid contents affect the right ethmoid sinus (*). Note marked stranding and enhancement of the preseptal soft tissues (arrowhead)
Fig. 4 Axial T1-W fat-saturated post-contrast MR of the face at the level of the maxilla demonstrates increased diameter, surrounding enhancement and hypointense filling defect affecting the right facial vein (arrow). The left facial vein shows normal morphology and enhancement (arrowhead). Note enhancement and stranding of the right cheek
Fig. 6 Axial T1-W fat-saturated post-contrast MR of the face demonstrates a hypointense filling defect within the right internal jugular vein
Pediatric orbital cellulitis describes a group of pathologies ranging from periorbital inflammation to subperiosteal and orbital abscess. Infection of the periorbital tissues occurs most commonly as a complication of acute sinusitis [1, 2]. Trauma and bacteremia have also been described as common causes for preseptal cellulitis . Regardless of the cause, progression of inflammatory changes in the orbital region can result in
complications such as cavernous sinus thrombosis and Lemierre syndrome with septic emboli when involvement of superficial subcutaneous veins of the face and deep cervical veins occurs [3, 4]. The facial vein is the main drainage of the face. It receives the drainage of the supratrochlear and supraorbital veins and descends along the side of the nose. This segment is also known as the angular vein. It crosses the mandibular angle and enters the neck, where it drains into the internal jugular vein. Both the superior and inferior ophthalmic veins within the orbit communicate with the facial vein anteriorly and drain into the cavernous sinus. The facial vein has been described as a valveless structure in which the previously described anastomoses may result in cavernous sinus or internal jugular vein thrombosis when infection or inflammation occurs . More recent studies have revealed that the facial and superior ophthalmic veins are not valveless and suggest that the consistent communication of the facial vein with the cavernous sinus and the normal direction of blood flow within these structures is what determines the spread of infection . Facial vein thrombophlebitis is an uncommon complication of facial cellulitis and periorbital cellulitis, both of which
Fig. 5 Axial T1-W fat-saturated post-contrast MR of the face at the level of the mandible demonstrates a hypointense filling defect within the distal right facial vein at the junction with the internal jugular vein (arrow). Note the difference in diameter and surrounding inflammatory changes compared to the left distal facial vein
Fig. 7 Axial T1-W fat-saturated post-contrast MR of the face demonstrates normal enhancement right and left cavernous sinuses (arrows)
Microbiology cultures of the purulent secretions from the girl’s right eye demonstrated coagulase-negative Staphylococcus and she showed clinical improvement with antibiotic therapy. Additional workup revealed a heterozygote factor V Leiden mutation. She was discharged on cefdinir and Lovenox (Sanofi US, Bridgewater, NJ) after 2 days when symptoms improved. Follow-up imaging obtained a month after the initial visit revealed resolution of the facial and superior ophthalmic vein thrombosis, cellulitis and sinusitis.
can result from sinusitis, as in our case. Coagulase-negative Staphylococcus was isolated from our patient’s orbital purulent secretions; Staphylococcus has been described as a frequent isolate in periorbital cellulitis and a common pathogen in the pediatric nasal and sinus mucosa. Fusobacterium necrophorum, the most common organism recovered from cases of septic embolization such as Lemierre syndrome, was not isolated from our patient. Hypercoagulability, including the factor V Leiden mutation, has been documented as a risk factor and was unknowingly present in our patient. Acquired risk factors such as infection with associated inherited thrombophilia may contribute to the development of thrombus. Clinically, facial vein thrombophlebitis is recognized by pain, heat, tenderness, erythema and induration affecting the involved vein and its surroundings . It is usually a unilateral finding, often preceded by trauma or infection . Fever and leukocytosis are often present . Although in some cases a cord-like palpable structure representing the palpable inflamed facial vein is found on physical exam, this is not always the case. Other more common pathologies in the differential diagnosis such as cutaneous infection, maxillary cellulitis or periorbital cellulitis are usually considered first, leaving this possible lethal entity undiagnosed . In cases where periorbital infection is diagnosed, this potential complication should be considered; it is usually linked to acute sinusitis if no obvious causes such as trauma or external ocular infection are present. Clinical findings of swelling and erythema extending beyond the orbital region into the cheek in these children should alert the physician to consider imaging and prompt attention to the vascular structures of the face, neck and orbit by the radiologist. In addition, careful evaluation for acute frontal and anterior ethmoidal sinusitis should also be pursued . Contrast-enhanced cranial or orbital CT including the sinuses is indicated when intracranial or orbital complications of sinusitis are suspected . CT is a better examination for the evaluation of bony abnormalities than MRI; however the latter is more sensitive for the detection of intracranial complications that are sometimes not depicted on initial CT imaging . Contrast-enhanced CT of the face and neck is the study of choice in the evaluation of vascular thrombosis of the face and neck and it may also identify associated and causal, unsuspected pathology, as in our case . Doppler US could show the filling defect and flow disturbance within the facial vein . However Doppler US is not routinely performed because facial vein thrombosis is not always diagnosed clinically. CT findings of venous thrombosis include hypodense filling defects or lack of opacification of the vein of concern. Surrounding inflammatory changes such as fat stranding, vessel wall enhancement and increase of the vessel diameter should raise suspicion for acute thrombosis and thrombophlebitis in the appropriate clinical setting. Comparison with the contralateral normal side is of great value and
shows asymmetry of the facial veins, as in our case. Careful evaluation of the internal jugular vein and cavernous sinus should be conducted in these cases. Contrast-enhanced MRI and MR venography confirm flow abnormalities within the vascular structures of the face and neck . This modality helps in the evaluation of venous thrombosis with the advantage of eliminating radiation exposure to the pediatric patient. Treatment of facial vein thrombophlebitis differs from that of other superficial thrombophlebitides given its potentially fatal complications . Besides symptomatic treatment with heat compresses and anti-inflammatory drugs, systemic antibiotic and anticoagulant therapy is necessary [3, 4, 7]. Children who develop life-threatening thrombosis benefit from a search for genetic or congenital causes, as in our case, that might lead to prophylactic treatment that can possibly prevent other hypercoagulability complications. However screening for thrombophilia is not a routine practice and only after other risk factors such as infection or trauma are resolved can the need for lifelong anticoagulation be considered.
Conclusion Preseptal cellulitis is a common pathology in children that is usually caused by trauma, bacteremia, or more commonly acute sinusitis. Regardless of the cause, this entity is usually confined to the periorbital soft tissues. Refractory cases with an unusual course suggested by increased swelling and erythema that extends into the cheek as in our case should alert the physician to the need of further imaging and prompt attention to the vascular structures of the face and neck. Clinical suspicion and detailed imaging analysis are crucial to prevent fatal outcomes. Contrast-enhanced CT is usually performed in the emergency setting; however contrast-enhanced MRI and MR venography demonstrate venous involvement of the facial vein and its possible complications with the advantage of eliminating radiation exposure to the child. Early diagnosis and treatment can only be reached with early suspicion and radiologic imaging.
Conflicts of interest None
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