Bilateral sixth nerve paralysis as a sequelae of cavernous sinus thrombosis in a child

A five year old male child presented with complaint of inward deviation of the left eye for the past two days. There was history of fever with cellulitis and boil over the tip of nose for the past two weeks for which the child was treated outside. On general examination, there was cellulitis over the tip of nose. The child was febrile. On ocular examination, visual acuity was 66 in both eyes. Anterior segment examination and fundus were normal. Orthoptic assessment of the child revealed left convergent squint. There was limitation of abduction in both eyes right eye more than left eye. A clinical diagnosis of bilateral sixth nerve palsy probably due to cavernous sinus thrombosis due to spread of infection from dangerous zone of face was made. The child was advised emergency MRI brain with contrast and systemic antibiotics and steroids. The child was started on parenteral cloxacillin, amikacin, metrogyl, and cefotaxime. Inj dexamethasone 2 mg was given intravenously for three times a day in paediatric hospital. MRI brain was normal. After one week there was improvement in abduction of both eyes with residual abduction limitation in left eye. With the clinical features of bilateral sixth nerve palsy with infection in the dangerous area of face suggestive of cavernous sinus thrombosis as a possibility, the child was treated with parenteral broad spectrum antibiotics and steroids. Clinically the child improved. This is to emphasize the importance of starting earlier broad spectrum antibiotics and steroids in case of suspicious facial infections to prevent the complications of cavernous sinus thrombosis.