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Intracranial Epidural Abscess in the Setting of Sinusitis

Intracranial Epidural Abscess in the Setting of Sinusitis. Peter Morgenstern, MS4. M.B. 32 RHM c/o headache + retro-orbital pain x 3d Denies fevers, chills, nausea, vomiting, photophobia, neck stiffness, vision changes, nasal drainage PMH – Samter’s Triad Asthma

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Intracranial Epidural Abscess in the Setting of Sinusitis

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  1. Intracranial Epidural Abscess in the Setting of Sinusitis Peter Morgenstern, MS4

  2. M.B. • 32 RHM c/o headache + retro-orbital pain x 3d • Denies fevers, chills, nausea, vomiting, photophobia, neck stiffness, vision changes, nasal drainage • PMH – Samter’s Triad Asthma • PSxH – Multiple nasal polypectomies (2005, 2007, 2009)

  3. M.B. • Denies smoking, minimal alcohol use • Meds: Ventolin inhaler, fluticasone, flovent • Allergies: Aspirin, Ibuprofen • Exam • Afebrile • Well-appearing, uncomfortable 2/2 HA • HEENT: frontal and maxillary sinus tenderness • Neuro: intact

  4. M.B. • 101 11 • 105 • 3.6 26.3 0.9 15.2 15.4 209 41.1 PT 13.5 PTT 21.0 INR 1.1

  5. Imaging – Pre-op

  6. CNS Abscess • Epidural • Spinal • Intracranial • Subdural • Intraparenchymal

  7. Intracranial Epidural Abscess • Predisposing factors • Sinusitis • Neurosurgical Procedure • Trauma • Numerous causative organisms • Incidence decreasing • Morbidity/Mortality decreasing Hlavin et al. 1994

  8. Presentation and Diagnosis • Fever, headache, nausea/Vomiting • Confusion, agitation, seizures, hemiparesis, cranial neuropathies • Periorbital cellulitis or frontal edema (45%)1 • CT and MRI • Other studies Pradilla et al. 2009

  9. Management Hastings 1907

  10. Management • Surgical • Drainage – ENT and Neurosurgical • Trans-ethmoidal drainage1 • Removal of infected bone, possible CSF diversion • ENT in the acute setting2 • Medical • Antibiotics • Possible AEDs, corticosteroids, hyperosmolar fluids • Hyperbaric oxygen therapy3 • Role for conservative approach4 1. Patron et al. 2010 2. Delgaudio et al. 2010 3. Heran et al. 2003 4. Baechli et al. 2008

  11. Outcomes • Historically poor • Favorable in most cases today • Positive predictors young age, - encephalopathy, neuro deficit, comorbidities • Negative predictors – herniation, delayed neuroimaging, delayed diagnosis

  12. M.B.

  13. M.B. • Urgent bifrontal craniotomy • Broad-spectrum antibiotics after OR culture • Vancomycin, Gentamycin, Metronidazole • Consult with ENT and ID • Modify antibiotic coverage based on culture

  14. Imaging – Post-op

  15. M.B. • Uncomplicated post-op course • Notable improvement in symptoms • Discharged on POD #7 • 4-6 week course of IV vancomycin and ceftriaxone pending cultures • Culture: pan-sensitive coagulase negative staphylococcus

  16. Conclusions • Maintain high clinical suspicion • Image early • Collaborative approach • Aggressive drainage + antibiotic therapy • Are more rigorous studies needed?

  17. Thank You

  18. References • Baechli H, Schmutz J and Mayr JM. Hyperbaric Oxygen Therapy for the treatment of an epidural abscess in the posterior fossa of an 8-month-old infant. Pediatr Neurosurg 2008; 44: 239-242. • Enoch DA, Gillham MI, Macfarlane R, Antoun N, Sule O. A troublesome head-butt. Lancet Infect Dis 2007; 7: 694. • Erman T, Demirhindi H, Göçer AI, Tuna M, Ildan F and Boyar B. Risk factors for surgical site infections in neurosurgery patients with antibiotic prophylaxis. Surg Neurol 2005; 63(2): 107-12. • Hastings H. A Report of Two Cases of Epidural Abscess of Otitic Origin. California State Journal of Medicine 1907; 5(10): 257-260. • Heran NS, Steinbok P, Cochrane DD. Conservative neurosurgical management of intracranial epidural abscesses in children. Neurosurgery 2003; 53(4): 893-7. • Hlavin ML, Kaminski HJ, Fenstermaker RA and White RJ. Intracranial suppuration: a modern decade of postoperative subdural empyema and epidural abscess. Neurosurgery 1994; 34: 974-981. • Johnson DL, Markle BM, Wiedermann BL, Hanahan L. Treatment of intracranial abscesses associated with sinusitis in children and adolescents. J Pediatr 1988; 113: 15-23. • Kim JE, Kountakis SE. "The prevalence of Samter's triad in patients undergoing functional endoscopic sinus surgery". Ear, Nose, Throat J 2007; 86(7): 396–9. • Kombogiorgas D. and Solanki G. The Pott puffy tumor revisited: neuosurgical implications of this unforgotten entity. J Neurosurg (2 Suppl Pediatr) 2006; 105: 143-149. • Patron V, Orsel S, Caire F, Aubry K, Jegoux F. Transethmoidal drainage of frontal brain abscesses. Surg Innov 201. Epub ahead of print. • Pradilla G, Ardila GP, Hsu W and Rigamonti D. Epidural Abscesses of the CNS. Lancet Neurol 2009; 8: 292-300.

  19. Samter’s Triad Asthma • Widal 1922, Samter and Beers 1968 • Aspirin Sensitivity • Asthma • Nasal/ethmoidal polyposis • Onset: 20s-30s • Possible cross-reaction with NSAIDS • Pathophysiology: arachadonic acid cascade malfunction Kim et al. 2007

  20. Pott Puffy Tumor • Percival Pott - 1760 • Sub-periosteal abscess • Often secondary to frontal sinusitis • May extend epidurally

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