Brainstem abscess

A case of midbrain abscess that was successfully treated by surgical evacuation is reported. The abscess was located in the rostral tegmentum of the midbrain and was aspirated using an infratentorial supracerebellar approach. The patient subsequently returned to his high school. Early accurate diagnosis and appropriate surgical management are especially important for successful treatment of this previously fatal condition.     

Recurrent cerebellar abscess secondary to middle ear cholesteatoma: case report

We report a case of recurrent cerebellar abscess secondary to middle ear cholesteatoma. A 57-year-old man was admitted to our hospital because of symptoms of headache and nausea in August, 1992. Brain CT scans revealed acute hydrocephalus complicated by a cerebellar abscess. The patient was discharged without any neurological deterioration after systemic antibiotics combined with intrathecal aminoglucoside administration via ventricular drainage. Mannitol was also administrated for 7 days immediately after the patient's admission. The clinical course was uneventful for 8 years afterwards. Follow-up MR images revealed no signs of recurrence. Unfortunately, the patient suffered a recurrence of cerebellar abscess in October, 2000. His condition continued to deteriorate in spite of being treated by systemic antibiototics. MR images and CT scans targeting a portion of his middle ear revealed extensive pus-coated mastoiditis and middle ear cholesteatoma. We thus performed radical mastoidectomy including removal of the middle ear cholesteatoma. After the operation, the cerebellar abscess was ameliorated. He has been free from recurrence for 2 years, so far. Early diagnosis and prompt intervention are necessary for reducing mortality and morbidity rates due to otogenic brain abscess. Recognizing middle ear cholesteatoma as one of the major causes of neurological entities in the cerebellopontine angle portion, accurate otological examination and prompt treatment can possibly bring about a better prognosis.     

Brodie's abscess of the cuboid bone: a case report

The case of a patient with Brodie's abscess of the cuboid bone and who presented with a painful and swollen right foot is described. The patient was treated successfully by surgical evacuation of the abscess and with antibiotics. To the authors' knowledge, Brodie's abscess of the cuboid bone has not been reported previously. The clinical presentation and diagnostic difficulties which may be encountered are discussed.     

Luc’s abscess as an unlucky complication of mastoiditis

Luc’s abscess is a rare but important complication of acute otitis media (AOM), whereby infection spreads from the middle ear, resulting in a subperiosteal collection beneath the temporal muscle. Unlike other extracranial abscesses relating to AOM, Luc’s abscess is not believed to involve the mastoid bone. We present the case of a patient with a Luc’s abscess with mastoid involvement and discuss its successful management. We believe that patients presenting with a subperiosteal collection beneath the temporal muscle and mastoiditis may represent a different group of patients to those described originally by Luc. These individuals can be differentiated using computed tomography (CT) of the temporal bones. We advocate CT in patients with Luc’s abscess and AOM; this aids preoperative surgical planning.     

Surgical treatment of cerebral abscess with the use of a mobile ultralow-field MRI

Surgical intervention in cerebral abscess is indicated to confirm diagnosis, to identify pathogens for specific antibiotic therapy, or to reduce mass effect. Regarding long-term outcome, freehand or stereotactic aspiration are equally efficient compared to surgical resection. However, direct observation of relief of mass effect is not possible by either method. Six patients presenting with neurological symptoms and laboratory signs of infection and diagnosed with an intra-axial cystic lesion underwent frameless stereotactic aspiration of a cerebral abscess in our institution with the use of a mobile intraoperative magnetic resonance imaging (MRI) with a field strength of 0.15 T. Images were acquired before and during the procedure and used for neuronavigation. In all six cases, complete evacuation of the abscess with collapse of the cyst could be achieved and documented intraoperatively. No complications were observed. All patients showed clinical improvement postoperatively. We highlight the advantages of using a mobile intraoperative MRI unit with an illustrative case of a patient who had already undergone abscess evacuation without alleviation of symptoms before using intraoperative MRI. Finally, we discuss surgical treatment options of cerebral abscesses.     

Amebic Liver Abscess With Intra-Biliary Rupture

The case of a large amebic liver abscess with an atypical presentation is reported. High output bile drainage persisted after ultrasound guided percutaneous catheter drainage because of a preexisting communication of the abscess with the right hepatic ductal system. The abscess was managed successfully by surgical evacuation and internal drainage into a defunctioned jejunal loop.     

Experience with 'open evacuation of pus' in the treatment of intracerebral abscess

Twenty-seven of 29 consecutive patients with brain abscess were treated by 'open evacuation of pus'. This technique involves wide exposure of the brain so that the abscess capsule may be incised and cleared of pus under direct vision. The empty capsule is left in situ after antibiotic irrigation and the wound is closed without drainage. Of the 27 patients, one died (3.7%), two were partly disabled and 24 (88.9%) were left with no neurological disability caused by the abscess. In only one case was a further operation required to remove pus which had reformed after an adequate primary clearance. There were no cases of wound sepsis or of late recurrence of the abscess. The author believes that 'open evacuation of pus' is the most satisfactory surgical technique for an intracerebral abscess.     

Unilateral psoas abscess following posterior transpedicular stabilization of the lumbar spine

A case of unilateral psoas abscess in a 58-year-old patient, shortly after posterior lower spine stabilization and fusion for spinal stenosis using transpedicular spine fixation is reported. The diagnosis was delayed because the patient’s symptoms were referred to the thigh and the plain roentgenograms were negative for pathology. The technetium scintigram and computed tomography (CT) helped localization, diagnosis and treatment of the psoas abscess. Percutaneous CT-guided drainage was followed by recurrence of the abscess, and open surgical evacuation was performed successfully in combination with antibiotic treatment for 8 weeks. Psoas abscess should always be suspected when recurrent pain is associated with fever and elevated erythrocyte sedimentation rate after instrumentation of the lumbar spine. Hardware of a low profile and volume should be used to decrease dead space in the fusion area, and the volume of bone substitutes should be limited for the same reason. Received: 28 January 2000 Revised: 17 May 2000 Accepted: 22 May 2000     

Pericardial abscess--a rare complication of sepsis.

Pericardial abscess is a very rare complication of sepsis. Authors describe the case of a 69-year-old woman. In her case staphylococcus sepsis led to pericardial abscess. During the course positive blood cultures (3x) indicated the sepsis and pus was obtained from the left pleural cavity (pleuropneumonia). Concomitant purulent process in the left shoulder also was noted. Decline immunity due to long-standing corticoid therapy (prednisone) for proctocolitis idiopathica was observed. Following antibiotic treatment successful surgical evacuation of the pericardial abscess was performed.     

Right hemiparesis caused by massive otogenic brain abscess in children: Unusual case report and review of the literature

IntroductionHemiparesis caused by otogenic brain abscess in children is an unusual complication of Chronic Suppurative Otitis Media. Complications can occur when the disease is not treated properly so that the infection in the middle ear spreads intracranially.Case presentationWe report a case of Chronic Suppurative Otitis Media with cholesteatoma in a 14-year-old boy with complications of right hemiparesis caused by an otogenic brain abscess. His management included open craniotomy, drainage of the abscess, radical mastoidectomy and intravenous antibiotics according to the result of the culture and sensitivity.Clinical discussionCommonly, the location of the abscess is closely related to the source of infection. Affected brain lobes usually depend on predisposing factors that cause the development of brain abscesses. In this case, clinical manifestations appear in the form of contralateral hemiparesis even though the source of infection comes from the ear. This can occur due to massive abscesses and the presence of extensive perifocal edema which results in pressure in the subcortex area. The patient underwent radical mastoidectomy in conjunction with an abscess excision craniotomy.ConclusionHemiparesis caused by an otogenic brain abscess is unusual. Rapid and precise diagnosis and treatment can minimize patient mortality and morbidity.     

Local tissue coverage for the management of exposed endografts

This case report describes the use of local tissue coverage for the treatment of surgically exposed endografts. In two cases, an endograft used for the treatment of a pseuodaneurysm was visualized through the arterial defect during open surgical evacuation of an abscess in one case and a sterile hematoma in the second case. Obtaining arterial control to remove the endograft was prohibitive owing to the anatomic location and extensive scarring and inflammation. The endografts were preserved and hemostasis was maintained by using a vein patch in one case and a local muscle flap in both cases. Both cases have had satisfactory short-term follow-up (4-12 months). An exposed endograft represents a rare and challenging problem. Local tissue coverage offers a feasible strategy for maintaining hemostasis and avoiding a potentially morbid surgical dissection. Although the short-term results of this approach have been encouraging, the long-term consequences remain unknown.     

Spinal epidural abscess in the lumbar spine after dental extraction in a 53-year-old man

Spinal epidural abscess is rare in patients following dental extraction. Only seven cases have been described in the literature. We report the first case of an epidural abscess in the lumbar spine following dental extraction, and present a review of the relevant literature. A 53-year-old man presented with low back pain 1 week following dental extraction, and imaging revealed the presence of a lumbar epidural abscess. He underwent surgical drainage by decompressive laminectomy with evacuation of pus and debridement of the infected bone, and he was treated with a prolonged course of intravenous antibiotics. The patient demonstrated no neurologic sequelae at the 6-month follow-up examination. A search of the relevant literature showed that, of the seven epidural abscesses that occurred following dental extractions, five were cervical and two were intracranial. An epidural abscess in the lumbar spine following dental extraction had not been reported. Thus, this is the first report of an epidural abscess in the lumbar spine following dental extraction. It is also the first case of epidural abscess following dental extraction that was determined to be caused by Streptococcus suis. Our findings indicate that epidural abscess must be considered as a diagnosis for all patients presenting with intractable low back pain, with or without fever and neurologic impairment, after a recent dental extraction. We conclude that appropriate imaging must be conducted for early diagnosis.     

Compressive thoracic spondylodiscitis associated with a pleural abscess: Surgical treatment through an enlarged posterior approach

The authors report a case of a patient with paraparesis secondary to T5-T6 spondylodiscitis accompanied by a closely lying, well-formed pleural abscess. This rare association has previously been reported only twice in the literature. The technical difficulty of surgery for both the abscess and the compressive spondylodiscitis was resolved by the use of an enlarged posterior approach. This approach enabled evacuation of the pleural lesion, curettage of the disc space, interbody grafting, and spinal osteosynthesis in one stage.     

Cochlear implantation in patients with chronic otitis: indications for subtotal petrosectomy and obliteration of the middle ear

Normally, active chronic suppurative otitis media is regarded as a contraindication for cochlear implantation. In case of a radical cavity after surgical treatment for cholesteatoma, the electrode covered by the epithelial lining of the mastoid will likely become exposed or extruded. Under these circumstances we suggest the subtotal petrosectomy, obliteration of the middle ear cleft with abdominal fat, and the blindsac closure of the external ear canal before cochlear implantation.Fourteen patients with chronic otitis media were successfully implanted with an intracochlear multichannel cochlear implant. After an average follow-up of 28 months a temporary facial palsy in one patient and an insufficient closure of a retroauricular fistula over the mastoid cavity in two cases were observed as postoperative complications. One patient with a tumefactive inflammatory pseudotumor developed a massive inflammation in the implanted ear 2 months after surgery which could not be controlled by conservative treatment. The implant had to be removed and after administration of cyclophosphamide she could be successfully reimplanted 7 months later.Implantation of a foreign body in a potentially infected space which communicates with the endocranium means a surgical challenge which can be managed by obliteration of the middle ear. In case of massive inflammation we prefer a two-stage procedure.     

Post-surgery cholesteatoma complicated by facial nerve paralysis: A case report from Afghanistan

IntroductionCholesteatoma is a benign tumoral lesion of squamous epithelial cells in middle ear that can exist as congenital or acquired forms.Presentation of casesA 35-year-old housewife presented to ENT clinic of a private hospital in Kabul, Afghanistan, with a complete facial nerve paralysis in the right side. In her antecedents, there is a tympanomastoidectomy due to chronic middle ear infection. First symptom was right side earache without any discharge. She started to notice a progressive nodule in the posterior-inferior side of her right ear. The patient was taken to the operating room. She underwent general anesthesia, an extensive cholesteatoma was removed, and a limited area of the fallopian canal in which facial nerve oedema or redness was evident. Post-operative House Brackmann grade was 1 on day 15 after the surgery.DiscussionCholesteatoma is primarily managed surgically and currently there is no suitable medical substitute treatment strategy for cholesteatoma. Hearing improvement, making the ear dry and total omission of cholesteatoma are primary goals of surgical interventions in cholesteatoma management.ConclusionCholesteatoma after surgical manipulations of middle ear is a rare complication with notable morbidity that has been reported almost from all around the world but our patient is the first reported case of cholesteatoma formation after surgical management of COM from Afghanistan that presented with facial nerve paralysis and hear decline.     

Cochlear Implantation in Patients with Chronic Otitis: Indications for Subtotal Petrosectomy and Obliteration of the Middle Ear

Normally, active chronic suppurative otitis media is regarded as a contraindication for cochlear implantation. In case of a radical cavity after surgical treatment for cholesteatoma, the electrode covered by the epithelial lining of the mastoid will likely become exposed or extruded. Under these circumstances we suggest the subtotal petrosectomy, obliteration of the middle ear cleft with abdominal fat, and the blindsac closure of the external ear canal before cochlear implantation.

Fourteen patients with chronic otitis media were successfully implanted with an intracochlear multichannel cochlear implant. After an average follow-up of 28 months a temporary facial palsy in one patient and an insufficient closure of a retroauricular fistula over the mastoid cavity in two cases were observed as postoperative complications. One patient with a tumefactive inflammatory pseudotumor developed a massive inflammation in the implanted ear 2 months after surgery which could not be controlled by conservative treatment. The implant had to be removed and after administration of cyclophosphamide she could be successfully reimplanted 7 months later.

Implantation of a foreign body in a potentially infected space which communicates with the endocranium means a surgical challenge which can be managed by obliteration of the middle ear. In case of massive inflammation we prefer a two-stage procedure.

     

Psoas abscess communicating to an implanted hip due to delayed hematogenous tuberculosis arthritis

Summary The authors report a rare case of an 75-year-old female patient who had had a Mueller cemented total hip arthroplasty for osteoarthritis. Eight years after implantation of the THA the patient developed a hematogenous TB arthritis in the already implanted hip. During the revision operation the infected hip was found to communicate with the ipsilateral psoas muscle sheath through a fistula which was induced by one of the screws used for stabilization of the socket. The evacuation of the abscess from the psoas sheath and the affected hip joint in combination with anti-TB medication was followed by an uneventful course, up to 48 months postoperatively.With this report the authors wish to draw the attention of physicians on such a rare complication and its sequellae.     

Emergency preoperative embolization using coils of ruptured sylvian aneurysm. Apropos of a case

The authors report a case of a 73 year old patient who presented with a right temporal lobe hematoma secondary to rupture of a right middle cerebral artery bifurcation aneurysm. Treatment consisted of partial thrombosis of the aneurysm by the endovascular introduction of metallic coils followed by surgical hematoma evacuation and aneurysm clipping. Thrombus of the aneurysm done probably diminished the risk of intraoperative rupture. Partial endovascular treatment has a very small risk and may be done on a emergency basis at the same time as the diagnostic arteriogram. It can also be suggested for patients in poor condition to diminish the risk of recurrent hemorrhage until the patient is well enough to undergo definitive surgical clipping.     

Ruptured lung abscess; report of a case

We reported an extremely rare case of ruptured lung abscess. A 60-year-old male was admitted to our hospital with sudden loss of consciousness. Thoracocentesis demonstrated pneumopyothorax. Right middle and lower lobectomy for ruptured abscess was performed. The patient remains well with no recurrent lung abscess 2 years postoperatively. This case emphasizes that ruptured lung abscess is a cause of pneumopyothorax.