Conservative neurosurgical management of intracranial epidural abscesses in children

OBJECTIVE: Traditional management of epidural abscesses caused by sinusitis in children involves neurosurgical drainage. With better techniques to drain affected sinuses, to identify causative organisms, and to guide medical therapy, some pediatric epidural intracranial abscesses may be treated effectively with sinus drainage and antibiotics, without an intracranial procedure. METHODS: Charts and computed tomographic scans of children with isolated intracranial epidural abscess associated with sinusitis who were treated in a pediatric hospital were reviewed retrospectively. RESULTS: Eight patients were treated between 1982 and 2002. All patients received antibiotic therapy appropriate to the causative organism(s). Four patients treated before mid-1997 had an intracranial procedure additionally (operative group, Group 1), and four patients treated thereafter did not (conservative group, Group 2). Abscesses had a mean size of 3 x 3 x 1 cm (length x width x depth) in both groups. All patients experienced clinical and radiographic resolution of the infection with treatment. In Group 1, neurosurgical management consisted of burr hole drainage in two patients and craniotomy in two patients. Extranasal otorhinolaryngological procedures for sinus drainage were performed in two patients. In Group 2, endonasal procedures were used in three patients for paranasal sinus infections to effect drainage and obtain specimens for culture. A radical mastoidectomy was required in the single patient with mastoiditis. Although two of four patients initially demonstrated transient worsening of headaches, all patients subsequently improved rapidly after the first week of treatment. Computed tomographic follow-up revealed minimal or no enlargement of the abscess or mass effect at 1 week, decrease or stable size at 2 weeks, and resolution by 6 weeks. CONCLUSION: Sinus-related intracranial epidural abscesses in children may be managed without neurosurgical procedures in the setting of adequate sinus drainage, appropriate antibiotic therapy, and minimal extradural mass effect from the abscess. Symptomatic worsening without significant increase in mass effect during the first week of therapy is not necessarily an indication for an intracranial drainage procedure.