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Subtentorial subdural empyema: Case report
208
Surg Neurol 1992 ;37 :208-10
Subtentorial Subdural Empyema : Case Report S. Toth, M .D., D .Sc., S. Szabo, M.D., J. Kollar, M .D., and J . Sikula, M .D. Department of Neurosurgery and Department of Radiology, Medical University of Debrecen, Debrecen, Hungary
Toth S, Szabo S, Kollar J, Sikula J. Subtentorial subdural empyema: case report . Surg Neurol 1992 ;37 :208-10 .
We present a case of an extensive subtentorial subdural empyema of otorhinological origin. Although 3%-6% of all intracranial suppurations are infratentorial, there is no report on extensive multiloculated subtentorial empyema so far . Subdural empyema ; Posterior fossa; Subtentorial, otorhinological infection ; Drainage ; Craniotomy KEY WORDS :
Infratentorial subdural empyemas (SDE) are rare complications of infections, most of them otorhinological [2,3,8,9,11,121 . Recently Borovich and Johnston [3], in a review of the literature, found only one short description of a case and added three more of their own . No reports were found on subtentorially localized SDE .
Case Report A 46-year-old man suffered a left ear injury from a blow by a snowball in his early childhood . Chronic otitis and intermittent otorrhea developed, with progressive hearing loss that lasted for decades . One month prior to admission the patient complained of increasing headaches and fever with otorrhea . At the Ear, Nose, and Throat Department of a local hospital a radical antrotomy was performed . Surgery revealed an ascending thrombophlebitis along the sigmoid sinus . The condition of the patient worsened after surgery ; drowsiness and gait disturbances appeared together with the worsening of his headache . He was admitted to our department . After admission, neurological examination revealed nystagmus, left dysdiadochokinesis, mild dysarthria, and difficulty in swallowing . Computed tomography (CT) revealed an extensive multiloculated subtentorial empyema that extended
Address reprint requests to : S . Toth, Department of Neurosurgery, Medical University of Debrecen, PO Box 31, 4012 Debrecen, Hungary . Received April 16, 1991 ; accepted September 9, 1991 . 1992 by S . Toth et al .
from the transverse sinus to the tentorial incisura (Figure 1 A and B) . A small suboccipital craniectomy was performed . The thick membrane of the enormous supracerebellar, subtentorial, bilateral empyema was strongly adherent to the cerebellar surface and to the tentorium, so drainage would have been possible only through the cerebellum . Therefore we decided to go through the transtentorial route, by which means drainage is possible without damage to the brain . The suboccipital craniectomy was extended with a small left supratentorial occipital craniotomy . The stituation over the tentorium was normal . Through a transtentorial incision the thick membrane of the empyema was opened, and complete drainage of the multiple collections was possible . Two drains were introduced through the tentorial opening to both sides (Figure 2) . Continuous external drainage through these drains, irrigation, and local and systemic antibiotic therapy resulted in gradual clinical improvement . CT examinations 3 weeks, 1 month, and 2 months following surgery revealed gradual disappearance of the pathology (Figures 3 and 4) .
Discussion SDE is said to constitute 13% to 23% of localized intracranial bacterial infections [5] . Infratentorial SDE is an even rarer condition . Borovich and Johnston [3] reviewed four cases . Pathak et al [10], analyzing a 10-year period, reported three infratentorial SDEs selected from 41 cases of intracranial suppurations . We did not find any publication on subtentorial empyema. During the past 4 years in our department, of 16 cases of intracranial suppurations, three were localized infratentorially . Two were intracerebellar abscesses, and only the case reported here was an infratentorial SDE . In correlation with the data from the literature this means that the incidence of infratentorial SDE can be expected to amount to 3% to 6% of all intracranial localized bacterial infections . Otorhinological infection is a major etiological factor in infratentorial SDE . Ascending thrombophlebitis along the sigmoid and transverse sinus is a possible way of infection .
Subtentorial Subdural Empyema
Surg Neurol 1992 ;37 :208-10
2 09
Figure 2. Diagram of the subtentorial empyema suggested by the surgery .
Figure 3 . CT scan I month after surgery, The Subtentorial collection bar nearly dirappeared .
Figure 1 . (A) GT scan immediately before surgery . (B) CT scan immediately before surgery : the empyema is adherent to the wall of antrotomv .
Chronic otological infections entail a higher incidence of intracranial complications, as was the case with our three patients, who all had chronic infections . Rapid and effective otological therapy has great importance in prevention . Regarding management, controversy exists in the literature [7] . Conservative treatment alone has only re-
210
Surg Neurol 1992 ;37 : 2 0 8 -10
Toth et al
Follow-up CT scans revealed that resolution was quite slow . Summarizing our experience with this uniquely localized SDE, rapid diagnosis, surgical removal without further brain damage through craniotomy, local and systemic antibiotic therapy, drainage, and CT follow-ups were the main steps of correct management, which led to the curing of this patient's infection .
References
Figure 4 .
CT scan 2 months after surgery . The subtentorial collection has totall9 disappeared. Traces of surgery are visible.
cently been accepted ; surgery, however, still plays a major role { 1,4,6] . Since the empyema can be multiloculated and the membrane thick and tenacious, as in our case, craniotomy offers a better result than burr holes, especially in posterior fossa SDEs [101 . Craniotomy offers a total evacuation of the multiple collections early and it decreases the mass effect and the toxic and inflammatory effect on the brain . Furthermore, surgical techniques that make drainage possible without brain damage are important, as was the transtentorial route in our case .
1 . Bannister G, Williams B, Smith S . Treatment of subdural empyema. J Neutosurg 1981 ;55 :82-8 . 2 . Bhandari YS, Sarhari NBS . Subdural empyema . A review of 37 case. J Neurosurg 1970 ;32 :35-9. 3 . Bnrovich B, Johnsron E . Infratentorial subdural empyema: clinical and computerized tomography findings . Report of three cases . .1 Neurosurg 1990 ;72 :299-301 . 4 . Fetterman T, Phillip A, et al . Craniotomy improves outcome in subdural empycma . Surg Neurol 1990 ;32 :105-10 . 5 . Greenlee JE . Subdural empyema . In: Mandell GI, Douglas RG, eds . New York : W iley, 1979 :786-9 . 6 . Hockley AD, Williams BW . Surgical management of subdural empyema . Child's Brain 1983 ;10:294-300 . 7 . Leys D, Destee A, Petit H, Warot P . Management of subdural intracranial empyema should not always require surgery . J Neurol Neurosurg Psychiatry 1986 ;49:635-9 . 8 . Luken MG, Whelan MA . Recent diagnostic experience with subdural empyema. J Neurosurg 1980 ;52 :764-71 . 9 . Macewen W. Pyeogenic infective diseases of the brain and spinal cord . Meningitis . Abscess of the brain . Infective sinus thrombosis . Glasgow : James MacLchouse and Sons, 1893 :146-91 . Cited in Alexander E Jr, Davis CH . Macewen's sign . "The cracked pot sound ." Surg Neurol 1987 ;27 :519-22 . 10 . Parhak A, Sharma BS, et al . Controversies in the management of subdural empyema. A study of 41 cases with review of the literature . Acta Neurochir [WienJ 1990 ;102 :25-32 . 11 . Wackym PA, Canalis RF, Fetterman T. Subdural empyema of otorhinologicalorigin .,) LaryngolOral 1990 ;104 :118-22 . 12 . Yogev R . Suppurative intracranial complications of upper respiratory tract infections . Pediatr Infect Dis J 1987 ;6:324-7 .
Surg Neurol 1992 ;37 :208-10
Subtentorial Subdural Empyema : Case Report S. Toth, M .D., D .Sc., S. Szabo, M.D., J. Kollar, M .D., and J . Sikula, M .D. Department of Neurosurgery and Department of Radiology, Medical University of Debrecen, Debrecen, Hungary
Toth S, Szabo S, Kollar J, Sikula J. Subtentorial subdural empyema: case report . Surg Neurol 1992 ;37 :208-10 .
We present a case of an extensive subtentorial subdural empyema of otorhinological origin. Although 3%-6% of all intracranial suppurations are infratentorial, there is no report on extensive multiloculated subtentorial empyema so far . Subdural empyema ; Posterior fossa; Subtentorial, otorhinological infection ; Drainage ; Craniotomy KEY WORDS :
Infratentorial subdural empyemas (SDE) are rare complications of infections, most of them otorhinological [2,3,8,9,11,121 . Recently Borovich and Johnston [3], in a review of the literature, found only one short description of a case and added three more of their own . No reports were found on subtentorially localized SDE .
Case Report A 46-year-old man suffered a left ear injury from a blow by a snowball in his early childhood . Chronic otitis and intermittent otorrhea developed, with progressive hearing loss that lasted for decades . One month prior to admission the patient complained of increasing headaches and fever with otorrhea . At the Ear, Nose, and Throat Department of a local hospital a radical antrotomy was performed . Surgery revealed an ascending thrombophlebitis along the sigmoid sinus . The condition of the patient worsened after surgery ; drowsiness and gait disturbances appeared together with the worsening of his headache . He was admitted to our department . After admission, neurological examination revealed nystagmus, left dysdiadochokinesis, mild dysarthria, and difficulty in swallowing . Computed tomography (CT) revealed an extensive multiloculated subtentorial empyema that extended
Address reprint requests to : S . Toth, Department of Neurosurgery, Medical University of Debrecen, PO Box 31, 4012 Debrecen, Hungary . Received April 16, 1991 ; accepted September 9, 1991 . 1992 by S . Toth et al .
from the transverse sinus to the tentorial incisura (Figure 1 A and B) . A small suboccipital craniectomy was performed . The thick membrane of the enormous supracerebellar, subtentorial, bilateral empyema was strongly adherent to the cerebellar surface and to the tentorium, so drainage would have been possible only through the cerebellum . Therefore we decided to go through the transtentorial route, by which means drainage is possible without damage to the brain . The suboccipital craniectomy was extended with a small left supratentorial occipital craniotomy . The stituation over the tentorium was normal . Through a transtentorial incision the thick membrane of the empyema was opened, and complete drainage of the multiple collections was possible . Two drains were introduced through the tentorial opening to both sides (Figure 2) . Continuous external drainage through these drains, irrigation, and local and systemic antibiotic therapy resulted in gradual clinical improvement . CT examinations 3 weeks, 1 month, and 2 months following surgery revealed gradual disappearance of the pathology (Figures 3 and 4) .
Discussion SDE is said to constitute 13% to 23% of localized intracranial bacterial infections [5] . Infratentorial SDE is an even rarer condition . Borovich and Johnston [3] reviewed four cases . Pathak et al [10], analyzing a 10-year period, reported three infratentorial SDEs selected from 41 cases of intracranial suppurations . We did not find any publication on subtentorial empyema. During the past 4 years in our department, of 16 cases of intracranial suppurations, three were localized infratentorially . Two were intracerebellar abscesses, and only the case reported here was an infratentorial SDE . In correlation with the data from the literature this means that the incidence of infratentorial SDE can be expected to amount to 3% to 6% of all intracranial localized bacterial infections . Otorhinological infection is a major etiological factor in infratentorial SDE . Ascending thrombophlebitis along the sigmoid and transverse sinus is a possible way of infection .
Subtentorial Subdural Empyema
Surg Neurol 1992 ;37 :208-10
2 09
Figure 2. Diagram of the subtentorial empyema suggested by the surgery .
Figure 3 . CT scan I month after surgery, The Subtentorial collection bar nearly dirappeared .
Figure 1 . (A) GT scan immediately before surgery . (B) CT scan immediately before surgery : the empyema is adherent to the wall of antrotomv .
Chronic otological infections entail a higher incidence of intracranial complications, as was the case with our three patients, who all had chronic infections . Rapid and effective otological therapy has great importance in prevention . Regarding management, controversy exists in the literature [7] . Conservative treatment alone has only re-
210
Surg Neurol 1992 ;37 : 2 0 8 -10
Toth et al
Follow-up CT scans revealed that resolution was quite slow . Summarizing our experience with this uniquely localized SDE, rapid diagnosis, surgical removal without further brain damage through craniotomy, local and systemic antibiotic therapy, drainage, and CT follow-ups were the main steps of correct management, which led to the curing of this patient's infection .
References
Figure 4 .
CT scan 2 months after surgery . The subtentorial collection has totall9 disappeared. Traces of surgery are visible.
cently been accepted ; surgery, however, still plays a major role { 1,4,6] . Since the empyema can be multiloculated and the membrane thick and tenacious, as in our case, craniotomy offers a better result than burr holes, especially in posterior fossa SDEs [101 . Craniotomy offers a total evacuation of the multiple collections early and it decreases the mass effect and the toxic and inflammatory effect on the brain . Furthermore, surgical techniques that make drainage possible without brain damage are important, as was the transtentorial route in our case .
1 . Bannister G, Williams B, Smith S . Treatment of subdural empyema. J Neutosurg 1981 ;55 :82-8 . 2 . Bhandari YS, Sarhari NBS . Subdural empyema . A review of 37 case. J Neurosurg 1970 ;32 :35-9. 3 . Bnrovich B, Johnsron E . Infratentorial subdural empyema: clinical and computerized tomography findings . Report of three cases . .1 Neurosurg 1990 ;72 :299-301 . 4 . Fetterman T, Phillip A, et al . Craniotomy improves outcome in subdural empycma . Surg Neurol 1990 ;32 :105-10 . 5 . Greenlee JE . Subdural empyema . In: Mandell GI, Douglas RG, eds . New York : W iley, 1979 :786-9 . 6 . Hockley AD, Williams BW . Surgical management of subdural empyema . Child's Brain 1983 ;10:294-300 . 7 . Leys D, Destee A, Petit H, Warot P . Management of subdural intracranial empyema should not always require surgery . J Neurol Neurosurg Psychiatry 1986 ;49:635-9 . 8 . Luken MG, Whelan MA . Recent diagnostic experience with subdural empyema. J Neurosurg 1980 ;52 :764-71 . 9 . Macewen W. Pyeogenic infective diseases of the brain and spinal cord . Meningitis . Abscess of the brain . Infective sinus thrombosis . Glasgow : James MacLchouse and Sons, 1893 :146-91 . Cited in Alexander E Jr, Davis CH . Macewen's sign . "The cracked pot sound ." Surg Neurol 1987 ;27 :519-22 . 10 . Parhak A, Sharma BS, et al . Controversies in the management of subdural empyema. A study of 41 cases with review of the literature . Acta Neurochir [WienJ 1990 ;102 :25-32 . 11 . Wackym PA, Canalis RF, Fetterman T. Subdural empyema of otorhinologicalorigin .,) LaryngolOral 1990 ;104 :118-22 . 12 . Yogev R . Suppurative intracranial complications of upper respiratory tract infections . Pediatr Infect Dis J 1987 ;6:324-7 .