Temporal Lobe Abscess Research Articles

Diagnosis and treatment complications of chronic otitis media

Keywords Chronic otitis media ComplicationsTo the Editor,The article by E. Yorgancilar et al. [1] presents interestingand very important clinical observations. The authorsdescribed clinical data and therapeutic approach to 121patients with EC and IC complications of CSOM. Theypresented methods of treatment and epidemiological dataof these complications (the most common was subperios-teal abscess—28.3 % and lateral sinus thrombophlebitis—19.5 %). The decrease in mortality in the authors’ clinicfrom 16.1 to 0 % is an excellent result and we would like tocongratulate on it. Let us present some comments on thisproblem on the basis of our clinical experience. In the lastyears the outcome of treatment of these conditions is sig-nificantly better than in the past. Presently intracranialcomplications of CSOM are very rare in our Department asmost commonly EC intricacy is observed. In the data (inthe years 2001–11) of our Department we found 98 cases(86-EC and 12-IC) of CSOM otogenic complications. Themost frequent EC intricacy was labyrinthitis and the mostpopular IC one was lateral sinus thrombophlebitis. Nowa-days the symptoms of complications are less prominentthan in the past due to antibiotic treatment of COM prior tohospital admission. The time required for full diagnosisof patients with complicated COM is reduced due to CTwith contrast and MRI availability (useful to diagnoseextradural abscess, subdural empyema, meningitis orthrombophlebitis of the dural veins). This technique isparticularly useful in children [2] (Fig. 1).In connection with the article let us ask some questionsto the authors: Were all of the patients operated on pri-marily? Why were the extradural abscesses and the tem-poral lobe abscesses not evacuated during the mastoidsurgery? Temporal lobe abscesses may be evacuated dur-ing ear surgery (by puncture and aspiration). In this methodof temporal lobe abscesses evacuation neuronavigation is avery serviceable tool. Neurosurgical approach to the

Aspergilluspetrous apicitis associated with cerebral and peritubular abscesses in an immunocompetent man

Petrous apex aspergillosis is an uncommon and dangerous condition, with only four previously reported cases. As with other forms of petrous apicitis, the clinical symptoms are often non-specific and this contributes to diagnostic delay. This paper presents the first reported case of Aspergillus petrous apicitis associated with an intracranial or nasopharyngeal abscess. A 72-year-old man with chronic otorrhoea developed neuralgic headaches and progressive lower cranial nerve palsies despite antibiotic therapy. Imaging revealed petrous apicitis, a temporal lobe abscess and nasopharyngeal abscess. Analysis of biopsy tissue indicated invasive aspergillosis. The patient recovered on a protracted course of voriconazole in addition to medium-term antibiotic therapy. Invasive fungal disease should be considered early in the course of skull base osteomyelitis that is clinically unresponsive to empirical broad spectrum antibiotics. This paper highlights the role of tissue biopsy in diagnosis, and the efficacy of voriconazole therapy without the need for radical surgery.

Central condylar displacement with brain abscess from chronic mandibular osteomyelitis

In this case report, we describe a unique long-term complication from undiagnosed mandibular osteomyelitis. A 53-year-old female who underwent a dental extraction complicated by chronic postoperative odontogenic infection and cutaneous parotid fistula formation 2 years earlier presented with acute mental status change, gradual unilateral facial nerve palsy (House-Brackmann score V), and nontraumatic dislocation of the condylar head into the middle cranial fossa. The patient's chronic mandibular osteomyelitis led to glenoid fossa erosion, middle cranial fossa penetration, and temporal lobe abscess formation. A combined middle cranial fossa approach through a burr hole placed in the squamous temporal bone near the zygomatic root and intraoral mandibular approach to ipsilateral condylar head was performed to complete partial mandibulectomy, including condylectomy. The patient was treated with 6 weeks of meropenem perioperatively. Four months after the surgery, the patient had complete resolution of skull base osteomyelitis, parotid fistula, and neurologic deficits and full recovery of facial nerve function (House-Brackmann score of I).

Management and Treatment of Otogenic Temporal Lobe Abscess Secondary to Mastoiditis: A Case Report and Review of Literature

Temporal lobe abscess is a rare complication of mastoiditis or other otogenic infections. Signs and symptoms are caused by tissue damage or displacement, and the presentation includes fever, headache, meningeal signs, and altered mental/sensory status. In the setting of acute mastoiditis, the rate of occurrence of a cerebral abscess is very rare, and therefore poses a diagnostic challenge for the physician. Here, a case of temporal lobe abscess is presented, and radiological findings, surgical treatment, and outcome are discussed.

Complications of Chronic Suppurative Otitis Media: A Left Otogenic Brain Abscess and a right Mastoid Fistula

Otogenic brain abscess and postauricular fistula are complications of chronic suppurative otitis media. We describe a rare case of bilateral chronic suppurative otitis media that caused a left temporal lobe abscess and a right mastoid fistula.

Otitic Meningitis, Superior Semicircular Canal Dehiscence, and Encephalocele

Otitic meningitis in the postantibiotic era is still a serious condition, requiring intensive treatment and prolonged rehabilitation. In view of the significant morbidity and mortality rate, conditions that may increase the likelihood of otitic meningitis developing should be treated promptly. The incidence of meningitis after asymptomatic encephaloceles of the middle cranial fossa varies greatly, and the management differs between elective surgical repair and expectant careful observation. Superior semicircular canal dehiscences (SSCDs) are postulated to have a congenital origin and are associated with a thin or dehiscent tegmen. Several cases of simultaneous SCCD and tegmen defects have been reported, but the findings of otitic meningitis, SCCD, and encephaloceles has, to the best of our knowledge, not been previously explored in the literature. We reviewed a series of 4 patients who all presented with a combination of otitic meningitis, encephaloceles, and SSCD. All the 4 patients we reviewed had meningitis secondary to otitis media with computed tomographic scans confirming the presence of SCCD with ipsilateral tegmen tympani defects and associated cephaloceles. All patients were treated with intravenous antibiotics and underwent surgery that ranged from myringotomy and ventilation tube insertions, mastoidectomy, and burr hole drainage for temporal lobe abscess. They were all associated with intensive care unit admission, significant morbidity, and prolonged hospital stays. There were no mortalities. We propose that in all SSCD patients, a careful computed tomographic examination of the cranial base should be undertaken to exclude other associated tegmen tympani defects. In cases of SSCD requiring surgery, we support the view that elective surgical repair be recommended where asymptomatic ipsilateral encephaloceles are found, to reduce the risk of otitic meningitis.

Treatment Strategies for Lateral Sphenoid Sinus Recess Cerebrospinal Fluid Leaks

To highlight concepts critical to achieving successful repair and avoiding intracranial complications in the treatment of cerebrospinal fluid (CSF) leaks from the lateral recess of the sphenoid sinus (LRS). Outcomes study. Tertiary referral university hospital. Eleven patients with LRS CSF leaks from June 2008 to June 2010. Endoscopic transpterygoid approach and multilayer repair of skull base defect in the LRS. Recurrence, graft techniques, postoperative intracranial pressure (ICP), and use of ventriculoperitoneal (VP) shunt. Thirteen CSF leaks originating in the LRS were surgically repaired in 11 patients; 2 patients required bilateral leak repair. The endoscopic transpterygoid approach was used in 12 of 13 repairs. Eight patients had failed attempts at repair prior to presentation (4 endoscopic sphenoidotomies and 4 middle cranial fossa [MCF] approaches). One patient presented with a temporal lobe abscess following hydroxyapatite "obliteration" to seal off the LRS. This required a combined MCF/transpterygoid approach to drain the abscess, remove the encephalocele and hydroxyapatite, and seal the skull base defect. In 2 cases, the LRS was left patent owing to concerns of inadequate mucosal extirpation. The median duration of follow-up was 10.8 months (range, 2-29 months). One patient experienced a failure (2 months after repair), which was successfully sealed on the second attempt. Postoperatively, 5 patients required VP shunts, and 5 were maintained on acetazolamide for elevated ICP (average, 26.7 cm H₂O in 8 patients; presumed elevated in 2 patients). The current study demonstrated a 92% success rate using the endoscopic transpterygoid approach for LRS skull base defects providing support for routine use in the treatment algorithm. Poor outcomes were observed with previous surgical attempts to obstruct the LRS without repairing the skull base defect.

Tuberculous brain abscess and subdural empyema in an immunocompetent child: Significance of AFB staining in aspirated pus

Tuberculous brain abscess and subdural empyema are extremely rare manifestations of central nervous system tuberculosis. Here, we report a case of an 11-year-old immunocompetent child who developed temporal lobe abscess and subdural empyema following chronic otitis media. A right temporal craniotomy was performed and the abscess was excised. The Ziehl Nielsen staining of the aspirated pus from the temporal lobe abscess yielded acid fast bacilli. Prompt administration of antituberculous treatment resulted in complete recovery of the child. Even though the subdural abscess was not drained, we presume that to be of tubercular aetiology. Ours is probably the first case of brain abscess and subdural empyema due to Mycobacterium tuberculosis reported in the same child. This case is being reported because of its rarity and to stress the importance of routine staining for tubercle bacilli in all cases of brain abscess, especially in endemic areas, as it is difficult to differentiate tuberculous from pyogenic abscess clinically as well as histopathologically.

A Case of Cerebral Venous Thrombosis in a 77-Year-Old White Man

A Case of Cerebral Venous Thrombosis in a 77-Year-Old White Man

Cerebral Herniation Caused by Post-irradiation Brain Abscess: A Report of Two Cases and a Systematic Review

Radiation-induced necrosis is commonly seen after radiotherapy for nasopharyngeal carcinoma (NPC), but a post-irradiation brain abscess is rarely encountered and easily overlooked, which may lead to a dismal outcome. We describe two Chinese men with cerebral herniation caused by temporal lobe abscess within a radio-necrotic lesion presenting only with headache and neurological defects. Cranial magnetic resonance imaging (MRI) or computed tomography (CT) showed cystic lesions in the temporal lobe with a severe mass effect. Both patients had brain herniation before emergency operations. Therefore, our findings suggest that a post-irradiation brain abscess may insidiously develop into disastrous herniation, and regular multi-modality neuroimaging follow-up should be carried out to help avoid this situation.

Temporal Lobe Abscess in a Patient with Isolated Sphenoiditis

A 74-year-old immunocompetent man admitted for severe retro-orbital headache was diagnosed with isolated sphenoiditis. At the time of scheduled surgery, the patient was mildly obtunded, and a head CT revealed a temporal lobe abscess. The patient underwent a left temporal craniectomy and a bilateral endoscopic sphenoid sinusotomy, which revealed gross fungal debris. The patient made a full recovery with resolution of abscess and sinus findings. Suspicion for intracranial infection should be raised in any sinus patient with neurological changes. Early diagnosis with imaging studies is extremely important for surgical drainage before permanent neurological sequelae.

Transmastoid approach to otogenic brain abscess: 14 years experience

Objectives: Objectives of this study were to review our experience in on otogenic brain abscess and its management by transmastoid drainage and compare the results. Materials and Methods: All patients with brain abscess secondary to CSOM presenting to our department from January 1997 to December 2010 were included in this study. All patients subjected to clinical, neurological, opthalmological examination and CT scan was done as an imaging modality. All patients managed by radical mastoidectomy or modified radical mastoidectomy and transmastoid drainage of brain abscess as neurosurgical facility not available. Results: Seventy-two patients in whom brain abscess secondary to chronic suppurative otitis media was diagnosed and has been treated since 1997 are presented. 85% of patients were below 20 years of age. More than 50% patients presented with more than one complication of chronic suppurative otitis media. 85% of patients were having extensive cholesteatoma and 15% patients were having extensive granulations in middle ear and mastoid air cells. 83% patients were having cerebellar abscess while 17% patients were having temporal lobe abscess. 80% of the pus culture was sterile while in 20% patients various microorganisms such as Proteus spp., Escherichia coli, Pseudomonas aeruginosa, Staphylococcus spp., and Streptococcus spp were cultured. Overall mortality in this series was 4.4%. Conclusion: In diagnosis of otogenic brain abscess CT scan with constrast is of immense help. Transmastoid drainage of brain abscess is a safe and effective method that can be performed by otologists in cases of otogenic brain abscess.

Should ancillary brain blood flow analyses play a larger role in the neurological determination of death?

We present two patients who regained spontaneous respiration following clinical neurological determination of death (NDD) while ancillary radiological imaging demonstrated brain blood flow. A 26-yr-old male with chronic otitis media presented with a Glasgow Coma Scale (GCS) score of 3 and fixed 7-mm pupils. Computed tomography demonstrated right-sided mastoiditis and a temporal lobe abscess associated with uncal herniation. The patient was diagnosed brain dead seven-hr later when motor responses and brainstem reflexes were absent and his apnea test was positive. Approximately 28-hr after NDD, during post-declaration organ resuscitation, the patient regained spontaneous respiration and magnetic resonance imaging revealed brain blood flow. Spontaneous respirations persisted for five-days before cardiovascular collapse occurred. In the second case, a 50-yr-old female presented with a GCS score of 3 and fixed 6-mm pupils following a traumatic brain injury and a five-minute cardiac arrest. The patient was deemed clinically brain dead six-hr later when physical examination revealed absent motor responses and brainstem reflexes and her apnea test was positive. As confirmation of brain death, a cerebral radionuclide angiogram was performed, which surprisingly revealed intracranial arterial flow. During organ resuscitation, 11-hr after NDD, the patient regained spontaneous respiration. She expired hours after family decision to withdraw treatment. For both patients, several unrecognized confounding factors for NDD were present. These cases illustrate the difficulties encountered by experienced clinicians in determining brain death using clinical criteria alone, and they suggest that more routine use of ancillary brain blood flow analyses should be recommended.

Hydrocéphalie unilatérale secondaire à un abcès temporal traitée par septotomie endoscopique : à propos d’un cas

Hydrocephalus is a rare complication of brain abscess, due to either the mass effect on the ventricular system or to the rupture of the abscess in the ventricles. We report here the case of 44-year-old man who was operated on for a temporal lobe abscess of pulmonary origin who presented 6 weeks later with obstructive hydrocephalus secondary to a likely choroid plexus thrombophlebitis. This patient was treated successfully with an endoscopic septotomy. In light of the pertinent literature, we discuss the pathophysiological and management aspects of this unusual entity.

The Number of Instability Markers is a Significant Predictor of Outcome in Distal Radial Fractures and Can Be Used as a Guide to Devise a Standardised Management Strategy for These Fractures

The Number of Instability Markers is a Significant Predictor of Outcome in Distal Radial Fractures and Can Be Used as a Guide to Devise a Standardised Management Strategy for These Fractures

Temporal Lobe Abscess in a Patient With Isolated Fungal Sphenoiditis

Pathology References Isolated sphenoid sinusitis accounts for 2-3% of all sinus infections evaluated by radiologic imaging. Fungal sphenoiditis is present in approximately 5% of isolated sphenoiditis. The most common presenting symptom is frontal/retro-orbital headache; this occurs in roughly 70% of cases. Nasal obstruction is the next most common symptom presenting in 30% of cases. Noninvasive fungal sphenoid sinusitis rarely presents with serious complications. However, diplopia and/or transient vision loss have been the most severe reported complications and have been seen in up to 3% of cases. Intracranial extension and cerebral abscess is another serious complication of fungal sphenoiditis, and to our knowledge has not been reported until now. Intracranial extension from sinusitis is a rare but potentially fatal disease characterized by bony erosion of the skull base and fungal extension into the adjacent cavities, such as the orbit or cranial vault. It is usually associated with acute fulminant invasive fungal sinusitis (AFIFS) in the immunocompromised population, such as patients who have undergone hematopoietic stem cell transplantation or solid organ transplant, those with HIV/AIDS or diabetes mellitus, or those who are undergoing treatment with chemotherapy or immunosuppressants.3, 4 However, this complication has now been shown to very rarely occur in immunocompetent individuals as well, and seems to be increasing in frequency in this population.4-7 Of the approximately twenty pathogenic fungi, the three most common fungal infections in the nasal sinuses are the opportunistic genera of Aspergillus, Mucor, and Candida, of which Aspergillus is the most prevalent organism.1, 8 While rare, each of these can invade the adjacent structures, with Mucor being the most invasive and requiring the most aggressive surgical treatments. Intracranial extension and abscess formation most commonly occurs from the frontal sinus to the frontal and frontoparietal areas of the brain. 4 The rarest occurrence of invasive fungal sinusitis is seen in the sphenoid sinus, due to only 2.7% of all sinus infections occurring there.9 The rarity of this infection in comparison to other sinuses is because of both the anatomical orientation of the sphenoid sinus receiving little directed airflow, and because the sinus mucosa is lined by relatively few glands, producing less mucus to serve as a reservoir for infection.10 When invasion does occur from the sphenoid sinus, it can occur through one of two mechanisms: retrograde thrombophlebitis through diploic veins of the skull, or by direct extension through normal anatomic pathways or wall erosion.11 The fungus can either enter the frontoparietal areas of the brain similar to extension from the frontal and ethmoid sinuses, or it can extend into the cavernous sinus, causing visual defects secondary to destruction of cranial nerves III, IV, V, and VI. Another potential site of invasion is the temporal lobe, which has rarely been documented.10, 11 Case Report

Temporal Lobe Abscesses and the Role of Ent: A 10-Year Review

Temporal Lobe Abscesses and the Role of Ent: A 10-Year Review

Intraparenchymal temporal lobe abscess caused by group F streptococci

Intraparenchymal temporal lobe abscess caused by group F streptococci

DELAYED EXTRUSION OF HYDROXYAPATITE CEMENT AFTER TRANSPETROSAL RECONSTRUCTION

Use of hydroxyapatite cement has been advocated for closure of transpetrosal defects to decrease the incidence of cerebrospinal fluid leaks. We previously identified delayed extrusion of this cement as a significant complication associated with this closure technique and now update our long-term experience. In our retrospective review, we identified 1231 patients who underwent transpetrosal procedures by our multidisciplinary cranial base team between 1984 and 2005. Of the subgroup of 177 patients who had hydroxyapatite cement used during the closure of the procedure, 13 patients (7.3%) experienced delayed extrusion of hydroxyapatite cement. Extrusion occurred in 3 patients within 12 months and in 10 patients within 68 to 140 months. Twelve patients presented with draining fistulae and concomitant Staphylococcus aureus infection; 1 patient presented asymptomatically with a large temporal lobe abscess identified on surveillance magnetic resonance imaging. All 13 patients underwent reoperation, including 1 who underwent a second procedure. Delayed extrusion of hydroxyapatite cement resulted in significant morbidity to our patients and often presented in an indolent manner. We recommend serial examination and imaging studies in patients who have had transpetrosal closures with hydroxyapatite cement. Because of the complication rates associated with hydroxyapatite cement, we have discontinued its use.

Fungal Sinusitis with Intracranial Extension in Immuno-competent Patients: Surgical Planning According to Relation to Eloquent Neurovascular Structures

Abstract Objective To evaluate the results of combined neurosurgical and ENT surgical management for patients with fungal sinusitis with intracranial extension. Methods We managed 10 cases with fungal sinusitis with intracranial extension. This included 7 females and 3 males. Four patients presented with unilateral proptosis, 2 with deterioration of level of consciousness due to meningitis, 2 with chronic headache, one with epilepsy and one patient presented with trigeminal pain. All cases had long history of chronic headache and nasal obstruction. CT was done in all cases, MR in 8 patients, CT angiography and conventional cerebral angiography in one patient. Surgical intervention was decided according to the relation of the fungal granuloma to eloquent intracranial structures. Endonasal approach alone was used when the granuloma was not related to the optic nerve, internal carotid artery or cavernous sinus (n = 3). Combined subfrontal and endonasal approach was used when the granuloma was closely related to one or more of these structures (n = 5). Transcranial approach alone was done for 2 patients with isolated sphenoid fungal sinusitis that was associated with a mycotic internal carotid artery aneurysm in one patient and with a temporal lobe abscess in the other. In addition, antifungal treatment was used for 8-12 weeks. Patients were followed up clinically and radiologically for 6-36 month period. Results No morbidity related to the operative procedures was recorded in the study group. One patient died two month post-operatively due to fungal meningitis. In survivors (n = 9): headache and nasal obstruction improved, proptosis was corrected, epilepsy and trigeminal pain were controlled by medication. Follow-up CT showed eradication of the fungal granuloma in all survivors. Histopathological results showed mucormycosis (n = 2), aspirgillosis (n = 4), and no fungus (4 patients). Conclusion Team work by ENT and neurosurgical staff and early diagnosis are mandatory in the management of fungal sinusitis with intracranial extension in immune-competent patients. Surgical planning according to the relation of fungal granuloma to eloquent neurovascular structures is the corner stone for save removal of granuloma.