Percutaneous tapping for the treatment of sinusitis-related intracranial epidural abscess in children.

A 13-year-old boy with medically intractable sinusitis-related intracranial epidural abscess in the frontal region was treated using percutaneous tapping. Drainage of pus measuring 7 ml yielded excellent postoperative course without cosmetic disadvantage on the forehead. Percutaneous tapping is considered to be the ideal treatment because of minimal invasiveness and cosmetic aspects of the wound.

Introduction

Recent literature on the intracranial epidural abscess in infancy is sparse, different from that of the subdural lesion. The treatment modalities include burr hole drainage, craniotomy and transcranial needle aspiration, last being less popular even in the computed tomography (CT) and magnetic resonance imaging (MRI) era. The authors have experienced a case of an infant with medically intractable intracranial epidural abscess in the frontal region, for which percutaneous tapping on the forehead yielded excellent results of neurological and cosmetic aspects of the wound. Usefulness of this treatment modality is discussed.

Case Report

The 13-year-old boy without significant medical history presented with headache and fever at our emergency room in April, 2013. Physical and neurological examination showed no abnormality. Head CT and MRI revealed an epidural mass lesion including air collection in the right frontal region [Figure 1]. The air was noted to be moving in the abscess cavity, indicating the abscess to be liquid material, not to be gelatinoid tissue.

Figure 1

Plain computed tomography (left) and T2-weighted magnetic resonance imaging (right) on admission, revealing epidural abscess with air collection moving in the cavity (arrows)

After admission to the Department of Pediatrics, further examination revealed sinusitis on the right side possibly secondary to a decayed tooth, which was considered to be the cause of the intracranial epidural abscess.

He was treated with administration of intravenous anti-biotics including vancomycin and ceftriaxone, failing to relieve the headache and inflammatory reaction.

Enlargement of the epidural abscess on subsequent CT prompted to emergency surgical intervention on the 3rd day after admission.

Under orotracheal general anesthesia, after opening of the frontal sinus and the maxillary sinus on the right side by the otorhinolaryngologists, percutaneous tapping on the right forehead was performed using the subdural tapping needle [Figure 2].

Figure 2

Assembly of subdural tapping needle. Left: Drill needle, middle: Outer needle, right: Inner needle (Manufactured by FUJITA Medical Instruments,Co., Ltd., 3-6-1 Hongo, Bunkyou-ku, Tokyo, 113-0033, Japan)

Removal of the inner needle was followed by purulent material gushing through the outer needle [Figure 3]. Totally 7 ml of pus was drained by aspiration using an intravenous extension tube [Figure 4]. His postoperative course was uneventful and was discharged from our hospital without neurological deficits. The wound healing was also excellent [Figure 5]. Culture of the purulent material failed to isolate any pathogenic organisms.

Figure 3

Pus gushing through the outer needle of the subdural tapping needle

Figure 4

Aspiration of pus, totally measured 7 ml

Figure 5

A photograph 7 days after tapping, showing a minimal scar on his forehead (arrow)

Discussion

Percutaneous transcranial tapping is decreasingly adopted as a treatment modality for intracranial mass lesions. Actually, intracranial epidural abscess is also exclusively treated with burr hole drainage or craniotomy.[1] In addition, percutaneous tapping is a blind procedure, seemingly carrying the possibility of hemorrhagic complications. On the other hand, the authors have sufficient experience of percutaneous tapping for subdural hematoma in pediatric populations, confirming this procedure as safe as other treatment with minimal complications.[23]

In this patient, CT and MRI revealed air moving in the abscess cavity, showing the lesion in the epidural space,[4] and the abscess to be liquid material rather than gelatinoid tissue, by which percutaneous tapping is feasibly scheduled. Because burr hole drainage requires at least 2–3 cm of skin incision on the forehead or large scalp incision circulating the lesion, percutaneous tapping is preferable from the cosmetic point of view.

Although this patient underwent general anesthesia for the preceding otorhinolaryngological surgery, tapping could be performed by local anesthesia considering his age being 13-year-old. Thus, percutaneous tapping seemed to be ideal for the treatment of this patient. To maximize the safety of this procedure, tapping needle should be preferably device.

Classical twist-drill technique was adopted using the drill needle, followed by insertion of the subdural tapping needle in the drilled hole. With this technique, the authors have treated chronic subdural hematoma in adult patients more than 20 years, confirming the safety and efficacy.[5] This technique is also available for children suffering from intracranial mass lesions as less invasive intervention.

Conservative treatment for intracranial epidural abscess with anti-biotics for at least 6 weeks has been proposed.[6] However, considering the anxiety of the “wait-and-see” policy associated with prolonged length of hospital stay, early choice of percutaneous tapping should be indicated not only as less invasive intervention but also as radical treatment.