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Infratentorial empyema: analysis of 22 cases
N Nathoo1, S S Nadvi, J R van Dellen
1Department of Neurosurgery, University of Natal Medical School, Durban, South Africa.
Objective:
Infratentorial empyema is an uncommon form of intracranial suppuration that is usually secondary to neglected otogenic infection. The diagnosis is frequently delayed and often confused with that of meningitis. The associated mortality is distressingly high, yet it has, as a clinical entity, received scant attention in the literature. We present a 13-year experience of this condition.
Patients And Methods:
From a retrospective analysis of 3865 patients with intracranial suppuration during a 13-year period, 22 patients with infratentorial empyema were identified. The inpatient notes for these patients were analyzed with reference to clinical, radiological, bacteriological, operative, and outcome data.
Results:
Twenty-two patients with infratentorial empyema accounted for 0.6% of admissions caused by intracranial suppuration during the study period. Of these 22 empyemas, 13 were subdural and 9 epidural. Hydrocephalus was present in 17 (77.3%). Except for two epidural empyemas that did not warrant neurosurgical intervention, all patients underwent standard surgical management (wide posterior fossa craniectomy). Nineteen underwent mastoidectomy because the source of infection was otogenic. Concomitant and persistent hydrocephalus was treated aggressively. Five patients died (mortality rate of 22.7%). All fatalities had subdural empyemas, and all three patients with cerebellopontine angle extension of subdural purulent collections died.
Conclusion:
Although rare, infratentorial empyema, especially when subdural, is a lethal disease. Cerebellopontine angle extension of pus was a particularly ominous sign in our experience. Early surgical drainage via wide posterior fossa craniectomy, aggressive treatment of associated hydrocephalus, eradication of the primary source of sepsis, and, finally, intravenous high dosage of appropriate antibiotics form the mainstay of treatment.
Insights
Infratentorial empyema, a rare brain infection, carries a high mortality, particularly subdural cases with cerebellopontine angle extension. Prompt surgical drainage and aggressive treatment are crucial for survival.
Area of Science:
- Neurosurgery
- Infectious Diseases
- Neurology
Background:
- Infratentorial empyema is a rare but serious intracranial suppuration, often stemming from neglected otogenic infections.
- Diagnosis is frequently delayed and misdiagnosed as meningitis, contributing to high mortality rates.
- This clinical entity has received limited attention in medical literature.
Purpose of the Study:
- To analyze a 13-year experience with infratentorial empyema.
- To identify risk factors and outcomes associated with this condition.
- To highlight the importance of early diagnosis and treatment.
Main Methods:
- Retrospective analysis of 3865 patients with intracranial suppuration over 13 years.
- Identification and detailed review of 22 patients diagnosed with infratentorial empyema.
- Analysis of clinical, radiological, bacteriological, operative, and outcome data.
Main Results:
- Infratentorial empyema represented 0.6% of intracranial suppuration cases.
- Subdural empyemas (13 cases) were more common than epidural (9 cases).
- Hydrocephalus was present in 77.3% of patients; mortality rate was 22.7%, with all fatalities having subdural empyemas and three with cerebellopontine angle extension.
Conclusions:
- Infratentorial empyema, particularly subdural, is a lethal condition.
- Cerebellopontine angle extension of pus is a significant negative prognostic indicator.
- Effective treatment involves early surgical drainage, aggressive management of hydrocephalus, source control, and antibiotics.