Subgaleal Abscess in the Newborn - The Annals of Pediatric Surgery

Annals of Pediatric Surgery, Vol 2, No 1, January 2006, PP 48-49Case ReportSubgaleal Abscess in the Newborn: A Case Report1 Ogunrinde G. O, Ogala W. N., 2 Ameh E. A., Onalo R., 1 Lukong C. S,1 Department of Pediatrics, and 2 Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University,Teaching Hospital, Zaria, NIGERIAAbstract:A 9-day old baby developed a large subgaleal abscess following precipitate delivery at homes. Treatment was by adequateincision and drainage, and intensive antibiotic therapy. Recovery was uneventful. Subgaleal abscess is rarely reported in thenewborn. Early recognition and prompt drainage along with administration of appropriate antibiotics is necessary tominimize morbidity and mortality.Index Words: Subgaleal abscess , NewbornINTRODUCTIONInfections of the deep spaces of the head and neck arenot common but may result in life- threateningconsequences if inadequately treated. 1 Subgalealabscesses have been reported in older children andadults, mostly from scalp trauma, and in majority ofcases, there was a break in the skin overlying thearea. 2,3 Subgaleal abscess is rarely reported in thenewborn.CASE REPORTA 9-day old boy presented with 8 days history of rightsided scalp swelling, 6 days history of intermittentfever and excessive crying and 3 days history ofbilateral periorbital swelling. The symptoms started aday after precipitate delivery at home. The baby criedimmediately after birth but no bruises, indentation orany other abnormality on the head was noticed at thetime. The next day, the right side of the scalp becameswollen. The swelling was slowly progressive. Therewere no swellings on other parts of the body. Therewas no convulsion, jaundice or bleeding from anysite. The baby had uvulectomy on the 3 rd day of life athome. Cord care was by warm compress.Physical examination showed temperature of 38.8 o C,no jaundice, no cyanosis and the hydration was good.There was a tender swelling of the right parietooccipitalscalp. It measured 8cm x 6 cm, and was firm.The skin over the swelling was normal. There wasalso bilateral periorbital oedema and purulent eyedischarge. The cranial nerves were intact and therewere no focal neurological deficits. Primitive reflexeswere present and normal. The anterior fontanelle wasnormal. Heart rate was 152/minute and heart soundswere normal. The umbilical cord was normal. Theuvula was absent otherwise pharyngeal examinationwas normal.Skull x-ray showed a soft tissue mass over the rightparieto-occipital region but no other abnormalitieswere seen. CT scan of the skull and brain was notpossible. Packed cell volume was 33%, white bloodcell count 7.4 x 10 9 /L with a differential count of 40%neutrophils and 60% lymphocytes. Blood and eyeswab cultures were sterile.An initial diagnosis of cephalhaematoma andsepticaemia was made and treatment withintravenous ampicillin 100mg/kg/day, cloxacillin100mg/kg/day and intramuscular gentamycin7.5mg/kg/day was started. Despite these antibiotics,--------------------------------------------------------------------------------------------------------------------------------------------------------------------Correspondence to: G. O. Ogunrinde, Department of Paediatrics, Ahmadu Bello University, Teaching Hospital, Zaria, Nigeria. E-mail:eaameh@yahoo.co.uk

pyrexia persisted. By the 6 th day of admission, thescalp swelling became fluctuant and starteddischarging pus spontaneously (Fig 1). Culture of thepus was sterile. An incision and drainage was doneand 60mls of thick, creamy and inoffensive pusdrained from the subgaleal space. The abscess cavitywas dressed and packed daily with honey-soakedgauze. The child subsequently did well, the abscesscavity gradually reduced and the wound healed. Hewas discharged after 22 days in hospital and hasremained well after 6 months.Fig 1. The abscess, discharging thick creamy pusDISCUSSIONSubgaleal abscess is rare in the newborn. Mostreported cases occurred following scalp trauma, orneedle electrode inserted for fetal monitoring. 2-4Although, infected scalp wounds are generallylimited and readily treated, they can progress if notpromptly and adequately managed. 5 Although directspread through scalp bruises is the mechanism ofinfection in most reported cases, this abscess has beenreported following minor trauma with a scalp wound.The patient in the present report may have developeda haematoma, which became infected byhaematogenous route from the uvulectomy.The bacteriology of subgaleal abscess in the fewreported cases revealed the predominance ofStreptococcus species among the bacterial isolates.Group A β haemolytic streptococcus 3 and group Cstreptococcus such as Streptococcus cremoris 6 andStreptococcus viridans, 2 are among the frequentlyreported agents. Other bacteria isolated includecoagulase negative staphylococci, Eilkenellacorrodens, Edwardsiella tarda 7 andPeptostreptococcus micros. 2 However in this report,the abscess was sterile probably due to antibioticsadministered before the swelling became fluctuant.Several extracranial and intracranial complicationscould arise from subgaleal abscess. These includecranial osteomyelitis and sinusitis due to closeproximity of the subgaleal space to these structures.Intracranial extension could occur through theemissary veins resulting in cavernous or superiorsaggital sinus thrombosis, meningitis and intracranialabscess. No complications occurred in our patient.The diagnosis of subgaleal abscess is mainly clinical.Needle aspiration should confirm the presence of pus.CT scan, when available is helpful to excludeintracranial complications.In early cases, complete aspiration by wide boreneedle and antibiotics may be effective. However, ifthe collection recurs, and in large abscesses, adequateincision and drainage is necessary. The abscess in thisbaby was large, and required incision and drainage.In newborns with suspected cephalhaematoma,needle aspiration should be done to exclude anabscess if fever persists. Prompt treatment of anyabscess is necessary to prevent complications.REFERENCES1. Endicott JN, Nelson RJ, Saraceno CA. Diagnosis andmanagement decisions in infections of the deep facial spaceof the head and neck utilizing computerized tomography.Laryngoscope 1982; 92:630-3.2. Wang WH, Hwang TZ. Extensive subgaleal abscessand epidural empyema in a patient with acute frontalsinusitis. J Formos Med Assoc. 2003; 102:338-41.3. Wiley JF 2 nd , Sugarman JM, Bell LM. Subgaleal abscess:an unusual presentation. Ann Emerg Med 1989; 18:785-7.4. Razzouk A, Collins N, Zirkle T. Chronic offensivenecrotising abscess of the scalp. Ann Plast Surg 1988; 20:124 – 7.5. Granick MS, Conklin W, Ramasastry S, Talamo TS.Devastating scalp infections. Am J Emerg Med 1986; 4:136-40.6. Brien JH. What’s your diagnosis? Available on theInternet at http://idinchildren.com/200/09/wyd.asp.7. Ganzalez AB, Ruffolo EH. Edwardsiella tarda: etiologicagent in a post-traumatic subgaleal abscess. South Med J1966; 59:3449

Ogunrinde et al50Annals of Pediatric Surgery