extensive subgaleal abscess and epidural empyema in

Pott’s Puffy TumorA) B)Fig. 2. A) Pretreatment axial computed tomogram showing left maxillary opacification. B) Pretreatment coronal computedtomogram showing left ethmoid opacification.A) B)Fig. 3. A) Coronal computed tomogram showing air-fluid level in the left frontal sinus and extensive subgaleal abscess inthe bilateral parietal regions. Note: this section was taken in the supine position, showing fluid above air. B) Axial computedtomogram showing subgaleal abscess and epidural empyema.with prompt light reflex, unimpaired visual acuityand unlimited extraocular muscle movement. Nasalexamination revealed purulent discharge in the leftmiddle meatus. Laboratory investigations showedleukocytosis with a left shift; C-reactive protein was20.4 mg/dL (normal range, 0 to 5 mg/dL).Computed tomography (CT) demonstrated leftpansinusitis (Fig. 2A and 2B), extensive subgalealabscess in the bilateral frontoparietal regions andepidural empyema of the frontal lobe (Fig. 3A and3B). Bony destruction of the frontal sinus was noted,indicating osteomyelitis of the frontal bone (Fig. 4).A preoperative diagnosis of acute sinusitis complicatedby subgaleal abscess and epidural empyema was made,and the patient was taken to surgery.An eyebrow incision was performed in the gullwing fashion. As the scalp was incised, a significantamount of pus gushed from the incision. The scalphad been spontaneously dissected subgaleally byabscess formation. The outer table of the left frontalsinus was centrally eroded with a bony defect, activelydischarging pus. The defect was widened and bone withabnormal appearance was removed using an air drill.Mucoperiostectomy was performed. A bony defect ofthe inner table was found and a burr hole was drilled todrain the purulent, epidural accumulation. The inferiorwall was removed with preservation of the supraorbitalridge. Endoscopic sinus surgery was then conductedfor intranasal ethmoidectomy, particularly focusingon unroofing the frontal recess. Middle meatal antrostomywas also performed for the concomitant maxillarysinusitis. The scalp wound was vigorously irrigated andclosed in layers. Catheters were placed subgaleally fordrainage and removed 9 days after surgery.Intraoperative cultures grew viridans streptococci,coagulase-negative staphylococci and Peptostreptococcusmicros. The patient received 3 weeks of treatment withintravenous antibiotics (penicillin 3 MU 4-hourly,J Formos Med Assoc 2003 • Vol 102 • No 5 339