Which should be appropriate surgical treatment for subtentorial epidural empyema? Burr-hole evacuation versus decompressive craniectomy: Review of the literature with a case report

Abstract

Subtentorial empyema is a rare intracranial complication of chronic otitis media. Moreover, if not correctly treated, it is a life-threatening infection. Epidural and subdural empyemas on subtentorial space have different effects. This difference is not mentioned in literature. If the distinction can be made, surgical treatment method will be different, and the desired surgical treatment may be less minimal invasive. A 26-year-old male patient was found to have developed epidural empyema in the subtentorial space. We performed a burr-hole evacuation in this case because there was low cerebellar edema, Also, the general condition of the patient was good, the empyema was a convex image on the lower surface of tentorium on magnetic resonance images, and when the dura mater base is reached during mastoidectomy for chronic otitis media, we were observed to drain a purulent material through the epidural space. After 10 days from surgery increased posterior fossa edema caused hydrocephalus. Therefore, ventriculoperitoneal shunt insertion was performed. The patient fully recovered and was discharged after 6 weeks. Complete correction in the posterior fossa was observed by postoperative magnetic resonance imaging. Burr-hole evacuation from inside of the mastoidectomy cavity for subtentorial epidural empyema is an effective and minimal invasive surgical treatment.

Keywords: Chronic otitis media; drainage; epidural empyema; hydrocephalus; subtentorial empyema.

Figure 1

Preoperative magnetic resonance imaging and early postoperative computed tomography images. (a-c) Re-operative magnetic resonance imaging of a 26-year-old male patient. Coronal, sagittal, and axial images with peripheral contrast enhancement. Subdural empyema viewed on the lower surface of tentorium (d) axial tomography of the patient 2 days before the first surgery (e and f) course of the catheter on computed tomography image and view of the mastoidectomy cavity in the bone

Figure 2

Anatomical landmarks and surgical planning. (a and b) A–A line = Reid's base line; the base line of the skull; line extending from the inferior orbital margin to the center of the external acoustic meatus (B point). C point: Sigmoid sinus. The distance between the points B and C is approximately 15–20 mm. D point: Asterion. The D point is just below the transverse sinuses. E point: Presigmoid burr-hole point. F point: Posterior edge of the mastoidectomy cavity. G point: Retrosigmoid burr-hole point. H point: Subtentorial empyema (our target). Figures were drawn for orientation to the sigmoid sinus according to the patient's surgical position and sagittal view of the cranium. The mastoidectomy cavity is depicted throughout the course of the sigmoid and transverse sinuses, and the relationship between these two sinuses is shown. The C point is 1 cm above the level A–A line. The transverse sinus is proximal to the C point

Figure 3

Computed tomography and magnetic resonance imaging images after burr-hole evacuation. (a) Hydrocephalus occurred in the early postoperative computed tomography image. (b) Posterior fossa edema on axial T1 magnetic resonance imaging 1 week after the first operation. (c) A ventriculoperitoneal shunt was inserted on the 10th postoperative day. The view 1 day after the ventriculoperitoneal shunt was inserted. (d) Coronal T1 magnetic resonance imaging after ventriculoperitoneal shunt. (e and f) Posterior fossa view on T1 magnetic resonance imaging with contrast enhancement 3 months after ventriculoperitoneal shunt insertion