Lytic lesion of skull: a rare presentation of chronic granulomatous disease.

An 18-month-old boy presented with lytic lesion of skull and recurrent abscesses with Serratia marcescens The extensive work up revealed a gene mutation confirming the diagnosis of chronic granulomatous disease (CGD). This case scenario underscores the importance of exploring the possibility of immunodeficiency if there is a history of recurrent abscesses with atypical organism. The case also demonstrates that CGD can present as lytic lesion of skull.

Mycobacterium riyadhense infections.

Mycobacterium riyadhense is a newly described slowly growing, non-tuberculous mycobacterium species. We describe 2 new cases of Mycobacterium riyadhense infections presenting with extra-pulmonary involvement, and reviewed all previously reported cases in the literature. We also describe the spectrum of the disease and explore treatment options based on the experience with the current and previously reported cases.

[A girl with a swelling on her forehead]. / Een meisje met een zwelling op haar voorhoofd.

A 9-year-old girl presented with headache and swelling of her forehead caused by a Pott's puffy tumour.

Pus and free bone flaps.

OBJECT: The goal of this investigation is to describe the results of a vigorous attempt to preserve contaminated free bone flaps and avoid the problems associated with the traditional and common practice of discarding the flap, administering a course of antibiotics, and after several months, performing a cranioplasty. METHODS: Patients with clearly contaminated, free cranial bone flaps, including so-called high risk cases, were treated by meticulous debridement of the surgical bed, scrubbing, soaking, and then replacing the bone flap in its normal position, and administering a course of intravenous antibiotics. RESULTS: Fourteen patients with contaminated avascular cranial bone flaps were treated using this technique. All bone flaps were able to be preserved. Conclusions Patients with bacteriologically contaminated, free bone flaps can be treated successfully without discarding the flaps. Success is dependent upon aggressive surgical debridement and persistence.

Pott's puffy tumor after acupuncture therapy.

We report a case of Pott's puffy tumor (PPT) with Pseudomonas infection occurring after acupuncture therapy in a ventilator-dependent child. Acupuncture use has been growing during the past decade in the whole world. Infectious complications range from benign to lethal. PPT is a subperiosteal abscess of the frontal bone associated with underlying osteomyelitis. It presents as a localised swelling of the forehead. This paper describes a 12-year-old girl with PPT. To our knowledge, this is the first case report of PTT caused by acupuncture therapy.

Pott's puffy tumor.

Pott's Puffy tumor is a rare clinical entity characterized by subperiosteal abscess associated with osteomyelitis. It is usually seen as a complication of frontal sinusitis or trauma predominantly in the adolescent age group. Pott's Puffy tumor can be associated with cortical vein thrombosis, epidural abscess, subdural empyema, and brain abscess. The cause of vein thrombosis is explained by venous derange of the frontal sinus, which occurs through diplopic veins, which communicate with the dural venous plexus; septic thrombi can potentially evolve from foci within the frontal sinus and propagate through this venous system. An apparently healthy 7-year-old girl presented to the emergency service of otolaryngology with complaints of swelling of forehead and periorbital zone, headache, chills, fever, and rhinorrhea. The patient described in this case report had 2 important complications of paranasal sinus disease: the relatively common complication of postseptal cellulites and the less common complication of Pott's Puffy tumor.

Frontal bone and epidural tuberculosis.

Cranial bone and epidural tuberculosis is rare manifestation extrapulmonary tuberculosis. The incidence of tuberculosis of calvaria is on the rise in developing countries because of malnutrition, poor socioeconomic conditions, and immunodeficiency. We present the clinical features, radiology, histopathology, and surgical findings of a case of tuberculosis of the frontal bone with epidural extension. A 46 year-old female had presented with a history of painless right frontal swelling for the previous 4 months. The patient was operated on at a peripheral center for swelling in the right frontal region. In postoperative period, a leak that did not reply to nonspecific antibiotic therapy developed on the lesion. Right frontal epidural effusion was found in the patient who presented our clinic. Histopathological and microbiological examination suggested a diagnosis of tuberculosis.

Cranial melioidosis presenting as a mass lesion or osteomyelitis.

OBJECT: Melioidosis is caused by Burkholderia pseudomallei and causes multiple abscesses in different organs of the body. Cranial melioidosis, although uncommon, is sometimes confused with tuberculosis and is therefore under-recognized. The authors report on 6 cases of cranial infections caused by Burkholderia pseudomallei, presenting as mass lesions or cranial osteomyelitis, and review the literature. METHODS: The authors performed a retrospective review of the records of patients with cranial melioidosis treated at their institution between 1998 and 2005 to determine the presentation, management, and outcome of patients with this infection. RESULTS: Of the 6 patients diagnosed with cranial melioidosis during this period, 4 had brain abscesses and 2 had cranial osteomyelitis. All patients were treated surgically, and a diagnosis was made on the basis of histopathological studies. All patients were started on antibiotic therapy following surgery and this was continued for 6 months. One patient died soon after stereotactic aspiration of a brain abscess, and the other 5 patients had good outcomes. CONCLUSIONS: Cranial melioidosis is probably more prevalent than has been previously reported. A high index of suspicion, early diagnosis, initiation of appropriate antibiotic therapy and treatment for an adequate period are essential for assuring good outcome in patients with cranial melioidosis. The authors recommend surgery followed by intravenous ceftazidime treatment for 6 weeks and oral cotrimoxazole for 6 months thereafter in patients with cranial melioidosis.

The role of free flaps in the treatment of persistent scalp osteomyelitis.

OBJECTIVE: To evaluate the efficacy of the combination of an extensive surgical debridement and simultaneous free flap repair in case of troublesome cranial osteomyelitis. METHODS: Five patients with persistent, frontal bone osteomyelitis were treated with surgical debridement of the infected bone and reconstruction with a free flap. In all patients, osteomyelitis occurred after neurosurgical procedures and lasted from 1 to 7 years. A latissimus dorsi muscle flap with a split skin graft has been performed. RESULTS: No flap failure occurred and donor site morbidity was negligible. No signs of osteomyelitis or soft tissue infection were observed during the mean follow-up period of 3.2 years. Furthermore, the contour of the cranium could be preserved without a need for bone grafts or implants. CONCLUSION: In our experience, the combination of an extensive surgical debridement and a free flap transfer is demonstrated to be an effective treatment for "chronic" osteomyelitis of the cranium.

The Pott puffy tumor revisited: neurosurgical implications of this unforgotten entity. Case report and review of the literature.

The Pott puffy tumor is a subperiosteal abscess of the frontal bone that appears as a localized swelling of the overlying region of the forehead associated with frontal osteomyelitis. The authors report the case of an 11-year-old boy who presented with a 6-week history of frontal headaches and a recent sudden-onset, progressively enlarging swelling of his midline forehead associated with immediate relief of headaches. A computed tomography (CT) study revealed 1) a subperiosteal abscess with intracranial extension through the perforated posterior table of the frontal sinus and 2) a large epidural abscess overlying a compressed and narrowed superior sagittal sinus. Emergency surgical relief of the epidural abscess, curettage of the osteomyelitic bone, and excision of the periosteal granulomatous puffy lump were performed. A 6-week course of intravenous antibiotic medication was completed, and the patient had an excellent recovery. The Pott puffy tumor remains a serious complication of frontal sinusitis. In the past 5 years, the frequency of published pediatric cases has increased. Undiagnosed or partially treated frontal sinusitis may lead to this serious complication, and the apparent increase in incidence rate may suggest that this complication of frontal sinusitis could be underestimated in clinical practice. The authors conclude that early diagnosis and complete treatment of frontal sinusitis is crucial.

The prevalence of intracranial complications in pediatric frontal sinusitis.

OBJECTIVE: Intracranial extension of infection represents a serious complication of sinusitis but with no clearly documented prevalence. The frontal sinus with its unique anatomical characteristics, has been singled out as a catalyst for intracranial spread, but without solid evidence. Our objective was to determine the prevalence of intracranial complications in pediatric acute frontal sinusitis and to test the claimed association. METHODS: A retrospective chart review of all children (

Intracranial fungal granuloma: analysis of 40 patients and review of the literature.

OBJECTIVE: To describe the characteristics of patients diagnosed with intracranial fungal granuloma (IFG) in the largest reported series to date (to our knowledge). METHODS: A 22-year retrospective, multi-institutional review of 40 patients, aged 16 to 62 years (mean, 40.2 years), was performed in patients with histopathologically confirmed IFG. The variables were symptoms/signs at presentation, predisposing factors, location of granuloma, involvement of paranasal sinuses, diagnostic studies including blood and urine cultures, surgical procedures performed, specific organism identified, treatment, and prognosis. Plain x-rays, computed tomography, and/or magnetic resonance imaging scans were performed. RESULTS: Predominant symptoms included headache (83%), vomiting (65%), proptosis (48%), and visual disturbances (48%). Other symptoms were fever, nasal congestion, and seizures (7 [18%]). Common signs included papilledema (12 [30%]), with cranial neuropathy (I, III/IV/VI, and V in 4, 7, and 2 patients, respectively), hemiparesis (3), and meningismus (3). Predisposing factors were diabetes (16 [40%]), tuberculosis (7 [18%]), and immunocompromise related to renal transplant (2), non-Hodgkin's lymphoma (1), and human immunodeficiency virus (1). Location was primarily frontal (10 [25%]), with anterior cranial fossa involved in 8 (20%) patients; 6 (15%) patients had sellar/parasellar involvement. Eighteen (40%) had paranasal sinus involvement. Twenty-nine patients underwent craniotomy for resection, with 11 undergoing biopsy (of which 3 were transsphenoidally approached). Histopathology revealed aspergilloma (25 [63%]), mucormycosis (7 [18%]), cryptococcoma (3), cladosporidium (3), Bipolaris hawaiiensis (1), and Candida species(1). Microbiological analysis of the specimen was positive in 28 (60%) patients. All patients were treated with amphotericin B, fluconazole, and/or flucytosine. Only 26 patients completed amphotericin B therapy (due to nephrotoxicity). Mortality was 63%, most commonly due to meningoencephalitis (16 [36%]). CONCLUSIONS: High index of suspicion of IFG should exist for the following groups: (1) immunocompromised patients with intracranial lesions and (2) diabetic patients with intracranial and rhinocerebral mass lesions. Early diagnosis, surgical decompression, and a complete course of promptly initiated antifungal therapy are associated with better prognosis.

Head and neck manifestations of disseminated coccidioidomycosis.

OBJECTIVES/HYPOTHESIS: Coccidioidomycosis is a fungal disease endemic to semiarid regions in the southwestern United States, northern Mexico, and parts of South America. Although this is primarily a pulmonary disease, approximately 0.5% to 1.0% of infected individuals develop disseminated disease affecting skin, subcutaneous tissue, bone, joints, and meninges. The objectives of the study were to present three cases of head and neck manifestations of disseminated coccidioidomycosis and to review the literature of head and neck presentations, diagnosis, and treatment of this potentially life-threatening disease. STUDY DESIGN: Case reports and literature review. METHODS: A Medline search was performed with the keyword "coccidioidomycosis." Of 1719 articles in all, 47 were selected for their relevance to otolaryngology, diagnosis, or treatment. RESULTS: Virtually all head and neck manifestations in patients with disseminated coccidioidomycosis involved the skin, with a predilection for the central face. Systemic symptoms such as fever and cough are often subtle, making the diagnosis difficult. Infections of multiple sites of the head and neck have been reported, including life-threatening airway lesions. CONCLUSION: The incidence of patients with coccidioidomycosis has been steadily increasing since the late 1980s in endemic areas. Otolaryngologists are increasingly being called on to diagnose and manage the head and neck manifestations of the disease caused by Coccidioides immitis.

Haemophilus influenzae osteomyelitis in adults: a report of 4 frontal bone infections and a review of the literature.

Haemophilus influenzae occasionally causes hematogenous long-bone osteomyelitis in children. In adults, however, bone infections caused by this organism are extremely rare. We report four adult cases of H. influenzae frontal bone osteomyelitis and review 12 cases from the literature.

Cytodiagnosis of tuberculosis of the skull by fine needle aspiration cytology: a case report.

Close to one-third of the world's population is believed to be infected with tuberculosis, with the vast majority being in the developing world. However, even in the developed world, the incidence of this disease has been steadily increasing. Tuberculosis is very common in the Indian subcontinent, but at the same time tuberculous infection of the skull is rare and very few cases have been reported. We report a child who presented with a swelling of the frontal bone of the skull. Fine needle aspiration yielded the cytological diagnosis of tuberculosis on the basis of a necrotising granulomatous process with acid-fast bacilli detected on Ziehl Neelsen stain. This procedure obviated the need for an operative procedure and the patient responded to anti-tuberculous therapy. As the incidence of tuberculous infection is on the increase, both in the developed and in the developing world, the importance of diagnosis by newer non-invasive techniques like fine needle aspiration cytology cannot be overemphasized. To the best of our knowledge, this is the first report of its kind in the world literature.

[Osteomyelitis of the frontal bone (Pott's puffy tumor). A report of 5 patients]. / Osteomielitis del hueso frontal (tumor blando de Pott). Presentación de cinco pacientes.

BACKGROUND: Frontal bone osteomyelitis is considered to be rare but it may develop intracranial complications such as subperiosteal abscess that appears as a painful fluctuated forehead tumor (Pott's puffy tumor). METHODS: We reviewed retrospectively the clinical history of those patients showing frontal swelling tumour in our Neurosurgery and Infectious Diseases Departments between July 1994 and December 1997 and whose definitive diagnosis was cranial osteomyelitis. RESULTS: We reported five cases of patients who had been submitted to a neurosurgical operation between 9 months and 27 years ago. The main clinical features were intermittent painful frontal swelling episodes (with or without fever). These episodes were self-limited or limited after short trend of antibiotics. Imaging techniques were necessary for the diagnosis and especially in order to exclude intracranial complications (such as epidural abscess found in two patients). The ascertain diagnosis is made by debriding, histological studies and cultures from the material. Staphylococcus aureus was isolated in three of the patients, Haemophilus influenzae in one patient and Pseudomonas aeruginosa in the other one. All patients were treated with surgery and specific antibiotic therapy during twelve weeks minimum, being definitively cured. CONCLUSIONS: It is not well know the etiopathogenic mechanism concerning this rare disease. We remark the importance of a prompt diagnosis because of the high frequency of intracranial complications as well as combined treatment: surgery and long term antibiotic therapy (not less than 8 weeks), is necessary to cure the disease.