Development of posttraumatic frontal brain abscess in association with an orbital roof fracture and odontogenic abscess: A case report
- Department of Neurosurgery, Rhode Island Hospital, The Alpert Warren Medical School of Brown University Providence, United States.
- Department of Plastic Surgery, Rhode Island Hospital, The Alpert Warren Medical School of Brown University Providence, United States.
Hael Abdulrazeq, Department of Neurosurgery, Rhode Island Hospital, The Alpert Warren Medical School of Brown University Providence, United States.
DOI:10.25259/SNI_813_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Hael Abdulrazeq1, Konrad Walek1, Shailen Sampath1, Elias Shaaya1, Dardan Beqiri2, Albert Woo2, Prakash Sampath1. Development of posttraumatic frontal brain abscess in association with an orbital roof fracture and odontogenic abscess: A case report. 18-Nov-2022;13:539
How to cite this URL: Hael Abdulrazeq1, Konrad Walek1, Shailen Sampath1, Elias Shaaya1, Dardan Beqiri2, Albert Woo2, Prakash Sampath1. Development of posttraumatic frontal brain abscess in association with an orbital roof fracture and odontogenic abscess: A case report. 18-Nov-2022;13:539. Available from: https://surgicalneurologyint.com/surgicalint-articles/12007/
Background: Brain abscess is a potentially fatal condition. Orbital fractures caused by penetrating injury may be associated with intracranial infection. Such complication associated with blunt trauma, orbital roof fractures, and odontogenic abscesses is exceedingly rare.
Case Description: We report the case of a 40-year-old transgender female with a frontal abscess presenting several weeks following a motor vehicle crash from which she suffered multiple facial fractures and an odontogenic abscess. On computed tomography scan, the patient had multiple right-sided facial fractures, including a medial orbital wall fracture and a right sphenoid fracture extending into the superior orbital roof. There was hemorrhage notable in the right frontal lobe. Communication with the ethmoid sinuses likely provided a conduit for bacterial spread through the orbit and into the intracranial and subdural spaces.
Conclusion: Skull base fractures that communicate with a sinus, whether it be frontal, ethmoid, or sphenoid may increase the risk of brain abscess, especially in patients who develop an odontogenic abscess. Surgical repair of the defect is essential, and treating patients prophylactically with antibiotics may be beneficial.
Keywords: Brain abscess, Odontogenic abscess, Orbital fracture, Trauma
Brain abscesses are a rare but serious complication of focal intracerebral infection.[
We present a case of a 40-year-old transgender female who suffered a right frontal abscess several weeks after a trauma that resulted in a number of complex right-sided injuries, including medial and superior orbital wall fractures. We discuss the surgical approach to treat this condition.
This is a 40-year-old transgender female with no pertinent medical history who presented to the emergency room after a motor vehicle accident, in which she reported that she was a restrained driver, but was found ejected 25 feet from the crashed vehicle. She described subjective right eye visual loss but was found on ophthalmologic evaluation to have intact visual fields. She had computed tomography (CT) imaging as part of the trauma work up which revealed a right sided contusion, traumatic subarachnoid hemorrhage [
(a) Coronal view of computed tomography brain without contrast demonstrating a right frontal contusion with associated subarachnoid hemorrhage at the site of future abscess. (b) Three-dimensional reconstruction of computed tomography face which reveals the complex facial fractures as well as the right-sided orbital fractures.
On hospital day 7, she was noted to have a fever and elevated white blood cell count, as well as facial swelling. She then began having purulent drainage from the oral cavity and was diagnosed with an odontological abscess of tooth #2 and #5. Dental specialists performed an incision and drainage of a maxillary buccal vestibular abscess and placement of drains which were removed on postprocedure day 2. The patient was discharged on oral amoxicillin/clavulanic acid for 2 weeks. At this time, cultures were not sent for analysis.
The patient’s mental status continued to improve, and she was discharged to a rehabilitation facility in stable condition on hospital day 15.
The patient returned 2 months after with 4 days of headaches and chills. Vital signs were stable, and the patient was neurologically intact. Laboratories revealed a normal white blood count, an elevated c-reactive protein level of 47 mg/dL (normal <1.0 mg/dL),[
Given the imaging findings, the patient was taken emergently to the operating room as a joint procedure between the neurosurgery and plastic surgery teams for evacuation of abscess and skull base reconstruction. After general anesthesia was administered and the patient intubated, she was placed in supine position on a Mayfield head rest. A bicoronal incision was planned and the flap was reflected anteriorly for exposure, preserving a pericranial flap for reconstruction of the skull base. A right frontal craniotomy was performed, which was close to midline and was extended anteriorly to the skull base. Given absence of a frontal sinus on the right side, the craniotomy was extended just above the orbital roof. After locating the abscess with intraoperative ultrasound, a U-shaped dural opening was performed. Using a combination of bipolar cautery and a 15-blade scalpel, corticectomy was extended until the abscess wall was identified. This was opened and copious purulent material was washed out. Attention was then shifted into developing the plane between the cortex and the abscess wall, which allowed for safe resection of what remained of the abscess wall.
At this point, it was noted that there was a dural defect under the abscess, which was overlying the orbital roof fracture and likely represented a conduit for bacterial spread [
Cultures obtained during the operative intervention resulted with Streptococcus intermedius, a β-hemolytic Gram-positive bacteria commonly found in the respiratory, gastrointestinal, genitourinary tracts, and a cause of dental abscesses.[
Orbital roof fractures place the overlying dura and frontal lobe at risk of further injury and complications. These include dural tear (such as in our case), CSF leak, cerebral contusion, subarachnoid hemorrhage, or subdural hematoma.[
The causative organism in this case, S. intermedius, represents one of the most cultured class of organisms in brain abscesses and is typically treated with a course of intravenous ceftriaxone.[
Whether the patient had a CSF leak that was undetected and led to increased risk of intracranial infection, which is unknown. The odontogenic abscess also represents a source of spread especially through a hematogenous route, though this is exceedingly rare and is usually a diagnosis of exclusion.[
Intracranial abscess is a rare and potentially fatal condition. Patients with complex facial fractures and those who present with orbital fractures after blunt trauma are at risk, even in the absence of clear evidence of CSF leak. Neurosurgeons should identify scenarios when there is communication with a sinus, whether it be frontal, ethmoid, or sphenoid. Patients must be cautious about nose blowing to prevent injection of bacteria under pressure into the brain. Beyond this, the question is raised whether such patients should be prophylactically treated with antibiotics, especially considering presence of other infections such as dental abscesses.
Patient’s consent not required as patient’s identity is not disclosed or compromised.
There are no conflicts of interest.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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