Endonasal Endoscopic Drainage of Intracranial Abscess

Introduction: The endonasal endoscopic approach continues to be an increasingly useful tool as skull base surgeons become more adept in its use for a variety of pathology. Intracranial abscesses have primarily been treated via an open craniotomy for drainage and washout. We present a case report of a patient with a 2.7cm right frontal lobe abscess that was drained through an endonasal endoscopic approach.

Methods: The patient is a 16 year old male with a history of new onset seizures and a right frontoethmoidal encephalocele resection, who presented with acute sinusitis and was noted to have a right frontal lobe abscess. He had failed conservative treatment with intravenous antibiotics and we recommended surgical washout of the abscess. We performed a right-sided endoscopic total ethmoidectomy and a right frontal sinusotomy. Image navigation was used to locate the abscess cavity which was sharply incised, and we noted immediate egress of copious purulence. Areas of loculations were disrupted, the cavity was irrigated vigorously and the edges were coagulated. There were no complications with the procedure.

Results: The patient's intraoperative culture was positive for coagulase negative staphylococcus species, and he was treated with a total 6-week course of imipenem and vancomycin per Infectious Disease. He has been followed for 2.5 years postoperatively. He had improvement in his headaches and did not develop any postoperative cerebrospinal fluid leak, neurologic deficits or sinonasal problems. He has also had several MRI scans postoperatively that has shown no residual or recurrence of the abscess or encephalocele.

Conclusions: The endoscopic endonasal approach is a very resourceful tool in the armamentarium of skull base surgeons, and its application continues to increase as it becomes widely accepted as a treatment modality for a variety of skull base pathology. There has only been one other case report of an endonasal endoscopic approach to treat intracranial abscess. We believe this is a valid tool for the right midline anterior skull base abscess and it should be considered as a valid alternative to open craniotomy in the treatment of intracranial abscesses.