Presentation
Exquisite tenderness on frontal bone and left orbit. Concern for sinus infection versus osteomyelitis.
Patient Data
There is a rim enhancing lesion along the anterior aspect of the outer table of the frontal bone. There is diffuse fat stranding adjacent to this lesion.
In the region of the frontal convexity, there is decreased opacification of the most anteroinferior aspect of the superior sagittal sinus. The frontal convexity cortical veins in the region of the abscess demonstrate mildly decreased flow but appear patent.
There is extensive subgaleal soft tissue swelling overlying the frontal calvarium and a subperiosteal abscess arising from the frontal calvarium. There is also evidence of reduced diffusivity subjacent to the inner table of the frontal calvarium.
Case Discussion
This is a case of a Pott puffy tumor with the formation of an epidural abscess. The initial concern for a superior sagittal sinus thrombosis on the CTV was thought to be secondary to compression/mass effect from the adjacent epidural abscess which was better elucidated on the MRI.
The patient underwent nasal endoscopy with debridement by ENT. Concurrently, neurosurgery performed a right frontal craniotomy for evacuation of epidural and subdural empyema and harvest of paracranial graft with complex dural closure. Pathology of the epidural "mass" was revealed non-viable tissue with necrotic and inflammatory debris, consistent with an abscess. Gram, GMS, and AFB stains were negative.
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