Case of the Month 2016-02, Page 4

Answer: D) Postseptal, extraconal

Postseptal abscess is another term for orbital abscess, while a preseptal infection would only involve the periorbital superficial soft tissues without extending into the orbit. The distinction between preseptal and postseptal infection is important, especially because while preseptal infections can potentially be treated on an outpatient basis, postseptal infections will require hospital admission and intravenous antibiotics. Note that the infection in this case is located outside the “cone” that is bordered by the eyeball at the anterior aspect and the posterior and lateral aspects by the extraocular muscles. As the intraconal space contains critical structures, most notably the optic nerve, disease in this space becomes an even more critical matter.

But that’s not all! You find another very concerning finding in the CT scan:

For larger images, please click on Head Pain 5 and Head Pain 6 .

These images demonstrate what appears to be an intracranial rim-enhancing fluid collection at the anterior aspect of the right frontal calvarium. Looks like a tiny epidural abscess!

The ED physician, making a note of your findings, now consults ophthalmology and neurosurgery as well as the hospitalist, infectious disease service, and the otolaryngologist. This appears to be becoming a pretty complex case. The neurosurgeon, learning about the epidural abscess, now requests an emergent MRI of the brain. You now see the following images:

For larger images, please click on Head Pain 7 , Head Pain 8 and Head Pain 9 .

These images confirm the presence of a tiny right frontal epidural abscess with reactive thickening and enhancement of the adjacent dura. Fortunately, it looks as if the brain itself is not affected.

The patient was taken for surgical drainage of several of the facial subperiosteal abscesses and placed on intravenous antibiotics.

For larger images, please click on Head Pain 10 , Head Pain 11 and Head Pain 12 .

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