Primary Excision of Pediatric Posterior Fossa Abscesses – Towards Zero Mortality?

Abstract

Nine children with infratentorial brain abscesses were treated at our institution over a 3-year period. Seven of them were boys and two were girls. In five cases, the abscesses were otogenic, and in two cases, the cause was tubercular (including one case of tubercular otitis). There were three cases of abscess formation in dermoids. All cases were managed with primary excision of the abscess. The average hospital stay was 12 days, and there was no mortality. The most common complication was hydrocephalus, noticed in three patients, of whom one eventually required shunt placement. Our policy of primary excision of these abscesses has yielded gratifying results. This approach also resulted in minimal morbidity and a substantially shortened hospital stay. Moreover, primary excision yields definitive histopathology of the lesion, especially in cases of tubercular and dermoid etiologies.

Management of brain abscesses in children

“…The condition of neurologically intact patients can rapidly deteriorate to a comatose state due to obstructive hydrocephalus and/or mass effect on the brainstem. 2,12,42,103 A wide decompression of the posterior fossa has been advocated because of the precarious state of a cerebellar abscess in the small volume of the posterior fossa. 2,39 In 1973, Bhatia et al 8 reviewed 55 cases of brain abscesses, in which 11 were located in the posterior fossa.…”

Management of bacterial brain abscesses

“…26,40,44 In the pediatric patient group, the most common predisposing factor is congenital heart disease or adjacent cranial infection. 1,2,12,39 Recently, Auvichayapat et al 2 in their series of 107 cases involving infants and children, found chronic otitis media the second most common predisposing factor after congenital heart disease, and they concluded that this was probably due to the poor socioeconomic status leading to neglect of chronic otitis media, with children going without treatment for years. Brain abscesses in patients with immunosuppression 12,40,44 and postneurosurgical nosocomial bacterial brain abscesses 45 are also increasing in incidence.…”

“…32,34,44 Endoscopic aspiration of brain abscesses is said to be more effective than other aspiration methods; in addition to facilitating retrieval of a specimen and reduction of intracerebral pressure, advantages include direct visual control and the possibility of treating multiseptate abscesses and intraventricular purulent collections. 14,25 Excision is generally recommended for cerebellar abscesses 1,29 and abscesses that are superficially located with thick membranes as well as posttraumatic and gas-containing abscesses. 7 Excision of gas-containing abscesses allows removal of the necrotic materials and closure of possible persistent extracorporal communication.…”

“…5). Agrawal et al 1 report that due to the relatively small volume of the posterior fossa and possible disproportionate edema effect, an abscess in this location may be catastrophic in pediatric patients; for this reason wide decompression with excision of the abscess is advocated. Abscesses that are resistant to aspiration may also be excised.…”

Multiple Cerebellar Abscesses in a 6 Year Old with Uncorrected Congenital Heart Disease: Anaesthetic Challenges

“…Cerebellar abscess however constitutes 6-35% of all brain abscesses, it is a potentially life threatening condition due to small sized posterior fossa and the possibility of causing brain stem compression [3]. Predisposing factors to brain abscess included cyanotic congenital heart disease, infection from contiguous structures like otitis media, sinusitis, mastoiditis, soft tissue infection of the face, scalp or dental infection [4][5][6]. However source of infection may be absent in 20% of cases [6].…”