Management of Pediatric Empyema in the Middle Cranial Fossa
Pediatric empyema in the middle cranial fossa requires immediate surgical drainage via craniotomy, along with appropriate antibiotic therapy and management of any underlying causes. While the guidelines primarily address pleural empyema, the principles of drainage, antibiotic therapy, and supportive care can be applied to intracranial empyema with appropriate neurosurgical considerations.
Diagnostic Approach
- Obtain neuroimaging (MRI with contrast preferred, or CT with contrast) to confirm diagnosis and determine extent of collection
- Blood cultures should be performed in all patients 1
- Complete blood count, inflammatory markers (CRP, ESR)
- Evaluate for potential sources of infection (otitis media, sinusitis, meningitis)
Surgical Management
- Craniotomy is the treatment of choice for middle cranial fossa empyema 2, 3
- Burr hole drainage alone is associated with higher rates of residual collection and need for repeat procedures 3
- Initial craniotomy is associated with:
- Fewer repeat procedures
- Better clinical outcomes
- More complete evacuation of purulent material 3
Antibiotic Therapy
- Start broad-spectrum IV antibiotics immediately upon diagnosis 1, 4
- Recommended regimens:
- Cefuroxime + metronidazole
- Benzyl penicillin + ciprofloxacin
- Meropenem + metronidazole 4
- Avoid aminoglycosides as they have poor penetration into infection sites 4
- Continue antibiotics for at least 14 days IV, followed by oral antibiotics based on clinical response 4, 5
- Total antibiotic duration typically 3-4 weeks 5
Management of Underlying Causes
- Address primary source of infection:
- Mastoidectomy for otogenic sources
- Sinus drainage for rhinogenic sources 2
- Management of hydrocephalus if present (occurs in up to 74% of posterior fossa empyemas) 2
- External ventricular drainage may be required temporarily
- Only about 21% need permanent CSF diversion procedures 2
Monitoring and Follow-up
- Monitor:
- Temperature curve
- White blood cell count
- Clinical symptoms (headache, neurological status)
- Radiographic improvement 4
- If no improvement after 48-72 hours:
- Reassess antibiotic coverage based on culture results
- Evaluate for inadequate drainage
- Consider repeat imaging to assess for residual collection 4
Pitfalls to Avoid
- Delaying surgical drainage - empyema is a neurosurgical emergency requiring prompt intervention 3
- Using burr holes alone instead of craniotomy - associated with higher failure rates 3
- Inadequate duration of antibiotic therapy - premature discontinuation can lead to recurrence
- Failure to identify and address the underlying source of infection
- Overlooking potential complications such as hydrocephalus, cerebral edema, or venous thrombosis
Prognosis
- With prompt surgical drainage and appropriate antibiotics, good outcomes (Glasgow Outcome Scores of 4-5) can be achieved in approximately 88% of cases 3
- Mortality rate is approximately 10.8% in supratentorial empyemas 3
- Early surgery can salvage most patients and reduce the need for permanent CSF diversion procedures 2