Wk 7, Case 5 - Review

Diagnosis
14-year-old male with history of asthma presenting with left preseptal soft tissue swelling.

Findings
Orbital and maxillofacial contrast enhanced prior CT exam showed 0.4 mm well defined oval shaped foreign body immediately lateral to the left globe. No evidence of intracortical abscess however there is small subperiosteal collection measuring maximum 2.7 mm in thickness. The medial rectus muscle is thickened with mild fat stranding in the vicinity of the medial rectus muscle. The preseptal soft tissues appear thickened. Left-sided pansinusitis with complete opacification of the left frontal sinus and ethmoid air cells. Partial opacification of the left sphenoid sinus.Partial opacification of the right frontal sinus, right ethmoid air cells. Air-fluid level in the left maxillary sinus. Mild mucosal thickening in the right maxillary sinus.

Visualized brain parenchyma appears within normal limits. Normal density of the brain parenchyma with normal gray-white matter differentiation. Normal sized ventricles with normal configuration. No evidence of a mass or mass effect. The paranasal sinuses and orbits are only minimally visualized.

Impressions
Foreign body immediately lateral to the left globe without invading the globe or deforming the globe. Small left subperiosteal collection measuring maximum 2.7 mm in thickness with increased thickness and surrounding inflammation in the medial rectus muscle. No evidence of intraconal abscess. Preseptal soft tissue thickening. Marked left-sided pansinusitis with mild right-sided sinusitis.

Findings
A small 1.1 x 0.5 cm hypodense epidural collection in the midline location adjacent to the frontal lobes with extension along the left frontal convexity. The collection is at the expected location of the superior sagittal sinus. There is no underlying parenchymal abnormalities. There is no bony dehiscence. Gray-white differentiation is preserved. There is no midline shift, mass, mass effect, herniation, or hydrocephalus. Midline structures are normal. No intraparenchymal hemorrhage is evident. Severe opacification of bilateral ethmoid air cells as well as bilateral frontal sinuses with air-fluid level within the right frontal sinus. There is no associated bony dehiscence. Mastoid air cells are well aerated. Visualized portions of the upper orbits appear normal.

Impressions
1. 1.1 x 0.5 cm midline epidural collection adjacent to the frontal lobes with extension along the left frontal convexity is highly concerning for empyema. No underlying parenchymal abnormality. No bony dehiscence.
2. Since the collection is at the expected location of the superior sagittal sinus, MRV could be performed to evaluate for venous sinus thrombosis.
3.. Near-complete opacification of ethmoid air cells and frontal sinus with air-fluid levels within the right frontal sinus is concerning for acute sinusitis.

Findings
INTRACRANIAL: There is decreased opacification of the superior sagittal sinus extending from the mid vertex anteriorly to the previously identified extra-axial collection in the parasagittal left frontal region. The epidural collection measures up to 5 mm thick and extends from midline along the left frontal lobe, unchanged in size. A smaller 3 mm thick extra-axial fluid collection is suspected more superiorly over the left frontal convexity.

The remainder of the superior sagittal sinus, the transverse sinuses, and the sigmoid sinuses opacify normally. The right jugular vein and sigmoid sinus are dominant. The straight sinus and internal cerebral veins also enhance normally. The distal internal carotid arteries, vertebral arteries, and basilar artery appear normal in contour and caliber. The middle cerebral arteries, anterior cerebral arteries, and posterior cerebral arteries enhance normally.

No enhancing intracranial lesions are seen. The ventricles are symmetric and normal in caliber. No mass effect or midline shift. The basal cisterns appear patent. Gray-white differentiation is grossly normal.

EXTRACRANIAL: Complete opacification of the left frontal sinus and near complete opacification of the pulmonary cells and right frontal sinus as well as air-fluid levels in both maxillary sinuses and the sphenoid sinus are again noted. Mastoid air cells are clear. Although no frank bony dehiscence is seen, the described epidural fluid collection lies immediately subjacent to the left frontal sinus. Postoperative changes in the paranasal sinuses are present with medial antrostomy on the left side and partial ethmoidectomy.

There is moderate to soft tissue thickening along the left nasal bone, with an apparent 5 x 11 mm preseptal fluid collection anteromedial to the left orbit that appears slightly increased in size since 7/25/2016. There is extent of inflammatory changes into the post septal soft tissues along the medial aspect of the left orbit, where there is a 17 x 5 x 9 mm subperiosteal fluid collection, mildly displacing thickening the left medial rectus, unchanged since the previous CT.

A few prominent lymph nodes in the upper cervical region are again noted, likely reactive.There is a hyperdense calcified abnormality along the left lateral orbit seen best on series 2 image 38 possibly a foreign body.

Impressions
1. There is thrombosis of the superior sagittal sinus anteriorly, adjacent to the previously described left frontal epidural abscess, which is unchanged in size from the study approximately 2 hours ago ago.
2. Extensive opacification with air-fluid levels is again noted throughout the paranasal sinuses concerning for sinusitis.
3. A postseptal subperiosteal abscess in the medial left orbit is unchanged in size. A small preseptal fluid collection anteromedial to the left orbit has slightly increased.