Internal decompressive craniectomy with craniotomy: a novel surgical therapy of giant frontal mucocele complicated by subdural empyema.

INTRODUCTION Giant frontal mucocele (GFM) is an extremely rare cause of frontal lobe syndrome. Subdural empyema (SDE) is an uncommon complication of paranasal sinisutis, for which craniotomy and decompressive craniotomy are the most effective surgical procedures. CASE REPORT A 54-year-old man was brought unconscious to the Emergency Room where recurrent generalized seizures occurred. Heroine abuse, HCV related hepatitis, prolonged antibiotic therapy for treatment of purulent rhinorrhea, along with recent personality changes, was reported. High white blood cell count, pansinusitis, GFM, SDE and cerebritis were documented. The patient underwent bifrontal craniotomy in emergency, extensive drilling of the inner aspect of the frontal bone, surgical toilette of the enlarged frontal sinus and its "cranialization". Prevotella intermedia and Fusobacterium nucleatum were isolated and antibiotic therapy was started intravenously and then continued orally for three months. Two years later the patient has recovered, though minor signs of frontal lobe syndrome persist. DISCUSSION To the Authors knowledge this is the first case of GFM with SDE reported in the literature. Although decompressive craniectomy is advocated in extreme conditions, as in this case, "internal decompressive craniectomy", obtained with craniotomy and cranialization of the frontal sinuses, is strongly advocated in cases of SDE associated with megasinuses.