Abstract
Osteomyelitis is an infection of the bone which is accompanied by bony destruction and sequestrum formation. Osteomyelitis of frontal bone requires us to deal with great caution as it can lead to a great deal of morbidity and mortality. Often when surgical treatment provided, it is radical and leaves behind surgical defect over the frontal bone. We report a case of a 14 year old boy diagnosed with frontal bone osteomyelitis of the left side who was treated using antibiotic loaded bone cement.
Supplementary Information
The online version contains supplementary material available at 10.1007/s12070-021-02667-w.
Keywords: Frontal sinus, Osteomyelitis, Bone cement, Debridement, Otolaryngology, Frontal sinusitis
Introduction
Frontal bone osteomyelitis of skull requires us to deal with great caution as it can lead to a great deal of morbidity and mortality as it can progress to intracranial complications by posterior table erosion or by septic thrombophlebitis of diploiec veins in around 29–60% of the cases. It usually presents with headache, fever, swelling over the forehead and upper eyelids, and sometimes as a discharging fronto-cutaneous fistula from the subperiosteal collection [1]. Intracranial complications include meningitis, epidural empyema, brain abscess formation and cavernous sinus thrombosis [2]. This entity requires quick and prompt diagnosis. Management requires drainage of the pus from the frontal sinus while ensuring prolonged culturally directed antibiotic coverage for 6–8 weeks.
Bone cement is being used in the treatment of orthopaedic infections like chronic osteomyelitis. It can be used either as a plain preparation or as an antibiotic loaded formulation which provides better antibacterial effectiveness as it gives good local therapy [3]. Multiple antibiotics can be added to the bone cement to broaden their efficacy spectrum. Moreover they have also been found to reduce the incidence of biofilm formation at their site of application which in turn leads to decreased chances of infection in the future [4].
Bone cement has been tried as a first step treatment option along with the surgical fixation in patients who had post traumatic frontal sinus defect and has been found to be effective without any recurrence of infection [5]. To the best of our knowledge, no study has been conducted so far to evaluate the efficacy of antibiotic loaded bone cement as a single step procedure in the treatment of frontal sinus osteomyelitis.
Case Report
A 14 year old boy who had presented to the Outpatient Clinic in the Department of Otorhinolaryngology with the chief complaints of swelling around his left eye and Headache since 1 month. He also had complaints of watery discharge from his left eye which was also accompanied with nasal obstruction since the past 5 days. On physical examination, his heart rate was 106 beat per minute, Blood pressure was 100/70 mm of Hg and was afebrile. On inspection a swelling measuring about 2 × 3 cm was noted over the super medial orbital rim, it was erythematous and tender. A fistula with granulation tissue also was noted in the inferior aspect of the swelling. The swelling was tender on palpation and bony defect was felt. There was no chemosis, no proptosis, or restriction of ocular movements. Nasal and oral cavity examinations were found to be normal. Upon laboratory evaluation, the patient was found to have leukocytosis and raised ESR. He was also subjected to a CT scan which revealed a soft tissue density with a bony sequestrum in the frontal sinus suggestive of Frontal Sinus Osteomyelitis (Fig. 1).
Fig. 1.
CECT paranasal sinuses showing bony sequestrum in the frontal sinus
The patient was started on intravenous antibiotics to cover both aerobic and anaerobic bacteria and underwent frontal sinus drainage using an external Lynch Incision (Fig. 2) The bony sequestra was removed and cavity mucosa, which was oedematous, was stripped off and sent for histopathological evaluation as well as culture and sensitivity. After thorough wash with antiseptic solution the cavity was filled with antibiotic loaded bone cement which was preparedly adding it to Hydroxyapatite bone cement in an inert bowl and 2 g of Meropenem and Vancomycin was also added to this 40 g batch bone cement to ablation an antibiotic concentration of 10%. Supraorbital rim was contoured using fingers to make it symmetrical to the normal side. The fistula edges were debrided and closed primarily. Haemostasis was confirmed and the wound was closed in layers. Intravenous antibiotics were continued postoperatively and the patient was also put on analgesics.
Fig. 2.
Intraoperative images showing frontal sinus drainage using an external Lynch incision
The postoperative period was uneventful and the patient was discharged in a stable condition on the 5th postoperative day. The patient was followed up every 2 weeks for a period of 6 months. Upon follow up, there was no evidence of any intracranial, nasal or intra orbital complications. There was no evidence of any recurrence or residual disease at the end of 6 months (Fig. 3).
Fig. 3.
Postoperative image at the end of 6 months
Discussion
Percival Pott had described the subperiosteal cellulitis or abscess of the frontal bone associated with frontal osteomyelitis in the eighteenth century. It is a life threatening complication of frontal sinus infection but the advent of antibiotics along with surgical modalities, the associated mortality has greatly reduced. Frontal sinus has a complex and unique anatomy, as the frontal sinus is separated from the frontal sinus mucosa by only 100–300 um [1]. The sinus mucosa, the marrow cavity and the frontal bone all drain via the valveless diploiec veins which facilitates the spread of the infection from the sinus cavity into the bone marrow leading to osteomyelitis of the frontal bone. It is seen more commonly in children these days and the patient usually presents with a swollen and puffy frontal area. Frontal osteomyelitis usually results from frontal sinusitis which erodes the anterior table of the frontal bone or due to direct trauma to the frontal bone. It usually presents with headache, swelling over the forehead and upper eyelids, fever and sometimes as discharging fistula frontocutaneous fistula from the subperiosteal collection [1]. This infection can spread posteriorly giving rise to intracranial sepsis either by erosion of the posterior table or by the septic thrombophlebitis via the diploeic veins leading to significant morbidity and mortality, especially in the older times. This entity requires quick and prompt diagnosis with the help of routine blood investigations which reveal leukocytosis and elevated erythrocyte sedimentation rate (ESR) along with imaging modalities like contrast enhanced computed tomography (CECT), magnetic resonance imaging (MRI), and Technitium 99 scanning to look for the possible intracranial extension. Many of these patients have been found to have Streptococcus anginosus infection when cultured which makes the prompt use of antibiotics of utmost importance [6]. The patients are managed with drainage of the pus from the frontal sinus while ensuring prolonged culturally directed antibiotic coverage for 6–8 weeks. Surgical management depends upon the location and the extent of the infection and include procedures as simple as frontal sinus trephination to radical debridement with frontal sinus obliteration and may also include neurosurgical intervention like craniotomy if intracranial extension is present. Some patients may benefit with endonasal drainage procedures alone or in combination of external procedures like Draf 3(endoscopic endonasal drainage procedure), Lynch with Draf 3 or osteoplastic flaps for their long term management [7]. However the penetration of the antibiotics into the marrow cavity remains notoriously poor and it can lead to progression of the disease to intracranial complications or recurrence of infection at a later date.
Bone cement was introduced by Gluck in 1870 for total knee replacement procedure [8]. It can be used either as a plain preparation or as an antibiotic loaded formulation which provides better antibacterial effectiveness as it gives good local therapy in chronic osteomyelitis [3]. For the treatment to be curative, the antibiotics must reach a minimum inhibitory concentration for a prolonged period and this can be achieved with the help of antibiotic loaded bone cement (ABLC) at the site of infection [4, 5] The antibiotics that are added to the bone cement are heat and water stable. The release of these antibiotics after incorporation into the local site of infection can be either burst release which releases a high dose of antibiotics instantly or it can be sustained release [5] Before the placement of the antibiotic bead, all the pus from the sinus is drained either endoscopically or conventionally. Antibiotic loaded bone cement is being increasingly used by orthopaedic surgeons to treat infections after placement of a prosthesis or to even treat chronic osteomyelitis with great success and can offer a solution to this problem as it is applied directly over the bone thereby facilitating better penetration and delivery of antibiotic into the bony marrow.
Bone cements have been used in otolaryngology practice in ear surgeries, CSF leak repair and fracture management. It is also commonly used in treatment of Frontal sinus leak repairs by neurosurgeons, where they obliterate the frontal sinus by use of bone cement.
Petruzzelli et al. in their study to evaluate the efficacy of hydroxyapatite bone cement for frontal sinus obliteration included 11 patients with frontal sinus trauma or chronic infections with or without mucopyocele and they reported complete resolution of all symptoms in 91% of the cases. Thus they concluded that hydroxyapatite is effective for full thickness reconstruction of frontal sinus defects [9].
Carl Moeller, Guy Petruzzelli et al. evaluated hydroxyapatite based frontal sinus obliteration and concluded that it is an ideal substance for obliteration as it is easily contourable, osseointegrative and has a low rate of infection and extrusion and so can be used to restore facial symmetry and thus is an excellent choice for defect repairs [10].
Taghizadeh et al. retrospectively evaluated hydroxyapatite cement for frontal sinus obliteration in 38 patients and they reported no attributable complications from its use thereby making it an effective and safe material to obliterate the frontal sinus infected with mucocele, with minimal morbidity and excellent postoperative contour [11]
The efficacy and safety of hydroxyapatite bone cement in frontal sinus surgery have been proven in the past. Although the use of antibiotic loaded bone cement in frontal sinus osteomyelitis as a single step treatment has not been reported so far. In our institute with this case we aimed to study efficacy and safety of antibiotic loaded bone cement in management of frontal sinus osteomyelitis as a single step treatment. Our patient post-operative results were promising with good cosmetic outcome and no complications.
The use of antibiotic loaded bone cement for the treatment of frontal sinus osteomyelitis seems to have promising results and offers great scope for further research.
Conclusion
Antibiotic loaded bone cement is a single step, effective, complication free approach to treat frontal sinus osteomyelitis and needs further research.
Supplementary Information
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Funding
None.
Declarations
Conflicts of interest
All the authors declare they have no conflicts of interest and have not received any funding.
Informed consent
Written informed consent was obtained from all the individual participants in the study.
Ethical approval
All procedures performed in the study were in accordance with the ethical standards of the institute.
Footnotes
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Contributor Information
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