THE NEW ARMENIAN MEDICAL JOURNAL

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1 THE NEW ARMENIAN MEDICAL JOURNAL Vol.9 (2015), Nо 4, p Clinicl cse A CASE OF SUCCESSFUL TREATMENT OF POST-TRAUMATIC FRONTAL LOBE BRAIN ABSCESS IN PATIENT DURING SUBACUTE PERIOD OF PENETRATING CRANIOCEREBRAL TRAUMA Byvltsev V.A. 1,2,3,4*, Klinin A.A. 2,4, Khchikyn A.F. 5, Zhdnovich G.S. 4, Egorov A.V. 2, Pnsenkov S.Y. 2, Dmdinov B.B. 2, Belykh E.G. 1, Antipin S.L. 2, Sorokovikov V.A. 1,2,3,4 1 Irkutsk Scientific Center of Surgery nd Trumtology, Irkutsk, Russin Federtion 2 Non-governmentl Helth Cre Institution Rod Clinicl Hospitl t Irkutsk-Pssenger sttion OJSC Russin Rilwys, Irkutsk, Russin Federtion 3 Irkutsk Stte Medicl Acdemy of Continuous Eduction, Irkutsk, Russin Federtion 4 Irkutsk Stte Medicl University, Irkutsk, Russin Federtion 5 Institute of Surgery nmed fter A.L. Mikelyn, Yerevn, Armeni Received 05/23/2015; ccepted for printing 08/22/2015 Astrct Brin scesses re dngerous complictions of penetrting trumtic rin injury, where the mortlity rte of inflmmtory processes progression is up to 60%. Risk fctors for this pthology re penetrting trumtic rin injury, purulent inflmmtion of the lungs, cteril endocrditis, rteriovenous fistul in the pulmonry circultion. Brin scesses s result of gunshot crniocererl trums during militry ctions in World Wr II were developed in % cses, 84% of which were single scesses, wheres in 16% - multiple, while during militry ctions in Chechny nd Afghnistn rin scesses rnge decresed up to 7.5%, nd during pece in cse of wepon injuries up to 5%. Firstly such decresing tendency cn e explined with the improved qulity of preliminry surgicl deridement, secondly with the ppernce of ntiiotics new genertion nd thirdly, with the improvement of dringe systems incorported onto the wounds. Brin scesses pthogens re streptococci nd stphylococci in 33-50% of cses. In 80% of cses severl microorgnisms re identified including neroic forms. Despite the fct tht trumtic rin scess is suject to surgicl tretment ccording to the clssic rules, there re reports of successful conservtive tretment in literture. The indictions for conservtive therpy re hrd-to-rech loction, multiple lesions less thn 2.5 cm in dimeter, ssocited meningitis, encephlitic stge of the rin scesses. There re not so mny supporters of conservtive tretment. According to severl uthors, solely conservtive tretment of the rin scesses is not effective t ll, or, if pplied in the lter stges, the formtion of rin scesses ends with persistent neurologicl deficit in more thn hlf of the ptients. Тhe rticle presents literture review out epidemiology, pthophysiology, dignostics nd the tretment of ptients with rin scesses, s well s clinicl cse of successful tretment of post-trumtic scess of the left frontl loe of the ptient in the sucute stge of open penetrting trumtic rin injury. This cse is interesting in its dynmics. Encpsulted scess ws formed in the result of inefficient conservtive therpy within 1 month fter trumtic rin injury. Keywords: purulent-inflmmtory diseses, centrl nervous system, rin scess, tretment. Address for Correspondence: Rod Clinicl Hospitl t Irkutsk-Pssenger sttion 10 Botkin Street, Irkutsk , Russin Federtion Tel.: ( ), ( ) Office: 8(3952) E-mil: yvl75vdim@yndex.ru Introduction Brin scess is defined s nidl empyesis which minly hs circulr shpe nd is loclized in medullry sustnce surrounded y cpsule. Presumly, the first report of rin scesses ppered in 1553, nd in G. Morggni found ptient who hd died of Antonov fire, which ppered to e n occipitl loe scess [Leedev V, Khutornoi N, 2008]. Clssifiction: Currently, there is no single stndrd clssifiction of rin scesses, ut the 80

2 The New Armenin Medicl Journl, Vol.9 (2015), No 4, p Byvltsev V.A. et l. most complete one, per some uthors, is the following [Nikiforov A et l., 2004]: ¾y mechnism scesses re clssified s hemtogenous, trumtic, otorhynogenic nd itrogenic; ¾y locliztion: frontl, prietl, temporl or occipitl loes, or in cereellum; ¾y the memrnes nd medullry sustnce: epidurl, sudurl, intrcererl nd periventriculr; ¾y types: single-chmer, dul chmer nd multi-chmer; ¾y volumes: smll - up to 20 ml, middle ml, lrge ml, extr-lrge/gint - more thn 60 ml; ¾y clinicl phse: compenstion, sucompenstion, moderte decompenstion, svge decompenstion, terminl phse; ¾y flow pce: cute, sucute, chronic. In ddition, scesses re clssified s single nd multiple. Some uthors identify erly scesses evolved during the first 3 months nd lte scesses [Leedev V, Khutornoi N, 2008]. Etiopthogenesis: Risk fctors for this pthology re penetrting trumtic rin injury, purulent inflmmtion of the lungs, cteril endocrditis, rteriovenous fistul in the pulmonry circultion [Nikiforov A et l., 2004]. Concurrently, rin scesses cn e cused y [Leedev V, Khutornoi N, 2008]: ¾poor primry surgicl deridement in the form of not removed foreign odies, especilly smll one frgments; ¾untimely dignosed nd treted cererospinl fluid fistul; ¾incompletely deleted trumtic intrcrnil hemtom; ¾foreign ody left in the wound (guze sponges, etc.) or implnted with foreign odies for therpeutic purposes in cse of non-sterility. The wys of pthogens spred in cse of rin scesses re contcting nd hemtogenous. The first one is more typicl for ptients with penetrting rin injury [Nikiforov A et l., 2004]. Brin scesses s result of gunshot crniocererl trums during militry ctions in World Wr II were developed in % cses, 84% of which were single scesses, wheres in 16% - multiple, while during militry ctions in Chechny nd Afghnistn rin scesses rnge decresed up to 7.5%, nd during pece in cse of wepon injuries up to 5% [Shhinyn G et l., 1997; Leedev V, Krylov V, 2000; Leedev V, Khutornoi N, 2008]. Firstly such decresing tendency cn e explined with the improvement of preliminry surgicl deridement qulity, secondly, with the ppernce of new genertion ntiiotics, nd thirdly, with the improvement of dringe systems incorporting onto the wounds. Brin scesses elong to the complictions of trumtic rin injury nd mong such ptients with single scesses lethlity is from 5 to 22%, with multiple scesses - from 23 to 78%, with n open trumtic rin injury - from 40 to 60% [Leedev V, Khutornoi N, 2008]. Streptococci nd stphylococci re the infectious gents in rin scesses in 33-50% of cses. In 80% of cses severl microorgnisms re identified including neroic forms [Nikiforov A et l., 2004]. There re 3 stges of rin scess development: ltent, cler (cler signs of the scess formtion) nd terminl (edem nd disloction of the rin) [Kurkov K et l., 2006]. Initilly, the rin tissue develops encephlitis tht occurs sed on vsculitis with the septic thromosis nd ll this leds to locl ischemi nd, consequently, to the formtion of the focus of septic necrosis [Leedev V, Khutornoi N, 2008]. Within 2 weeks or more cpsule is ppering round this re which hs 4 lyers: internl (necrotic grnultion), externl (encephlitic, rective) in the form of perifocl encephlitis, medium formed of connective tissue fiers, regenertive lyer (orgniztion nd encpsultion) - contins lood vessels, rgyrophilic nd collgen fiers. From the encephlitic nd regenertive lyers through metsttic (hemtogenous) wy, susidiry scesses cn occur t distnce from the primry focus [Leedev V, Khutornoi N, 2008]. Clinicl description nd dignosis The clinicl picture of rin scess includes cererl, meningel, focl, hypertensive nd disloc- 81

3 Byvltsev V.A. et l. The New Armenin Medicl Journl, Vol.9 (2015), No 4, p tion symptoms, the severity of which depends on the stge nd timing of development. Epileptic seizures development is not uncommon - the risk of their development is out 54-76%. In some typicl cses rin scesses re ccompnied y chnges in the peripherl lood leukocytosis with the left shift, ccelerted ESR, incresed C-rective protein [Nikiforov A et l., 2004]. There might e no chnges in lood in cses of thick-wlled cpsule. Cererospinl fluid chnges re noted in 90% of cses, however, they re lso not specific [Nikiforov A et l., 2004]. For exmple, when rin scess is in depth, the composition of cererospinl fluid my considerly vry in some cses there might e moderte cell count (usully neutrophil), in others hyperluminosis, in some cses- norml compositions [Kurkov K et l., 2006]. It should e noted here tht the suspected rin scess is reltive contrindiction to lumr puncture due to the risk of tentoril hernition syndrome. Another importnt symptom is the presence of stgntion in the oculr fundus, reching in one third of the ptients the degree of severe edem, nd in the other one third - the initil swelling of the optic nerve. In the presence of this symptom, other signs of incresed intrcrnil pressure re lso identified: hedche, vomiting, rdycrdi, rteril hypertension [Nikiforov A et l., 2004]. Usge of highly informtive noninvsive methods such s computed tomogrphy (CT) nd mgnetic resonnce imging (MRI) undoutedly improved the dignostics of rin scess. These methods llow to define the locliztion of the focus, its size nd shpe, depth, nd lso to follow the dynmics of tretment [Vereshchgin N et l., 1986; Leedev V, Krylov V, 2000; Okmi N et l., 2000]. On the rin CT scesses re identified s form of low-density formtions often ovl-shped with circulr shdow on the periphery crown effect. With the contrst medium infusion, it is primrily deposited in the cpsule due to its hyper vsculriztion [Kurkov K et l., 2006]. Resolution of MRI is higher thn CT which helps with the identifiction of cler visuliztion of secondry chnges in rin (edem, deformtion nd displcement of the cisterns). Fetures of MRI my e significntly incresed y using gdolinium contrst. The contrst selectively ccumultes in the cpsule of rin scess [Sufinov A et l., 2000; Nikiforov A et l., 2004]. Cererl ngiogrphy plys supporting role in differentil dignosis of rin tumor [Leedev V, Khutornoi N, 2008]. Tretment Among the surgicl methods for rin scess tretment the following ones should e underlined: puncture, rdicl scess removl within the cpsule without preliminry iopsy, puncture followed y the removl of the cpsule (comined method), opening of the scess nd externl dringe. Before the use of ntiiotics nd sulfonmides the postopertive mortlity in rin scess ws %. The use of those drugs decresed the mortlity y 3-4 times [Kurkov K et l., 2006]. Recently the method of puncture is preferle s the lest invsive method in consequence of which postopertive mortlity decresed to 4.7% [Mehdi A, Smeynovich A, 1996; Sufinov A et l., 2000]. Nevertheless, preservtion of the scess cpsule leds to risk of sustitute scess formtion in the other res of the rin through the hemtogenous wy [Leedev V, Khutornoi N, 2008]. Despite the fct tht rin scess is suject for surgicl tretment ccording to the clssic rules, there re reports of successful conservtive tretment in the literture [Blgoveshenskiy S et l., 2002; Kurkov K, Prots R, 2005]. The indictions for conservtive therpy re hrd-to-rech loction, multiple lesions less thn 2.5 cm in dimeter, ssocited meningitis, encephlitic stge of rin scess [Morgn H et l., 1973; Kurkov K, Prots R, 2005; Leedev V, Khutornoi N, 2008]. There re not so mny supporters of conservtive tretment. According to severl uthors, solely conservtive tretment of rin scess is not effective t ll, or, if pplied in the lter stges, the formtion of rin scesses ends with persistent neurologicl deficit in more thn hlf of the ptients [Leedev V, Khutornoi N, 2008]. The rticle presents clinicl cse of the clssicl encpsulted rin scess formtion ppered on the ckground of conservtive tretment fter month of severe penetrting open injury. 82

4 The New Armenin Medicl Journl, Vol.9 (2015), No 4, p Byvltsev V.A. et l. Clinicl cse description A 55 yers old ptient ws rought to the Neurosurgery Deprtment of the Rod Clinicl Hospitl t Irkutsk-Pssenger sttion of the OJSC «Russin Rilwys» from the Deprtment of Neurology on in criticl condition with dignosis of Sucute posttrumtic intrcererl monoloculr scess of rin s left frontl loe in the erly period, the stge of sucompenstion. Sucute period of severe penetrting crniocererl open injury. Moderte rin contusion injury with the formtion of foci of the 3 rd type in the right prietl loe nd the sl prts of the left frontl loe. From nmnesis: Domestic injury from , he got low on the hed with shovel, nd then he lost consciousness. He ws hospitlized in the surgicl deprtment in the regionl hospitl from to with the dignosis of trumtic rin injury. Brin contusion of moderte degree. Indented multisplintered frcture of the prietl one on the right. Sustnce of the rin is crushed to the right prietl loe. Multiple skin wounds in the right prietl region. The ptient ws operted on : resection crniotomy in the right prietl region, removl of the frcture of the prietl one. Removl of the contusion lesion in the right of the prietl loe. MRI of the rin from showed clvri defect in the right prietl one, injury foci in the right prietl, left frontl loe rin scess, there is no displcement of medin structures. CT of the rin from showed defect of the crnil vult in the right prietl one. Injury foci of the 2 nd type in the right prietl region, nd the injury focus of 3 rd type in the left sl frontl loe with the zone of hemorrhge of 2х2х4 cm. There is no displcement of medin structures. Ophthlmologist consult ws on : prtil swelling of the optic nerve on the left. The post-opertion period ws fvorle, the wound heled y the first intention. Infusion, nootropic, ntiiotic (cefotxime 1000 mg, X 3 r/d/m for 7 dys), symptomtic, vsoctive nd restortive therpy were conducting. The stitches were removed from the surgicl wound on , the edges diverged on , sero-purulent dischrge from the fsci hd strted. Sntion nd revision of suglel spce ws performed. No cererospinl fluid found. Exmining surgeon dignosed postopertive wound inflmmtion. Inocultion of wound dischrge found fecl streptococcus of 10 7 CFU. The ptient ws trnsferred to the deprtment of purulent surgery of Rod Clinicl Hospitl t Irkutsk-Pssenger sttion where he ws on in-ptient tretment from to The ptient ws conscious, responding to simple questions, sitting, eting himself, stnding with ssistnce. CT control of the rin from showed positive dynmics, reducing of the leeding re in the frontl loe, no signs of disloction of the medin structures, no compression of mient cisterns. He received ntiiotic tretment within 8 dys: tvnic (500 mg X 2 dy/drip) nd sulpersone (2000 mg. X 2 dy/drip). Ptient ws dischrged for rehilittion to the Neurology Deprtment of Rod Clinicl Hospitl t Irkutsk-Pssenger sttion on The level of moderte stupefction sensorium ws mrked in the generl condition on : moderte decrese of the consciousness nd rejection of the mel. MRI of the rin from 04/16/15 reveled rin scess in the left frontl loe nd medin structures disloction 10 mm off the midline from left to right (Fig. 1,). The ptient ws trnsferred to the Neurosurgicl Center of the Rod Clinicl Hospitl t Irkutsk-Pssenger sttion. Neurologicl sttus: the overll condition is grve, moderte level of consciousness decrese. He is ville for limited productive verl contct - nswers to simple questions, performs sic commnds. According to the neurosurgicl consulttion on , the ptient ws operted: resection crniotomy ws performed in the left fronto-temporl region. Left frontl loe rin scess ws punctured. Snittion of scess cvity, sutotl removl of scess cpsule nd dringe of the scess cvity. The opertion: under intrvenous nesthesi with mechnicl lung ventiltion fter clening of the surgicl field with ntiseptic solutions nd pre hydro-preprtion of soft tissues with sline, 83

5 Byvltsev V.A. et l. The New Armenin Medicl Journl, Vol.9 (2015), No 4, p Figure 2. Intropertive photo: ) opening of dur mter; ) ulging rin. Figure 1. MRI of 55 yers old ptient F.: ) T1 WI (weighted imge) sgittl section; ) T2 WI frontl section. Note: the rrow shows the rin scess. horseshoe-shped incision of the skin ws produced in the left fronto-temporl region. Soft tissue flp ws retrcted downwrd nd fixed. The periosteum ws dissected. Bone ws clened from deris. A urr hole ws mde in the frontl region, followed y n extension to the size of 5.0 х 6.0 cm. After removing of the one flp the dur mter ppered to e ple, without pulstion nd ws strined. The dur mter ws opened in rch fshion. There ws mild ulging of the rin, nd Mnnitol ws dministered (Fig. 2,). Hemodynmics ws stle, pulstion of the rin ws sluggish. Under the ultrsonic nvigtion ALOCA 500 (Hitchi, Jpn) the scess of the left frontl loe ws loclized, nd puncture cnnul ws inserted to drin the scess (Fig. 3) ml of pus mixed with hemolyzed lood were evcuted vi syringe. The content of the scess ws tken for the inocultion on microflor nd sensitivity to ntiiotics. The scess cvity ws wshed with the 0.05% chlorhexidine. The cpsule of the scess ws thick, well seprted from the rin tissue. Microsurgicl dissec- Figure 3. Intropertive ultrsound nvigtion: the rrow indictes the rin cnnul mounted in cvity of the rin scess. 84

6 The New Armenin Medicl Journl, Vol.9 (2015), No 4, p Byvltsev V.A. et l. tion of the cpsule from the surrounding rin tissue nd sutotl removl ws performed. Dorsomedil segments of the cpsule ws prtilly sved nd firmly ttched to the skull se (Fig. 4,). The wound ws wshed with ntiseptic solutions. Doule-lumen dringe equipped with the irrigtion system ws instlled in the left temporl region of scess cvity through the counterpuncture [Sufinov A et l., 1999] (Fig. 5). The dur mter ws sutured with seprte sutures. Wound ws closed in lyers with the instlltion of dringe under the fsci nd septic dressing. The estimted totl lood loss ws less thn 300 ml. Histologicl exmintion of the removed mteril confirmed the dignosis of rin scess with the formtion of connective-tissue cpsule (Fig. 6,). Description of the microslide: the wll of the scess hs lyered structure, is shown inside of overlpping necrotic tissues with neutrophilic infiltrtion, followed y lyer of grnultion ( lrge numer of newly formed lood vessels, fulllooded, minly cpillry type, nstomosing with ech other nd rrnged in different directions). Thin gry rgyrophilic fiers nd loops which contin numerous cells infiltrtes: neutrophils, lymphocytes, mcrophges lden lipoid inclusions re locted round vessels. There is thin connective tissue cpsule from outside, with the gentle network of collgen fiers nd firolsts. The ptient ws receiving symptomtic, ntineuritic, ntiedemtous, nticrmping nd nticteril (meronem 1000 mg X 3 dy/drip, mikcin 500 mg X 2 dy/m for 8 dys) therpy in post-opertive period. The dringe ws removed on the 8th dy fter surgery. Postopertive chnges re shown on MRI of the ptient (Fig. 7,). The ptient ws dischrged on the 14th dy in stisfctory condition with prtil regression of neurologicl symptoms. He ws stle on the susequent follow-up exmintion 3 months fter surgery nd hd no complints. Figure 4. Intropertive photo: ) lloction of the scess cpsule, ) view of surgicl wound fter the cpsule removl. Discussion Over the pst decde, our understnding of the etiology, clinicl presenttion, dignosis nd tretment of rin scess underwent susequent evolutionry chnges [Mehdi A, Smeynovich A, 1996; Figure 5. Intropertive photo - doule-lumen dringe instlled in the scess cvity. 85

7 Byvltsev V.A. et l. The New Armenin Medicl Journl, Vol.9 (2015), No 4, p Figure 6. Morphologicl imge of rin scess with the formtion of connective-tissue cpsule under X 40 mgnifiction: ) stining of hemtoxylin-eosin, ) stining of picrofuchsin. Shhinyn G et l., 1997]. In the lst century, up to 2/3 of rin scess hd otorhinogenetic etiology, ut tody metsttic rin scesses compose up to 34.3%, while the contct (minly otorhinogenetic) %, trumtic %, cryptogenic - 8.8% [Vereshchgin N et l., 1986; Prots R, 2000; Prots R, Vyhristenko S, 2002]. These chnges occurred due to the chievements in otolryngology, nd due to stedy growth of neuro-trumtism [Kurkov K et l., 2006; Morgn H et l., 1973]. According to vrious uthors, the percent of posttrumtic rin scess is more thn 30% [Mehdi A, Smeynovich A, 1996]. The modern dignostic CT nd MRI scns ply importnt nd sometimes decisive role in the dignosis of rin scess, ecuse clinicl detection of rin scess formtion on the ckground of severe hed injury or multiple orgn somtic pthology is not lwys possile [Sufinov A et l., 2000; Kurkov K et l., 2006]. There re numer of cses when ptient s condition remins stisfctory for long time fter the trumtic rin injury, nd then suddenly worsens, which usully corresponds with rek of n scess into the surchnoid spce or ventriculr system [Kurkov K et l., 2006]. The ccurte locliztion of lesion llows choosing the most pproprite pproch for surgicl evcution. Figure 7. Postopertive chnges on MRI of the 55 yers old ptient F.: ) T1 WI sgittl section; ) T2 WI frontl section 86

8 The New Armenin Medicl Journl, Vol.9 (2015), No 4, p Byvltsev V.A. et l. Brin scess result in mortlity in 0 to 10% of cses my led to disility in up to 45% of cses, nd hs potentil for the new seizures in 27% of cses. For comprison, efore the ntiiotics nd sulfonmides, mortlity rte ws 100% [Nikiforov A et l., 2004; Kurkov K et l., 2006]. Some uthors were le to otin fvorle outcomes with the puncture tretment nd decrese mortlity to 4.7% [Mehdi A, Smeynovich A, 1996; Nikiforov A et l., 2004]. It should e noted tht the desire to sustin witing tctics hoping for totl isoltion of rin scess y the formtion of the cpsule is quite nturl, however, this pproch my led to the development nd progression of the meningoencephlitis or to the spred of infection to the ones of the skull, septicopyemi nd formtion of purulent susidiry foci [Sufinov A et l., 2000; Leedev V, Khutornoi N, 2008]. Therefore, during the conservtive therpy, it is necessry to conduct strict dynmic ody temperture control (specil ttention should e pid to possile hectic nture), lood nlysis (leukocytosis, erythrocytes, hemogloin, hemtocrit), liquor (cell count, protein, crops dt), s well s the instrumentl dt (ultrsound, CT, MRI). Surgicl intervention is required in cse of the slightest signs of generliztion increse of purulent encephlitic focus, reduction in the defense rections (e.g., reduction of leukocytosis ginst the ckdrop of growing encephlitic focus) [Leedev V, Khutornoi N, 2008]. The successful tretment of rin scess with the high-energy cron dioxide lser is reported. The positive effect of this tretment ws oserved in 88.4% of ptients, nd the mortlity ws 11.5% (ginst the current mortlity rte from single scess from 5 to 22%, nd multiple - from 23 to 78%) [Mtveev S et l., 1995]. In this wy rin scesses still represent severe compliction of penetrting trumtic rin injuries with significnt risk of dverse outcome. Active surgicl tctics, long with dequte ntiiotic therpy sed on the culture sensitivity is priority pproch for rin scess tretment. Removl of rin scess in the sucute period of open penetrting crniocererl injury with the sutotl excision of the cpsule nd drining of the scess cvity llows successful locliztion of the inflmmtory process nd prevention of the postopertive complictions. The work presented in the rticle ws supported y the funds of Russin Scientific Foundtion N REFERENCES 1. Blgoveshenskiy SV, Kchkov IA, Kiselev AM. [Comprehensive tretment of intrcrnil scess nd empyem] [Pulished in Russin]. III Congress of Neurosurgeons of Russi. Sint Petersurg, pp Kurkov KM, Prots RN, Vyhristenko KS. [Post-trumtic rin scesses (Clinicl picture, dignostics, tretment)] [Pulished in Russin]. Surgery News. 2006; 14(1): Kurkov KM, Prots RN. [Achievements of fundmentl, clinicl medicine nd phrmcy] [Pulished in Russin]. Proceedings of the 60th session of the VSMU. Vitesk, pp Leedev VV, Khutornoi NV. [Brin scesses] [Pulished in Russin]. Neurosurgery. 2008; 1: Leedev VV, Krylov VV. [Emergency neurosurgery: guideline for doctors] [Pulished in Russin]. Moscow. Medicin (Medicine) p. 6. Mtveev SA, Lukin NM, Mtveev AS. [Surgicl tretment of rin scesses using high-co 2 lser (experimentl nd clinicl reserch)] [Pulished in Russin]. First Congress of Neurosurgeons of the Russin Federtion. Ekterinurg p. 7. Mehdi A, Smeynovich AF. [Surgicl tretment of rin scesses] [Pulished in Russin]. Helthcre. 1996; 10: Morgn H, Wood M, Murphy F. Experience with 88 consecutive cses of rin scess. J Neurosurg. 1973; 38 (7):

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