Proud flesh

 

One rarely sees proud flesh outside of the diabetic foot these days, what more in the neck. This patient had a badly infected tracheostomy and was taken of it for a couple of weeks for Pseudomonas infestation. This is the result of a wound desperately trying to fill the gaps with granulation tissue while never being able to epithelialise.

What I had to do was to excise the entire granulating mass with a cuff of skin, all the way down to the strap muscles before redoing the tracheostomy. Wound care is going to be very important for this not to happen again.

Wherefrom the infection?

A 55yr-old man had craniectomy and drainage for a huge intracranial temporal lobe abscess and an ipsilateral extracranial temporal abscess as seen in this CT scan. He was referred to ENT for clearance of a possible foci of infection from the mastoid or middle ear which would seem to be the case from the 2nd image presented here. A large area of erosion is seen in the mastoid, communicating with the middle fossa as well as the temporal space.







The history, however, was not quite so convincing. He had no history of chronic ear discharge, and was not diabetic. The only lead was one experience of external ear infection 3 months ago after he traumatised his ear canal by overenthusiastic cleaning. Examination would show an external canal filled with pus, a sagging posterosuperior meatal wall, a soft and fluctuant postauricular region and a discharging sinus.



























I proceeded to perform a mastoid exploration/cortical mastoidectomy but to my surprise found only a sclerotic mastoid and no foci of disease at all. Drilling was carried all the way down to the bony defect where dura is clearly seen. No pus, granulation, or cholesteatomas found.

So where was the foci of infection? How did an abscess of such magnitude, with such extensive destruction of bone come about? We are hoping a HRCT will give us more clues. Could this be a skull base osteomyelitis secondary to otitis externa?