How would you drain this abscess?
A 73 y.o. male came in from his doctor's office saying he needs his abscess drained.
This patient did not have an abscess; this was a temporal artery aneurysm. The patient had fallen ten days pta and injured the L side of his forehead. He gradually developed the swelling shown.
Bartholin published the first report of a superficial temporal artery aneurysm in the 17th century. In the initial case, the aneurysm was caused by trauma but theycan occur after face lifts and frontal sinus surgery. The times reported between the initial insult and the aneurysm range from 2 days to 17 years. Temporal artery aneursyms have also been reported in vasculitis
The treatment of these aneursyms is often surgical. More recently, large studies have reported that about 13% of patients have a percutaneous intervention like coiling or a thrombin injection. Following thrombin injections there have been reports of scalp necrosis. There is one report of a person curing himself by applying direct pressure to the aneurysm and causing thrombosis.
Teaching point
Not all reported abscesses are actually abscesses. Although this patient’s doctor thought he had an abscess, it was clearly pulsatile on exam. The same problem can occur with peritonsillar aneurysms; they can be mistaken for peritonsillar abscesses as in the references below.
Case conclusion:
A discussion was had between interventional and vascular surgery. In the end, vascular surgery excised the aneurysm and the patient did well.
Van Uden D, Truijers M, Schipper E, Zeebregts C, Reijnen M. Superficial temporal artery aneurysm: diagnosis and treatment options. 2013 Head and Neck Vol 35 issue 4: 608-614.
Sharma A, Tyagi G, Sahal A, Baijal S. Traumatic aneursyms of the superficial temporal artery. 1991 Neuroradiology;33:510-513.
Yoshimoto T, Kobaqashi H, Murai H. Multiple scalp aneursyms caused by atypical temporal arteritis. 1998 Neuro Med Chir 38: 405-408.
Altin G, Samil A, Erdogan P, et al. Huge internal carotid artery aneurysm presenting as tonsillar asymmetry. 2012 J Craniofacial Surgery sept 23(5) 1565-7.
Brzost J, Cyran A, et al. Internal carotid artery aneurysm mimicking peritonsillar abscess. 2015 Case Resports in Otolaryngology article ID 389298.