Pott ƒe Fuɖename Tumor (Ŋgɔgbeƒu ƒe Ƒumeŋuɖui Kple Subperiosteal Abscess Le Ŋgɔgbe Sinusitis Megbe): Doughy Forehead Swelling kple Intracranial Abscess Triage¶

Togbɔ be ŋkɔ si flua ame le ŋutinya me hã la, Pott ƒe dɔdzẽ si vuvu menye menye kansa alo dɔdzẽ o: enye amekoko ƒe dɔlékuiwo ƒe nɔnɔme kpata si ate ŋu ade ame ƒe agbe afɔku me, si me dɔlékui ƒe ŋgɔgbe ƒe taɖuame si nu sẽ (alo ŋgonu ƒe nuveviwɔame sue aɖe si me mekɔ o) si womewɔ atike na o alo esi womekpɔ o) ƒua du yia ŋgɔ to **ŋgɔgbe ƒu ƒe ŋgɔgbe kplɔ̃ dzi, ** taɖua ƒe gotagome lãkusi sesẽa kɔkɔ (periosteum / pericranium) be woawɔ dzodzoe, fafɛ, amɔwɔ, amɔwɔ, aŋɔ kotoku si me ʋuʋudedi le (subperiosteal abscess) tẽ le ŋgonu titina alo axadzi. Eŋlisi amekola Aƒetɔ Percivall Pott ye ƒo nu tso nɔnɔme sia ŋu zi gbãtɔ le ƒe 1760 me, eye wònye ahɔhɔ̃mekawo ƒe dɔwɔwɔ ƒe aflaga dzĩ vevi aɖe elabena megbegli (posterior table) ƒe ŋgɔgbeƒu ƒe titrime mede ŋgɔgbegli ƒe afã o eye wòma valveless diploic veins (veins of Breschet) siwo sina yia megbe tẽ yia ahɔhɔ̃a ƒe dural venous sinus kple frontal lobes me. Eyata le ** dome.60 and 85 percent ƒe ɖeviwo kple ƒewuiviwo (kple 30 to 40 percent ƒe ame tsitsiwo) siwo va kple Pott ƒe dɔdzẽ si fu le woƒe ŋgonu gota la dzraa Intracranial Complication (epidural abscess, subdural empyema, frontal lobe brain abscess, or superior sagittal sinus thrombosis) le woƒe tagbɔ ƒe eme. Ne ɖevi, ƒewuivi, alo ame tsitsi aɖe si ŋu sinus dɔlékui aɖe le fifia alo nyitsɔ laa alo ta ƒoƒo va a ŋgonu si le teƒe ɖeka, fafɛ, si le abe amɔwɔ ene, alo si nɔa tɔtrɔm le ŋgonu le ŋkume ƒe tame, ŋgɔgbe taɖuame sesẽ, dzoxɔxɔ, ŋkume ƒe akpa si le etame ƒe vuvu, ʋuʋudedi, alo amenyenye ƒe tɔtrɔ/kuviawɔwɔ si menya kpɔna dzea sii bɔbɔe o la, yɔ wò nutoa me tɔ xexlẽdzesi siwo wozãna kpata (911 le United States kple Canada, . 112 le Europa Dukɔwo ƒe Habɔbɔa katã me la, . 999 le United Kingdom, alo 000 le Australia) alo yi kɔdzi ƒe Dɔwɔƒe si Kpɔa Nudzɔdzɔ Kpatawo Gbɔ enumake. Ne èle dzadzram ɖo ɖe ʋuɖoɖo ŋu la, dzro míaƒe zɔhɛ mɔfiame siwo ku ɖe... orbital cellulitis kple cavernous sinus ƒe ʋumenugbagbeviɣidɔ, . meningitis kple meningococcal septicemia ƒe vovototodedeameme, kple acute coalescent mastoiditis kple ahɔhɔ̃ me ʋuʋudedi ƒe afɔku.

Nukatae ƒewuivi kple esiwo mexɔ ƒewuiwo haɖe o siwo xɔ tso ƒe 10 va ɖo ƒe 18 (vevietɔ ŋutsuvi ƒewuiviwo) nye ƒuƒoƒo #1 si me afɔku le ŋutɔ na Pott ƒe dɔdzẽ si fu kple subdural empyema? Elabena ŋgɔgbe ƒunukpeƒetetedɔ (siwo menɔa anyi le vidzidzi me o eye ɖeko wodzea yaƒoƒo gɔme le ƒe 6 xɔxɔ me ko) toa tsitsi kabakaba le sɔhɛmenɔɣi, si kpena ɖe ʋuka siwo me ʋu sina tona ƒe kɔkɔƒe kple Breschet** ƒe ʋuka siwo le ʋuʋu ɖi, siwo me ʋuka mele o, siwo me ʋu sina tona to ŋgɔgbeƒu si le tsitsim ƒe lãkusi si le abe ƒumeŋuɖui ene me. Dɔlékui ƒe dzamezã bɔbɔe si trɔna zua dɔlékui ƒe ŋkumeʋuʋu sesẽ le ƒe 14 vi ŋu ate ŋu aƒã nuku ɖe ŋgonu ƒe ŋgɔgbe kple tagbɔ ƒe teƒe siaa le ŋkeke aɖewo megbe, ne woŋlɔ amoxicillin alo azithromycin si woano na ƒewuivia xoxo le atikewɔƒe si wokpɔa dɔnɔwo gbɔ kpata gɔ̃ hã.

Wɔ esia fifia¶

1. Dzro ŋgonu le profile me eye nàtsɔ asibidɛ ɖeka aƒoe blewuu be "Doughy, Boggy, or Fluctuant Forehead Swelling" le eŋu hã. Tsi tre ɖe dɔnɔa ƒe axadzi le kekeli nyui me eye nàlé ŋku ɖe woƒe ŋgonu ƒe nɔnɔme ŋu tso ŋkume vaseɖe taɖa ƒe fli dzi:
2. To vovo na "goose-egg" hematoma sesẽ yeye le ta ƒe ƒoƒo vɔ megbe teti la, Pott ƒe dɔdzẽ si fu doa mo ɖa le ŋkeke geɖe va ɖo kwasiɖa geɖe me le "sinus cold" alo taɖuame (alo kwasiɖa 1 va ɖo 3 le ŋgonu ƒe ƒoƒo sue aɖe megbe), si dzena abe wode dzesi nyuie, dzoxɔxɔ, exquisitely tender, doughy/pitting alo water-balloon-like (fluctuant) vuvu le ŋgonu ƒe titina alo ŋkume ƒe nuto dzi.
3. Zi geɖe la, nuheŋusẽ ƒe ʋuʋu zɔna yia anyime tso ŋgonu yia ŋku ƒe akpa si le etame ɖeka alo evea siaa (periorbital edema), si wɔnɛ be ɖɔktawo bua eŋu vodadatɔe le gɔmedzedzea me be enye ŋku ƒe nulɔdɔ bɔbɔe alo ŋkume ƒe ʋumenugbagbeviɣidɔ si do ŋgɔ na septal negbe ɖe woka asi ŋgonu ƒe ƒu si le ŋgonu tame ŋu hafi.
4. Ƒo ka 911 / . 112 / . 999 enumake ne ŋgonu ƒe vuvu alo ŋgɔgbeƒu ƒe vevesese sesẽ kpe ɖe Intracranial alo Orbital Red Flag ANYE ŋu:
5. Nuwɔna, seselelãme, alo amenyenye ƒe tɔtrɔ siwo menya kpɔna dzea sii bɔbɔe o ("Silent Frontal Lobe Sign"): Ðekematsɔleme yeye, dzikudodo si mebɔ o, tɔtɔ, nyabiasewo ŋuɖoɖo blewu (abulia), alo alɔ̃dɔdɔ.
6. Dzesi Siwo Ðea Taɖuame ƒe Nyaƒoɖeamenu Dzi Ðe Edzi (ICP) alo Meningismus: Taɖuame si nu sẽna ɖe edzi si nyɔa dɔnɔa tso alɔ̃ me, projectile nausea/vomiting, kekeli si klẽna ƒe seselelãme (photophobia), alo kɔ sesẽ aɖe.
7. Focal Neurological Deficits alo Seizures: Focal ƒe ʋuʋu yeye ɖesiaɖe alo alɔ̃madɔmadɔ si bɔ (occurs in up to 30% of subdural empyemas), gbɔdzɔgbɔdzɔ le mo/abɔ/afɔ ƒe akpa ɖeka (hemiparesis), alo nuƒoƒo si me mekɔ o.
8. Orbital Extension: Ŋku si le ʋuʋum (proptosis), ŋkume ƒe ʋuʋu yi anyime kple egodo (globe dystopia), ŋku ƒe nukpɔkpɔ zi eve, alo ŋku ƒe ʋuʋu si le veve sem/si ŋu seɖoƒe le (subperiosteal orbital roof abscess).
9. Yi Kɔdzi Kpata ƒe Dɔwɔƒe gã aɖe si wowɔa Ahɔhɔ̃mekawo Kple Towo Ŋuti Dɔlélewo Gbɔkpɔƒe le gaƒoƒo 24 me tẽ (ENT) coverage, NEVER to an urgent care clinic or walk-in pharmacy clinic. Dɔnɔ ɖeka ɖesiaɖe si ŋu wosusu be Pott ƒe dɔdzẽ si fu le la hiã ahɔhɔ̃/sinus ƒe CT si me vovototodedeameme le enumake KPLE vovototodedeameme Brain MRI, central-nervous-system-penetrating intravenous antibiotics, kple urgent ƒo ƒu endoscopic/neurosurgical tsidzɔƒe.
10. Mègate kpɔ GBEÐE be yeatsɔ akplɔ, aƒoe, atsɔ aŋe akɔe, alo aƒo ŋgonu si vuvu le aƒeme alo le kɔdzi o. Zi geɖe la, ŋgonu ƒe ƒunukpeƒe ƒe ʋuʋudedi doa ka tẽ to do si me ʋuʋudedi le me (bony defect) le ŋgɔgbe kple megbe kplɔ̃wo dzi le ŋgɔgbe taɖuƒu ƒe ƒu dzi vaseɖe dura mater si tsyɔ ahɔhɔ̃a kple superior sagittal venous sinus dzi. Dɔnɔdzikpɔƒe ƒe lãɖeɖe si dzi womekpɔ ŋusẽ ɖo evɔ womewɔ CT/MRI ƒe nɔnɔmetatawo wɔwɔ do ŋgɔ o ate ŋu ana ŋutigbalẽ me dɔlékuiwo nage ɖe lãkusia ƒe teƒea tẽ alo ana ʋu gã aɖe nado le ʋuka me.
11. Na dɔnɔa nanɔ sesẽm NPO (naneke meli to nu me o: nuɖuɖu zero, tsi zero, tsi zero nu me) le ʋuɖoɖo me. Over 90 percent le Pott ƒe dɔdzẽ si vuvu ƒe dɔlélewo me hiã be woaɖe tsi si woɖe le amekokoxɔ me kpata (endoscopic frontal sinusotomy / Draf IIb-III procedure, external trephination, kple/alo neurosurgical craniotomy/burr hole evacuation) le atike si naa alɔ̃dɔdɔ ame katã me le gaƒoƒo geɖe me tso esime wova ɖo.
12. Na dɔnɔa ƒe ta kple akɔta ƒe akpa si le etame nakɔ ɖe dzi le 30 degrees le ʋuɖoɖo me be woana ahɔhɔ̃mekawo me tsi nayi nyuie to sagittal sinus si le etame dzi eye woaɖe taɖuame ƒe nyaƒoɖeamenu dzi akpɔtɔ.

Nyametsotsoti: ŋgonu ƒe vuvu, ŋgɔgbe taɖuame sesẽ, kple sinusitis ƒe dodokpɔ¶

flowchart TD
    Presentation["Ðevi, Ƒewuivi, alo Ame Tsitsi Si Ŋu Sinusitis, Ŋgɔme Taɖuame, alo Ŋgɔnu Siwo Do Do Ŋgɔ Le la Va Ŋgonu Vuvu (+/- Upper Eyelid Puffiness)"] --> PalpateForehead{"Afɔɖeɖe 1: Dzro & Ka asi Ŋkua Ŋu Blewu Le Ŋkumeƒua Tame: Ðe Teƒe aɖe, Tender, Warm, Doughy, Pitting, alo Fluctuant (‘Boggy’) Swelling Le Ŋgɔgbeƒua Dzia?"}

    PalpateForehead -->|"Ẽ: Doughy/Boggy Forehead Swelling = POTT ƑE ƲUƲU ƑE ƲUƲU (Ŋgɔgbeƒu ƒe Ƒumeŋuɖui + Subperiosteal Abscess) ."| CheckNeuro{"Afɔɖeɖe 2: Screen for Intracranial & Orbital Complications (Enɔa 60% va ɖo 85% me): Taɖuame sesẽ, Ʋuʋudedi, Kuviawɔwɔ, Amenyenye ƒe Tɔtrɔ, Alɔ̃madɔmadɔ, Kɔ Sesẽ, Abɔ/Afɔ si Gbɔdzɔ, ALOO Ŋku si le ƒoƒom/Frozen?"}

    CheckNeuro -->|"Ẽ na Ahɔhɔ̃mekawo alo Ahɔhɔ̃mekawo ƒe Dzesi AMESIAME"| Emergent911["POTT ƑE ƲUƲU ƑE ƲUƲU ƑE ƲUƲU KPLE NU ƑE ƲUƲU ƑE ƲUƲU / ƑUƑOƑO ƑE ƲUƲU (Epidural Abscess, Subdural Empyema, Brain Abscess, alo Sagittal Sinus Thrombosis): Yɔ 911 / 112 / 999 Enumake -> Do Ta Kɔ Dzi Degree 30 -> NPO Sesẽ"]

    CheckNeuro -->|"Ahɔhɔ̃mekawo ƒe Dzesi Siwo Medze Haɖe O Haɖe O (Xlɔ̃ nu Dɔnɔ Si ƒe ŋgonu Vuvu abe Amɔwɔ ene & Asrã/Taɖuame)"| UrgentHospital["POTT ƑE PUFFY TUMOR (AFƆKU GÃ BE SILENT EPIDURAL ABSCESS): Yi Tertiary Hospital Emergency Department Enumake (Kple Neurosurgery & ENT Coverage) -> Strict NPO for Imaging & OR"]

    PalpateForehead -->|"NO Ŋgo ƒe Ʋuʋu alo Ƒu ƒe Ʋuʋu: Ŋku ƒe Ʋuʋu Ko"| CheckEye["Da Do Do Ŋgɔ Na Septal vs. Post-Septal (Orbital) Cellulitis: Kpɔ Ŋku ƒe Ʋuʋu, Nukpɔkpɔ, & Proptosis -> Di Gbemagbe Atikewɔwɔ / ED Dadakpɔ"]

    Emergent911 --> HospitalBundle["Kɔdzi ƒe Ðoɖowɔɖi si Woɖo Kpeɖodzi: 1. STAT Ʋu Dekɔnuwo + Meningeal-Agbɔsɔsɔme IV Vancomycin + IV Ceftriaxone (2g q12h) + IV Metronidazole, 2. Vovototodedeameme ƒe CT si me kɔ nyuie le Sinuses/Orbits/Ahɔhɔ̃ (Ƒu + Lãmetsi Falɛfalɛ Fesrewo) + Vovototo Ahɔhɔ̃ MRI/MRV, 3. Urgent Combined ENT Endoscopic Frontal Sinus Drainage + Neurosurgical Evacuation of Any Epidural/Subdural/Brain Abscess + Kwasiɖa 6 IV Dɔlékuiwutikewo"]
    UrgentHospital --> HospitalBundle

--- .

Akpa 1: Ŋutilã ƒe Dɔléleŋutinunya: Breschet ƒe Ŋgɔgbe ƒe Gli Etɔ̃awo Kple Breschet ƒe Vein Siwo Me Valve Mele O¶

Be nàse nusita sinus dɔlékui dzro aɖe si le ŋkumeɖoboloa tame ate ŋu alɔ do aɖe ado goe to ŋgonu ƒe ŋutigbalẽ me le ɣeyiɣi ɖeka me EYE wòado ʋuʋudedi ɖe megbe ɖe ahɔhɔ̃a ƒe anyime gɔme la, lé ŋku ɖe amegbetɔ ƒe ŋgonu ƒe akpa si wotsɔ sagittal cross-section (frontal bone) ŋu:

========================================================================
       SAGITTAL CROSS-SECTION OF THE FRONTAL SINUS & POTT'S TUMOR
========================================================================

  [ FOREHEAD SKIN ]
         |
  [ PERIOSTEUM ] ===> (Lifted off skull by PUS -> "POTT'S PUFFY TUMOR"
         |             Subperiosteal Forehead Abscess)
         |
  +------+-----------------------------------+
  | ANTERIOR TABLE OF FRONTAL BONE           | <-- Thick Bone (2 to 4 mm)
  | (Contains Valveless Diploic Veins        |     Erodes OUTWARD.
  |  of Breschet in Spongy Marrow)          |
  +------------------------------------------+
  |                                          |
  |        [ FRONTAL SINUS CAVITY ]          | <-- Blocked Nasofrontal
  |        (Filled with Pressurized Pus:     |     Outflow Tract
  |         Streptococcus milleri +          |     (Pressure Cooker)
  |         Anaerobes + Staph aureus)        |
  |                                          |
  +------------------------------------------+
  | POSTERIOR TABLE OF FRONTAL BONE          | <-- PAPER-THIN (0.5 to 1 mm)
  +------------------------------------------+     Erodes INWARD.
         |                                                |
         v (60% to 85% Intracranial Spread)              v
  [ EPIDURAL ABSCESS / SUBDURAL EMPYEMA / ]    [ SUPERIOR SAGITTAL SINUS ]
  [ FRONTAL LOBE BRAIN ABSCESS            ]    (Septic Venous Thrombosis)
  ======================================================================
  (Note: Floor of Frontal Sinus = Roof of Eye Socket -> Orbital Abscess)
========================================================================

1. Gli Etɔ̃ Siwo Me Ƒu Le Le Frontal Sinus Pressure Cooker la me¶

Ne lãkusi ƒe vuvu, polyps, alo ʋuʋudedi ʋeʋĩ xe mɔ na gaƒoɖokui ƒe tsidzɔƒe xaxɛ si le ŋgɔgbe lãkusia te (ŋgɔgbe ƒe do / nasofrontal outflow tract) la, ŋgɔgbe lãkusia trɔna zua ƒu ƒe nyaƒoɖeamenuxɔ si wotu si wotre eye gli etɔ̃ ƒo xlãe: 1. Ŋgɔgbe Tabla (Front Wall: 2 to 4 millimeters thick): Ewɔa wò ŋgonu ƒe nɔnɔme sesẽ si le ŋkume kple ŋgonu ƒe ŋutigbalẽ te. Ne ƒumeŋuɖui vuvu to gli sia me (alo zɔ mɔ to ʋuka siwo wokpɔna me) la, ƒumeŋuɖui ƒoa ƒu ɖe gotagome ƒumeŋuɖui ƒe lãkusi sesẽa te (subperiosteal abscess), si wɔnɛ be gotagome ŋgonu ƒe ƒuƒoƒo si le abe amɔwɔ ene (Pott ƒe dɔdzẽ si fu) dona. 2. Amegbetɔ ƒe Tabla (Back Wall: Pepa-Tin at 0.5 to 1.0 millimeter): Ema ŋgɔgbe lãkusi si ŋu dɔlélea le la ɖa tẽ tso dura mater, superior sagittal venous sinus, kple ahɔhɔ̃ ƒe ŋgɔgbe lãkusiwo gbɔ. Esi wònye be megbegli sia le tsɛ wu ŋgɔgbegli la zi gbɔ zi eve va ɖo ene** ta la, kaka dɔlélea nu sẽ ale gbegbe be wòate ŋu age ɖe gli si le kpekpem la me 4 mm ŋgɔgbegli ɖe ŋgonu dzi, ɣesiaɣi kloe la, ege ɖe ƒumelã si le tsɛ la me xoxo 1 mm megbe gli yi tagbɔ ƒe do me**. 3. Gli si le anyigba (Floor of the Frontal Sinus = Roof of the Eye Socket): Ema ŋgɔgbe lãkusi kple ŋku dome. Ʋuʋudedi yi anyime to anyigba dzi kɔa ʋuʋudedi ɖe ŋkua ƒe akpa si le etame (superior orbital subperiosteal abscess), si tua ŋkua yi anyime kple gota (inferolateral proptosis) eye wònana ŋkume ƒe akpa si le etame la vuvu si srɔ̃a orbital cellulitis.

2. Alesi Dɔlékuiwo Tsia Tagbɔƒu * Si Megblẽ O* Gbɔgbɔ (The Valveless Diploic Veins of Breschet) .¶

Vevietɔ la, mehiã be do si woate ŋu akpɔ la naɖe do si woate ŋu akpɔ to taɖu ƒe ƒu me hafi axɔ Pott ƒe dɔdzẽ si fu alo subdural empyema si wua ame o. - Wotsɔ ʋuka siwo le abe ƒumeŋuɖui ene (the diploë) si me ʋuka siwo me gli tsɛwo le, 100% ʋuka siwo me ʋuka mele o, siwo woyɔna be Diploic Veins of Breschet ƒe ƒuƒoƒo aɖe si me tsi le si le ŋgɔgbekpa ƒe ƒu ƒe gotagome kplɔ̃ sesẽa kple ememe kplɔ̃ dome. - Diploic veins siawo siwo me valvɔ mele o doa ka kple mucosa of the frontal sinus tẽe yi ŋgɔ va ɖo ŋgonu ƒe ƒunukpeƒe KPLE megbe tẽe yia dural venous plexus kple superior sagittal sinus of the brain gbɔ. - Retrograde Septic Thrombophlebitis: Ʋu ƒe sisi si me dɔlélea le (septic thrombi) zɔa mɔ tẽ to Breschet ʋuka siwo me ʋuka mele o me yia ŋgɔ le ŋgonu ƒe lãkusi te eye wogbugbɔna toa dura la me yia akɔta ƒe teƒe kple ahɔhɔ̃ ƒe lãkusi me, ne ƒu ƒe megbe kplɔ̃a gakpɔtɔ dze abe ɖe wògblẽ ene le CT-mɔ̃ dzi gɔ̃ hã. - Nusita Ƒewuiviwo (10 to 18 Years Old) Are Hit Hardest: Le ƒewuiviwo ƒe tsitsi ƒe ʋuʋudedi si le ŋgɔgbeƒu me la, ʋuka si me ʋu sina tona le ʋuka eve me kple ʋukawo ƒe lolome ɖoa woƒe agbenɔƒe ƒe sesẽƒe, si wɔnɛ be ʋuka gã aɖe si le ʋuʋu ɖi tso ŋgɔgbe lãkusi me yia ƒumeŋuɖui kple ahɔhɔ̃ me.

3. Nu 4 siwo gbɔ Pott ƒe Dɔdzẽ si Fuɖename Gbɔna (Triggers).¶

1. Dɔlékuiwo ƒe Ŋgɔgbe me Dɔléle Sesẽ si Womedae O alo Wodae ƒe Akpa aɖe (75% to 80% of Cases): Zi geɖe la, ekplɔa dɔlékui ƒe vuvɔ alo tsiƒuƒu dzro aɖe ɖo; wona dɔlékuiwutike siwo woano kpuie siwo mete ŋu ge ɖe ŋkume ƒe lãkusi si xe mɔ na o la dɔnɔ siwo ade afã xoxo.
2. Ŋgonu ƒe Nuveviwɔame si mebɔ o (15% to 20% of Cases): Kamedefefewo ƒe gododo (bɔlƒoƒo ƒe ta, baseball, basketball ƒe abɔta), skateboard ƒe gege, alo ʋu ƒe gbagbã sue aɖe nana taɖa ƒe fli gbãna le ŋgɔgbe ƒe ŋgɔgbe lãkusi ƒe gli ŋu alo ʋu si le ŋgonu te si le ƒunukpeƒe ƒe dɔlékuiwo va xɔa dɔlékuiwo dzi emegbe le kwasiɖa 1 va ɖo 4 megbe.
3. Intranasal Cocaine / Methamphetamine Insufflation: Ʋukawo ƒe ʋuʋu atraɖii kple ischemic necrosis gblẽa no me septum kple frontal sinus outflow tract, si hea ƒumeŋuɖui vɛ.
4. Tagbɔ kple mo ƒe ahɔhɔ̃mekawo ƒe dɔwɔwɔ do ŋgɔ, Frontal Sinus Osteoma, alo Aɖu/Ŋutilã ƒe Kaka.

--- .

Akpa 2: Tagbɔdɔléle ƒe Kuxi 5 Siwo Wokpɔ Le 60% to 85% ƒe Nyawo¶

Esi wònye be dɔnɔ siwo ŋu Pott ƒe dɔdzẽ si vuvu le dometɔ ene le atɔ̃ ɖesiaɖe me dzraa tagbɔdɔlékui aɖe ɖo ta la, atikewɔlawo doa ahɔhɔ̃mekawo ƒe dɔwɔwɔ ŋuti dɔwɔƒe vovovo atɔ̃ kpɔna vevie:

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Akpa 3: Vovototodede Pott ƒe Fuɖename ƒe Dɔdzẽ kple Ŋgonu ƒe Ʋuʋudedi Si Mesẽ O Kple Orbital Cellulitis dome¶

Zã abadzivɔ ƒe kplɔ̃ sia si nàtsɔ asɔ kple wo nɔewo nàtsɔ ade vovototo Pott ƒe dɔdzẽ si fu kple "goose-egg" hematoma bɔbɔe si dzɔ le afɔku megbe, epidermoid cyst / skin carbuncle si ŋu dɔlékui le, kple isolated orbital cellulitis dome:

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Akpa 4: Nu gbagbe suesuewo ŋuti nunya kple kɔdzidzikpɔkpɔ si ŋu kakaɖedzi le (CT + MRI, . CNS-Dose IV Antibiotics, kple Combined ENT/Neurosurgery) .¶

1. Nusita Pott ƒe Puffy Tumor Nye Polymicrobial Microaerophilic & Anaerobic Dɔlékui¶

Esi wònye be ŋgɔgbe lãkusi si xe mɔ na wo zua do si me oxygen mesɔ gbɔ ɖo o (si me acid sɔ gbɔ ɖo kple esi me acid le ta la, dɔlékui siwo hea Pott ƒe dɔdzẽ si fu kple eƒe taɖuame ƒe ʋuʋudedi vɛ la to vovo kura tso to alo ŋutigbalẽ me dɔlékui bɔbɔewo gbɔ: - Fɔɖilawo ƒe Ƒuƒoƒo #1 (50% to 70%): Streptococcus anginosus (Streptococcus milleri) Ƒuƒoƒo (S. anginosus, S. constellatus, kple S. intermedius) kple viridans streptococci bubu siwo lɔ̃a ya suesuesuewo. Streptococcus intermedius / milleri ƒuƒoƒo xɔ ŋkɔ le dɔléle siwo xɔa ame me ƒe atikewɔwɔ me le eƒe enzyme wɔwɔ dzikutɔe ta (hyaluronidase and deoxyribonuclease) si naa ƒu ƒua gbe eye wòwɔa ahɔhɔ̃ kple epidural abscesses siwo gblẽa nu. - Strict Nu me & Sinus Anaerobes (30% to 50%): Fusobacterium ƒomeviwo (F. nucleatum, F. necrophorum), Prevotella, Porphyromonas, Bacteroides, kple Peptostreptococcus (enɔa dɔléle akpa gãtɔ me kple tagbɔ kekeɖenudɔ). - Atike si woyɔna be Staphylococcus aureus (15% to 25%, si ha le eme MRSA): Ebɔ vevietɔ le afɔku megbe dɔlélewo, ƒewuiviwo, kple sinusitis si nɔa anyi didi me. - Streptococcus pneumoniae, Haemophilus influenzae, kple Streptococcus pyogenes (Group A Strep).

2. Dɔlékuiwutike Si Wodona Ðe Ʋuka Me Si Wozãna Enumake (Meningeal / Brain Abscess Dosing) .¶

Esi woɖe ʋu ƒe dekɔnuwo vɔ teti (kple hafi woalala MRI ƒe nuwuwu vɔ megbe teti) la, atikewɔlawo dzea atike etɔ̃ ƒe dɔlékuiwutike siwo dona ɖe ʋuka me si gena ɖe lãmekawo me gɔme:: 1. Vancomycin si wodona ɖe ʋuka me (15 to 20 mg/kg IV every 6 to 8 hours) (be woatsɔ atsyɔ S. aureus si te ŋu nɔa te ɖe methicillin nu [MRSA] kple S si te ŋu nɔa te ɖe penicillin nu. aklãdɔ), PLUS . 2. Ceftriaxone si wodona ɖe ʋuka me (2 grams IV every 12 hours le ame tsitsiwo gome; 100 mg/kg/day divided q12h le ɖeviwo me: meningeal blibo ƒe agbɔsɔsɔme eve) ALOO Cefotaxime / Cefepime si wodona ɖe ʋuka me (be woakpɔ CSF kple ƒu ƒe agbɔsɔsɔ si sɔ gbɔ ɖe Streptococcus anginosus/milleri ƒuƒoƒoa kple Gram-negative rods ŋu), PLUS 3. Metronidazole si wodona ɖe ʋuka me (500 mg IV every 6 to 8 hours le ame tsitsiwo gome; 30 to 40 mg/kg/day le ɖeviwo me) (elabena metronidazole te ŋu gena ɖe ahɔhɔ̃mekawo, subdural pus, kple necrotic frontal bone** me **gogo-100% be wòaɖe anaerobes sesẽwo abe Fusobacterium kple Prevotella ene ɖa). - (Atikewɔwɔ Bubu: Meropenem si wodona ɖe ʋuka me + Vancomycin si wodona ɖe ʋuka me). - Atikewɔwɔ ƒe Ɣeyiɣi didi si wòle be woawɔ: Esi wònye be le gɔmesese nu la, Pott ƒe ƒumeŋuɖui si fu la nye ƒumeŋuɖui sesẽ si le ŋgɔgbe taɖui ƒe ƒu me (zi geɖe la, wotsɔa epidural/subdural abscess kpena ɖe eŋu) ta la, dɔnɔwo hiã **kwasiɖa 6 va ɖo 8 blibo ƒe dɔlékuiwutike si woɖo taɖodzinu na le ʋuka me (alo bioavailability prolonged IV-to-oral step-down) to PICC ka aɖe le amekoko ƒe tsiɖeɖe vɔ megbe.

3. Nusita Dɔnɔwo Hiã CT si Kpɔa Vovototodedeameme Gbɔ KPLEE Ahɔhɔ̃ ƒe MRI/MRV si Me Wozãa Vovototodedeameme Le EVEA¶

• Ahɔhɔ̃, Orbits, Kple Paranasal Sinuses ƒe CT si me woɖea vovototodedeameme le si ƒe nɔnɔme deŋgɔ (Thin 1 mm Slices with Bone and Soft-Tissue Windows):
• Ƒu ƒe Fesre le vevie na ENT kple ahɔhɔ̃ŋutinunyala: ewɔa milimeta ƒe gbɔdzɔgbɔdzɔ siwo tututu le afisi ƒumeŋuɖui ɖu to ŋgɔgbe kplɔ̃, megbe kplɔ̃, kple orbital anyigba si le ŋgɔgbeƒua me la ƒe nɔnɔmetata, eye wòɖea dɔnɔa ƒe ŋgɔgbeƒu ƒe sisi ƒe wɔwɔme fiana hena amekoko ƒe mɔfiame.
• Contrast Soft-Tissue Window ɖe ŋgonu subperiosteal abscess si doa rim-dzi ɖe edzi le pericranium te kple orbital alo epidural abscess gã ɖesiaɖe fia kɔte.
• Nusitae CT ɖeɖeko Mesɔ gbɔ O -> Ahɔhɔ̃ ƒe MRI si Wodona Ðe Vovototodedeameme si Wobia tso DWI kple MR Venography (MRV):
• Woate ŋu ato subdural empyemas siwo le tsɛ siwo le gɔmedzedzea me (vevietɔ esiwo ɣla ɖe anyigba ƒe akpa eveawo dome le tsitrenu le falx cerebri / interhemispheric fissure), frontal lobe cerebritis ƒe gɔmedzedze, kple superior sagittal sinus thrombosis le CT scan me.
• Ahɔhɔ̃ ƒe MRI si me Gadolinium ƒe Vovototo Kple Kaka ƒe Nɔnɔmetata Siwo Wotsɔ Kpe Ðe Eŋu (DWI) nye sika ƒe dzidzenu: ʋuʋudedi si le subdural empyema alo epidural abscess me ɖea bright restricted diffusion wɔdɔɖeamedzi fiana le DWI dzi, esime MRV ɖo kpe edzi nenye be superior sagittal sinus nye patent alo clotted.

4. Tomeŋutinunya si Woƒo Ƒu ( .ENT) kple Ahɔhɔ̃mekawo ƒe Dzɔtsoƒe Dzikpɔkpɔ le Amekokoxɔa me¶

Dɔlékuiwutikewo ɖeɖe mate ŋu ada Pott ƒe dɔdzẽ si fu la o; ele be woawɔ dɔ na aɖuɖɔ si le ŋgonu ƒe akpa si le ŋgonu te, si le ŋgɔgbe lãkusi si xe la me, kple epidural/subdural space me (source control), zi geɖe la, ƒunukpeƒe ENT + Neurosurgery ƒe ƒuƒoƒo aɖee wɔna le alɔ̃dɔdɔ ƒe ɣeyiɣi ma ke me: 1. Endoscopic Frontal Sinusotomy ( .Draf IIa / IIb or Draf III Modified Endoscopic Lothrop Procedure) ± External Frontal Trephination: ENT-dɔdala zãa no me nukpɔmɔ̃ siwo me kɔ nyuie kple amekoko ƒe mɔfianu si nɔnɔmetatawo fiaa mɔe to ŋɔti me, ʋua ŋgɔgbeƒu ƒe sisi ƒe mɔnu si xe la wòkeke tso ete, klɔa ʋuʋudedi kple ʋuʋudedi la doa goe, eye wòɖea tsi le ŋgonu ƒe ʋuʋudedi si le akɔta te (zi geɖe la, atsyɔ̃ɖomi sue aɖe kpena ɖe eŋu eyebrow-incision trephination alo percutaneous needle/drain placement ale be ŋgonu ƒe abi aɖeke naganɔ dzedzem o). 2. Ahɔhɔ̃mekawo ƒe Amekoko ƒe Ʋuʋu (Burr Hole or Craniotomy) + Necrotic Bone ɖeɖeɖa: Ne epidural abscess, subdural empyema, alo brain abscess le MRI dzi la, ahɔhɔ̃ŋutinunyala la wɔa frontal burr hole alo craniotomy si dona be wòaklɔ taɖua me ʋuʋudedi la ɖa eye wòaɖe osteomyelitic frontal skull bone (sequestrectomy).

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Nutome ƒe xexlẽdzesi siwo ku ɖe nudzɔdzɔ kpatawo ŋu kple ɖeviwo/ame tsitsiwo ƒe ahɔhɔ̃mekawo ƒe dɔwɔwɔ ƒe dɔwɔƒewo¶

Wosusu be Pott ƒe dɔdzẽ si vuvu la bia be woatsɔe ayi kɔdzi enumake ayi Atikewɔƒe Kɔkɔtɔ alo Ðeviwo ƒe Kɔdzi si Woɖo ɖi si me wowɔa dɔ gaƒoƒo 24 le Ahɔhɔ̃mekawo, Tomeŋutinunya (ENT) Rhinology, Ophthalmology, kple Pediatric/Adult Infectious Diseases ƒe kpekpeɖeŋunana:

• United States kple Canada: Ƒo ka na 911 hena ahɔhɔ̃mekawo, nukpɔkpɔ, alo dɔlékuiwutike ƒe nuxlɔ̃amedzesi ɖesiaɖe, alo yi suku gã aɖe alo Ðeviwo ƒe Kɔdzi Kpata Dɔwɔƒe tẽ. Wokpɔ edzi le Amerikatɔwo ƒe Tomeŋutinunya ƒe Suku-Ta kple Kɔ ƒe Amekoko (AAO-HNS), Amerika ƒe Dɔléle Siwo Xɔa Ame ƒe Habɔbɔ (IDSA), kple Amerika Ðeviwo ƒe Dɔlélewo Ŋuti Nusrɔ̃ƒe (AAP) mɔfiame sesẽ siwo ku ɖe dɔlékui sesẽwo ƒe rhinosinusitis ŋu.
• United Kingdom: Ƒo ka na 999 alo yi kɔdzi gã aɖe si kpɔa dɔléle sesẽwo gbɔ enumake Emergency Department (A&E) kple on-call ENT kple Neurosurgery. Wokpɔ edzi le NICE Mɔfiame NG79 (Sinusitis, Acute: Kɔdziyiyi Enumake le Tagbɔ alo Periorbital Kuxi siwo Wosusu ta) kple ENT UK / British Rhinological Society ƒe dzidzenuwo te.
• Europa Dukɔwo ƒe Habɔbɔ: Ƒo 112. Wokpɔ edzi le Europatɔwo ƒe Nɔnɔme Ŋuti Agbalẽ si Ku Ðe Rhinosinusitis Kple Nome Polyps Ŋu (EPOS 2020/2024: Ƒumeŋuɖui kple Tagbɔmekuxiwo Dzikpɔkpɔ le Acute Rhinosinusitis).
• Australia kple New Zealand: Ƒo 000 le Australia alo 111 le New Zealand. Wokpɔa edzi le ASOHNS kple Fia ƒe Ðeviwo ƒe Kɔdzi (RCH) Melbourne ƒe Sinusitis Sesẽ & Intracranial Sepsis Mɔfiamewo.
• Asia-Pacific: Ƒo ka na 119 (Japan, South Korea), 995 (Singapore), alo 112 / 108 (India). Bia kɔdzi si me wowɔa dɔ le gaƒoƒo 24 ƒe MRI, ahɔhɔ̃mekawo ƒe dɔwɔwɔ, kple dɔdzẽ ƒe dɔwɔwɔ to dɔgboa me.

Nya siwo wobiaa amewo enuenu¶

Ðe "Pott ƒe dɔdzẽ si fu" nye dɔdzẽ alo kansa nyateƒea?¶

Ao, togbɔ be nya dziŋɔ "dɔdzẽ" le eƒe ŋkɔ me hã la, kadodo aɖeke mele Pott ƒe dɔdzẽ si fu la kple kansa dome o. Esi Eŋlisi amekola Aƒetɔ Percivall Pott tsɔ ŋkɔ nɛ le ƒe 1760 me la, ɖeko Latingbe me atikewɔwɔ me nya "tumor" gɔmee nye "avuvu" ɖesiaɖe si le teƒea. Pott ƒe ƒumeŋuɖui si fu nye dɔlékui ƒe ƒu ƒe dɔléle (osteomyelitis) si le ŋgɔgbe taɖu ƒe ƒu me si naa kotoku si me ʋuʋudedi le le ŋgonu ƒe gotagome lãkusi te (si nye ƒumeŋuɖui te), si zi geɖe la, ŋgɔgbe lãkusi ƒe dɔlékui si womeda dɔ na o alo esi womeda eƒe akpa aɖe o alo ŋgonu ƒe ƒoƒo va yi gbɔ.

Nukatae ƒewuivi geɖe siwo ŋu Pott ƒe dɔdzẽ si vuvu le hã ƒe tagbɔ ɣla ɖe woƒe tagbɔ me le ahɔhɔ̃a gbɔ?¶

Ŋgɔgbe ƒe lãkusi nye yakotoku si me do le le ŋgonu ƒe ƒu me le wò ŋkumeɖobolo dome tututu. Eƒe ŋgɔgbegli (si dze ŋgɔ wò ŋgonu ŋutigbalẽ) nye ƒu si le ɣie (milimeta 2 va ɖo 4), gake eƒe megbegli (si ma sinus tso ahɔhɔ̃a kple dura mater gbɔ) ya le sue abe pepa ene (milimeta 0.5 va ɖo 1). Tsɔ kpe ɖe eŋu la, ʋuka siwo le abe ƒumebɔbɔ ene siwo me mɔ ɖeka dzi ʋukawo mele o (Breschet ƒe ʋuka siwo le eve) la tsoa lãkusia me tẽ yia ŋgɔ va ɖoa ŋgonu eye wogbugbɔna yia megbe va ɖoa ahɔhɔ̃a ƒe nutsyɔnu gbɔ, eye woƒe lolome ɖoa eƒe kɔkɔƒe kple ʋu ƒe sisi le ƒewuiviwo ƒe tsitsi ƒe ʋuʋu me. Eyata kaka ʋuka me dɔlékui aɖe nu sẽ ale gbegbe be wòatutu ʋuʋudedi ayi ŋgɔ to ŋgɔgbeƒu ɣia me ayi ŋgonu la, dɔlékuiwo tso ɖeviwo kple ƒewuiviwo ƒe dɔnɔ 60 va ɖo 85 le alafa me xoxo to megbegli tsɛ alo ʋuka siwo me ʋuka mele o me yi megbe tsɔ wɔ epidural abscess alo subdural empyema le taɖua me.

Nukatae dɔnɔ aɖe ate ŋu axɔ ahɔhɔ̃meka si le epidural alo frontal lobe si tso Pott ƒe dɔdzẽ si fu la gbɔ eye wòagazɔ azɔli ahaƒo nu nyuie le gɔmedzedzea me?¶

Ahɔhɔ̃a ƒe akpa si le ŋgɔgbe tututu si bɔbɔ nɔ ŋgonu megbe tẽ (ŋgɔgbe ƒe lãkusi ƒe ŋgɔgbe lãkusi) mekpɔa alɔ kple afɔ ƒe ʋuʋu, seselelãme, alo nuƒoƒo dzi o, teƒe mawo nɔa megbe wu le ahɔhɔ̃a me. Atikewɔlawo yɔa ŋgɔgbe ƒe ŋgɔgbe ƒe akpa si nye ahɔhɔ̃mekawo ƒe "teƒe si ɖoɖoezizi le" elabena zi geɖe la, kotoku si me ʋuʋudedi le si le dzidzim ɖe edzi si tena ɖe ŋgɔgbe ƒe ŋgɔgbe gome la naa gbɔdzɔgbɔdzɔ zero, lãmetutudɔ zero, kple nuƒoƒo si me mekɔ tututu o vɛ le gɔmedzedzea me. Ke boŋ kpeɖodzi gbãtɔ siwo gbɔ taɖuame kple dzoxɔxɔ ŋue nye amenyenye alo seselelãme ƒe tɔtrɔ siwo menya kpɔna dzea sii bɔbɔe o: ƒewuivi alo ame tsitsi aɖe ƒe ɖoɖoezizi, ɖekematsɔlemetɔ, dzikudodo, alɔ̃dɔdɔ, alo nyabiasewo ŋuɖoɖo blewu. Esia tae dɔnɔ ɖesiaɖe si ƒe ŋgonu vuvu abe amɔwɔ ene la wɔa CT kple ahɔhɔ̃ ƒe MRI kpata eɖanye aleke kee woƒe dodokpɔ vevitɔa dze abe alesi wòsɔe ene o.

Aleke mawɔ ade dzesi vovototo si le "goose-egg" ƒe abi si sɔ le ta ƒoƒo vɔ megbe kple Pott ƒe dɔdzẽ si fu dome?¶

"Goose egg" (hematoma) si nye nuveviwɔame si sɔ la vuvuna le aɖabaƒoƒo ʋɛ aɖewo ko me tso esime nèƒo ta, esena le eɖokui me be yeli ke alo abe goma ene, dzoxɔxɔ alo tsi si dona le lãkusi me menɔa eŋu o, eye wònɔa ɖeɖem kpɔtɔna vivivi le kwasiɖa si kplɔe ɖo me. To vovo na ema la, Pott ƒe dɔdzẽ si vuvu la doa mo ɖa le ʋuka me dɔlékui sesẽ/vuvɔ me evɔ ta mexɔ abi kura o, ALOO edzena tso ŋkeke va ɖo kwasiɖa geɖe le ŋgonu ƒe ƒoƒo megbe ne abi si le dɔyɔyɔm la gadze lolo zi ɖeka, exɔ dzo, biã, wòzu amɔwɔ/squishy, eye wòvivina ŋutɔ ne woka asi eŋu, eye taɖuame si le ƒoƒom kpe ɖe eŋu, dzoxɔxɔ, alo ʋuʋudedi si kaka ɖe ŋkume ƒe akpa si le etame.

Ðe woate ŋu atsɔ dɔlékuiwutike siwo woano ada Pott ƒe dɔdzẽ si vuvu la le aƒeme, alo atsɔ akplɔ adae le atikewɔƒe si wokpɔa dɔnɔwo gbɔ kpataa?¶

Gbɛɖɛ. Dɔlékuiwutike siwo woano mate ŋu age ɖe ŋgɔgbeƒu kuku si me dɔlékuiwo le me alo aɖe aɖuɖɔ ƒe kotoku si wotu nu ɖo le ŋgonu ƒe ƒunukpeƒe te o, le nyateƒe me la, dɔnɔ siwo wokpɔ be Pott ƒe dɔdzẽ si fu le wo ŋu la dometɔ siwo ade afã nɔ dɔlékuiwutike siwo woŋlɔ na woƒe ŋgonu ƒe dɔlékui aɖe nom xoxo esime woƒe ŋgonu vuvu. Vevietɔ nenema ke be mele be atikewɔla si kpɔa dɔnɔwo dzi kpata natso ŋgonu si vuvu la me gbeɖe kɔdzi ƒe CT kple MRI-dɔdamɔnu manɔmee o, elabena zi geɖe la, ʋuʋudedia toa do aɖe si le taɖua me me doa ka kple ahɔhɔ̃a ƒe gotagome lãkusi (dura) kple ʋuka gã si le ʋuka me tẽ. Atikewɔwɔ bia ɣesiaɣi be woaxɔ ame ɖe kɔdzi, woaɖe tsi le ENT kple ahɔhɔ̃mekawo ƒe dɔwɔwɔ le amekokoxɔ me ɖekae, eye woatsɔ dɔlékuiwutikewo ade ʋuka me kwasiɖa 6 va ɖo 8.

Ðe amekoko na Pott ƒe dɔdzẽ si fu la agblẽ abi gã aɖe ɖe ŋgonua?¶

Tsã la, ele be amekolawo naɖe lã gã aɖe le ŋgonu alo tagbɔ be wòaʋu ŋgɔgbeƒua. Egbea drain placement tucked right inside the hairs of the eyebrow ale be ŋgonua nahaya kple abi aɖeke kloe si woate ŋu akpɔ o.

Dzɔtsoƒewo kple dziɖuɖumegãwo ƒe mɔfiame¶

• Europatɔwo ƒe Nɔnɔmegbalẽ le Rhinosinusitis kple Nasal Polyps ŋu (EPOS 2020/2024, European Rhinologic Society): Ƒe kple tagbɔdɔléle sesẽwo ƒe hatsotsowo me toto kple wo dzi kpɔkpɔ kpata (Pott ƒe Puffy Tumor, Epidural Abscess, Subdural Empyema, kple Endoscopic Frontal Sinus Tsiɖɔɖɔ).
• American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) & American Academy of Pediatrics (AAP, United States): Dɔwɔƒe ƒe Mɔfiamewo na Dɔlékui ƒe Sinusitis Sesẽ Sesẽ le Ðeviwo Kple Ame Tsitsiwo Me (ƒewuiviwo ƒe dzidziɖedzi si sɔ gbɔ wu, diploic vein thrombophlebitis, kple dual CT/MRI neuroimaging si wòle be woawɔ).
• Dukɔa ƒe Lãmesẽnyawo Kple Belélename Ŋuti Nusrɔ̃ƒe (NICE) & ENT UK (United Kingdom): Sinusitis (Acute): Dɔlékuiwutikewo ƒe Atikewɔwɔ Kple Kɔdzi Kpata ƒe Ðoɖowɔwɔ ƒe Dzesiwo na Wosusu be Frontal Bone Osteomyelitis alo Intracranial Spread (NICE Guideline NG79).
• Dɔléle siwo xɔa ame ƒe habɔbɔ (IDSA, United States): Dɔwɔƒe ƒe Mɔfiamewo na Tagbɔdɔléle ƒe Kuxiwo Kple Ƒumeŋuɖui (empiric CNS-dose intravenous vancomycin, etɔ̃lia ƒe cephalosporin, kple metronidazole si xɔa Streptococcus anginosus/mileri ƒuƒoƒoa kple anaerobes hena kwasiɖa 6 va ɖo 8).
• Fia ƒe Ðeviwo ƒe Kɔdzi (RCH) Melbourne & ASOHNS (Australia): Ðeviwo ƒe Ŋgɔgbe ƒe Dɔléle Sesẽ Kple Pott ƒe Puffy Tumor Neurosurgical/ENT Protocol.

Mɔfiame siwo do ƒome kplii¶

• Orbital cellulitis, cavernous sinus thrombosis, kple afɔku ƒe dzogoe etɔ̃ me dɔlékuiwo
• Cavernous sinus thrombosis: Afɔku Dzogoe etɔ̃ me ƒoƒo, sinusitis, kple sixth-nerve palsy
• Acute coalescent mastoiditis: to ƒe pinna si dona ɖe gota kple sigmoid sinus thrombosis
• Meningitis kple meningococcal septicemia non-blanching ʋuʋudedi ƒe vovototodedeameme
• Ta ƒe abixɔxɔ kple ʋuʋudedi ƒe dzesidede