PMC5502301_01
Discharging sinus of the scalp in the left frontal region
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F1
Tamil Nadu, south India presented with complaints of headache for the past 4 months and persistent discharging sinus from the left frontal scalp region for 1 month [Figure 1]. There was no history suggestive of trauma.
Plain axial computed tomography showing lentiform shaped collection in the extradural space of left frontal region. The destruction of bone along with scalp involvement is also noted
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F2
Osteolytic changes in the left frontal bone with soft tissue swelling of the scalp over osteolytic focus were also noted [Figure 2].
Contrast enhanced MRI. (a) Coronal cuts showing enhancement of the extradural collection and soft tissue in the scalp. (b) Axial images showing the dural enhancement. (c) T2 weighted images showing oedema of left frontal cortex. (d) Diffusion restriction is seen
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F3
Contrast-enhanced magnetic resonance imaging (MRI) [Figure 3a and b] revealed osteolytic focus in the left frontal bone with irregular erosions of the inner table. A 2.5-cm thick extra-axial collection measuring 5 cm in the anteroposterior direction and 6 cm in the craniocaudal direction with thick irregular enhancing walls was visualized adjacent to the osteolytic focus with restricted diffusion [Figure 3d]. The left frontal cortex showed a small nodular enhancement with edema of white matter [Figure 3c].
Intra operative images showing (a) Necrotic bone and cheesy material underneath it. (b) Margins of healthy bone
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F4
Bone was soft and necrotic with cheesy material underneath [Figure 4a]. Debridement of the diseased bone was done till healthy bone was encountered [Figure 4b].
Histopathology images: (a) 10X images showing granuloma and langhan's giant cells. (b) 40X images showing Langhan's giant cells
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F5
Histopathological evaluation showed spicules of bone and fibrous tissue with clusters of epithelioid cells, Langerhans giant cells, and lymphocytes and areas of caseation necrosis [Figure 5].