|Year : 2011 | Volume
| Issue : 4 | Page : 155-158
Transmastoid approach to otogenic brain abscess: 14 years experience
VR Borade, SA Jaiswal, HO Nemade
Department of ENT, Dr. Vaishampayan Memorial Government Medical College, Solapur, India
|Date of Web Publication||29-Mar-2012|
H O Nemade
Department of ENT, 'B' Block, Shri Chhatrapati Shivaji Maharaj General Hospital and Dr. VMGMC, Solapur-413005
Source of Support: None, Conflict of Interest: None
Objectives: Objectives of this study were to review our experience in on otogenic brain abscess and its management by transmastoid drainage and compare the results. Materials and Methods: All patients with brain abscess secondary to CSOM presenting to our department from January 1997 to December 2010 were included in this study. All patients subjected to clinical, neurological, opthalmological examination and CT scan was done as an imaging modality. All patients managed by radical mastoidectomy or modified radical mastoidectomy and transmastoid drainage of brain abscess as neurosurgical facility not available. Results: Seventy-two patients in whom brain abscess secondary to chronic suppurative otitis media was diagnosed and has been treated since 1997 are presented. 85% of patients were below 20 years of age. More than 50% patients presented with more than one complication of chronic suppurative otitis media. 85% of patients were having extensive cholesteatoma and 15% patients were having extensive granulations in middle ear and mastoid air cells. 83% patients were having cerebellar abscess while 17% patients were having temporal lobe abscess. 80% of the pus culture was sterile while in 20% patients various microorganisms such as Proteus spp., Escherichia coli, Pseudomonas aeruginosa, Staphylococcus spp., and Streptococcus spp were cultured. Overall mortality in this series was 4.4%. Conclusion: In diagnosis of otogenic brain abscess CT scan with constrast is of immense help. Transmastoid drainage of brain abscess is a safe and effective method that can be performed by otologists in cases of otogenic brain abscess.
Keywords: Otogenic brain abscess, Transmastoid drainage, Complications of CSOM
|How to cite this article:|
Borade V R, Jaiswal S A, Nemade H O. Transmastoid approach to otogenic brain abscess: 14 years experience. Indian J Otol 2011;17:155-8
| Introduction|| |
Chronic suppurative otitis media (CSOM) with cholesteatoma has the potential for intracranial spread of infection. Although there has been a marked decrease in the incidence of otogenic intracranial complications because of early diagnosis and prompt treatment of ear infection, availability of higher antibiotics, and advances in otological surgical techniques, otogenic intracranial complication persists as a difficult problem. , CSOM accounts for 28,000 deaths and a disease burden of more than 2 million Disability Adjusted Life Years (DALYs).  Over 90% of the burden is borne by countries in the South-East Asia and Western Pacific regions, Africa, and several ethnic minorities in the Pacific rim. The most commonly encountered intracranial complication is meningitis followed by brain abscess. Brain abscess was the first complication of otitis media to be recognized and the first one successfully treated by operation. It was in 1768 that Morand reported a successful operation for brain abscess. In 1856, Lebert accurately described the pathology of brain abscess, confirming the fact that it follows infection of the ear, not the reverse. The treatment of otogenic brain abscess consists of medical management in the form of antibiotics and the agents to lower the intracranial pressure and surgical management which include burr hole or craniotomy to drain the brain abscess by neurosurgeon and removal of the ear and mastoid cholesteatoma by radical or modified radical mastoidectomy done by otologist. In our setup due to lack of neurosurgical facility, the otogenic brain abscess patients were treated by otologists by radical or modified radical mastoidectomy and approaching the brain abscess through defect in tegmen antri and Trautmann's triangle.
The objectives of this study were to review our experience on treating otogenic brain abscess transmastoid route with particular reference to symptoms, signs, intraoperative findings, and results.
| Material and Methods|| |
This article will review our experience with 72 patients of otogenic brain abscesses treated from January 1997 to December 2010 in our hospital. All cases of CSOM with suspected intracranial complications were subjected to clinical examination, neurophysicians opinion, fundoscopy by ophthalmologists, and imaging by computed tomography (CT) scan. Brain abscesses from other origins and extradural abscesses were excluded from this study. According to the severity of the disease, modified or radical mastoidectomy was performed under general anesthesia. In temporal lobe abscess, the dural plate was carefully examined to look for erosion. If granulations were present on dura, the tegmen antri was removed till healthy dura was seen. Brain cannula was inserted into the abscess cavity through the healthy portion of the dura and the pus was aspirated off [Figure 1]. The abscess cavity was irrigated with antibiotic solution. In cerebellar abscess, the sinus plate examined for erosion, presence of granulation, perisinus abscess, and sinus was palpated for signs of thrombosis, and aspiration of sinus was done. If no free flow of blood, sinus was exposed from sinodural angle up to mastoid tip and sinus was incised and thrombus was removed till there was free flow of blood. Aspiration of cerebellar abscess was done through the Trautman's triangle [Figure 2]. Hemostasis was achieved, and antibiotic pack was kept in operated cavity. Postaural wound was not sutured. Repeated aspiration of brain abscess was done after every 48 hours. Clinical status of patient was assessed and abscess was also assessed by repeat CT scan, when satisfactory secondary suturing of postaural incision was done at a later date. Antibiotics continued for almost 1 month after surgery.
|Figure 1: Transmastoid drainage of temporal lobe abscess through the dural plate|
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|Figure 2: Transmastoid drainage of cerebellar abscess through the Trautmann's triangle posterior fossa dura|
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| Results|| |
From the total of 72 patients, 40 patients were male and 32 were female. Ages of patients ranged from 6 years to 54 years with the mean age of 16 years. 85% patients were below 20 years of age. Otological diagnosis revealed that 62 (85%) patients were having cholesteatoma while 10 patients were having granulations in middle ear and mastoid air cells [Table 1]. Cerebellar abscess was found in 60 patients (83%) while temporal lobe abscess was found in 12 patients [Table 2].
In all, 48 patients were having more than one intracranial complication. Lateral sinus thrombosis was found in 15 patients, meningitis in 4 patients, and epidural empyema in 20 patients. Intratemporal complications such as labyrinthine fistula was found in 36 patients and facial nerve palsy seen in 6 patients [Table 3].
Out of 12 cases of temporal lobe abscess, morbidity was seen in one patient in the form of persistence of hemiplegia. Mortality was seen in two patients of temporal lobe abscess and in three patients of cerebellar abscess.
All patients of facial nerve palsy had undergone facial nerve decompression and two patients showed partial improvement.
Pus was sent for Gram staining and culture sensitivity. In 80% of patients, pus was sterile on culture. Remaining 20% showed variable causative organisms, e.g., Escherichia More Details coli, Pseudomonas aurugenosa, Proteus spp., Staphylococcus spp., and Streptococcus spp.
| Discussion|| |
A brain abscess is a focal suppurative process within the brain parenchyma surrounded by a region of encephalitis. The risk for a patient with chronic otitis media to develop a cranial abscess is of 1 in 10,000 patients per year, but in adults who's had the disease since the childhood this risk may increase to 1 in 200 patients per year. , Yen and associates' recent series of 122 consecutive patients seen in a Taiwan hospital between 1981 and 1994 revealed that otitis was the third most common cause of intraparenchymal brain abscess, exceeded only by those associated with cyanotic congenital heart disease and those secondary to head injury or neurosurgery. 
According to Nalbone et al., otogenic brain abscess carry a mortality rate ranging from 7% to 61%.  According to Ludman, 25% of all brain abscesses were otogenic in children, whereas in adults 50% brain abscesses were otogenic.  For some unknown reasons, otogenic intracranial complications occur predominately in males. As a rule, otogenic brain abscesses are single and multiple only in rare cases.  The mortality associated with brain abscess of otogenic origin in the antibiotic era is about 25%. Patients who present with altered mental status have more advanced disease and have a higher mortality rate. 
Spread beyond middle ear cleft can occur due to destruction by cholesteatoma, through fracture lines, preformed pathways, through the Haversian system of veins or through the periarterial space of Virchow Robin. In this era of antibiotics, incidence of complications is reduced due to awareness of disease, advances in diagnostic, and treatment modalities. The clinical diagnosis of intracranial complication and brain abscess are not reliable and must be confirmed by CT scan [Figure 3] and [Figure 4]. This is also not an invasive, quick, and reliable method of preoperative and postoperative assessment of patients of otogenic brain abscess. HRCT temporal bone sometimes misses the temporal bone abscess, so CT brain plain plus contrast must be complimented by the HRCT.
All patients presented with headache more than 7 days and associated with the nausea and vomiting, fever, and variable alteration in consciousness. All patients gave history of purulent and foul smelling discharge through the ear. Radical mastoidectomy is considered as the surgery of choice in event of the presence of intracranial complications. ,
Open cavity mastoidectomy was used as a method of choice in our series. In modified radical mastoidectomy, hearing preservation was attempted by ossiculoplasty and myrigostapedopexy.
The mean follow-up period was 1 year and seven patients required revision surgery. Hence, recurrence rate was 12% which was comparable to the existing series. The mean duration of hospitalization was 15 days. Postoperative follow-up was kept with serial CT scans in clinically suspicious cases.
| Conclusion|| |
Otogenic brain abscess is a challenging condition to manage. High degree of suspicion is indicated for diagnosis for which CT scan with contrast is of immense help.
Transmastoid drainage of otogenic brain abscess is equally safe and efficient modality of treatment of otogenic brain abscess in the area where neurosurgical facilities are not available. It deals with primary focus of infection with the secondary intracranial complication in single setting avoiding two-stage procedure.
| Acknowledgement|| |
Dr. Shinde Dean, Dr. VMGMC Solapur for permission for publication.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]