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 Table of Contents  
REVIEW ARTICLE
Year : 2015  |  Volume : 21  |  Issue : 4  |  Page : 286-289

Otogenic brain abscess: A rising trend of cerebellar abscess an institutional study


1 Department of Otorhinolaryngology and Head and Neck Surgery, Gauhati Medical College and Hospital, Guwahati, Assam, India
2 Department of Radiology, Gauhati Medical College and Hospital, Guwahati, Assam, India

Date of Web Publication16-Oct-2015

Correspondence Address:
Rupam Borgohain
Department of Otorhinolaryngology and Head and Neck Surgery, Gauhati Medical College and Hospital, Guwahati, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.165757

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  Abstract 

Chronic inflammation of the middle ear is the most frequent cause of otogenic complications. Meningitis is the most frequent intracranial complications, followed by otogenic brain abscess in neglected otitis media. Although temporal lobe abscesses are more common than cerebellar abscesses, the converse was found to be true in our series of 17 cases. 16 cases of cerebellar abscess and 1 case of temporal lobe abscess were reported as a complication of chronic otitis media (COM). In our group of patients, otogenic brain abscesses were more frequent in male patients of age group 5–20 years with mean age of 14 years. Diagnostic procedure included history, clinical, otorhinolaryngological examination, audiological, microbiological, neurological, ophthalmological, and radiological examinations. The treatment included primary neurosurgical approach (abscess drainage) followed by radical otosurgical treatment.

Keywords: Brain abscess, Cerebellar, Otogenic, Temporal lobe


How to cite this article:
Borgohain R, Talukdar R, Ranjan K. Otogenic brain abscess: A rising trend of cerebellar abscess an institutional study. Indian J Otol 2015;21:286-9

How to cite this URL:
Borgohain R, Talukdar R, Ranjan K. Otogenic brain abscess: A rising trend of cerebellar abscess an institutional study. Indian J Otol [serial online] 2015 [cited 2020 Sep 26];21:286-9. Available from: http://www.indianjotol.org/text.asp?2015/21/4/286/165757


  Introduction Top


Hippocrates noted in 460 BC that acute pain in the ear with a continued high fever is dreaded for the patient and may become delirious and die. It was Morgagni who recognized that ear infection came first, and brain abscess was secondary. Fifty percent of brain abscess in adults and 25% in children are otogenic in origin. As per the various literatures cerebral abscess is seen twice as frequently as cerebellar but in our study converse was found true.

Various routes of spread of infection from middle ear cleft are - Direct bone erosion, direct extension along preformed pathways, and venous thrombophlebitis. The infection spreads to cerebellum through trautmanns triangle, venous thrombophlebitis, and erosion of sinodural plate. In our case series of 17 patients, it has been reported that cerebellar abscess is more common than temporal lobe (cerebral abscess).

Aim

The aim of our study is to emphasize that otogenic brain abscess is more commonly located at cerebellum, which is in contrary to most authors who have reported that otogenic brain abscess is more likely to be located in the cerebrum, that is, the temporal lobe abscess. To discuss the various modes of spread of infection and to correlate the radiological findings with intraoperative findings.


  Material and Methods Top


A retrospective study was carried out in the Department of ENT that included 17 cases of COM with intracranial complications, that is, brain abscess admitted from July 2013 to December 2014. Following parameters were analyzed:

Age, sex socioeconomic status, predisposing focus nose/throat, symptoms and signs, microbiology of ear discharge, pathology in ear, neurological examinations, audiological, radiology, intraoperative findings, other otogenic complications, site of abscess, and otosurgical procedures.


  Results and Observations Top


  • Sex - Male preponderance was seen. Of 16 cases of cerebellar abscess, 12 were males and 4 females [Figure 1]
  • Age- Average age was 14 years. The age range was between 5 to 20 years
  • Site of brain abscess - In 16 cases, the site of the abscess was cerebellum, and in only 1 case, it was cerebrum (temporal lobe).


Microbiology

Aural swabs were taken and sent for culture and sensitivity in every case. Klebsiella found in 5 patients, pseudomonas in 7 patients, and no organisms were detected in 5 patients.
Figure 1: Pie chart of sex incidence

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Symptoms and signs

All the 17 cases are presented with prolonged ear discharge, headache, nausea, and vomiting. Only 10 cases presented with seizures. Nominal aphasia was present in only 1 case (temporal lobe abscess). Ipsilateral ataxia was present in 13 cases of cerebellar abscess. Past pointing and dysdiadokinesia were present in 16 cases of cerebellar abscess. In all 17 cases including both cerebellar and temporal lobe abscess neck rigidity, Kernig sign, Romberg sign, and nystagmus were present. Fistula test was positive in 2 cases (1 of cerebellar abscess and other that of temporal lobe abscess). Papilledema was present in 12 cases of cerebellar abscess. Vertigo was seen in only 4 cases of cerebellar abscess.

Radiological findings and its correlation with intraoperative findings

Computed tomography (CT) scan with and without contrast, High-resolution CT mastoid, and magnetic resonance imaging (MRI) brain were done in all cases. Magnetic resonance venography was done in selected cases. The brain abscess appears as a hypodense area, known as signet ring appearance in CT brain [Figure 2]. MRI brain is showing sigmoid sinus thrombophlebitis [Figure 3] and [Table 1].
Figure 2: Computed tomography brain is showing ringlike enhancement in cerebellum in axial and saggital plane

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Figure 3: Magnetic resonance imaging brain is showing left sided cerebellar abscess with sigmoid sinus thrombophlebitis

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Table 1: Preoperative and intraoperative findings

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Intracranial extension of COM occurs more commonly from poorly pneumatized than well pneumatized temporal bones; this is in consistence with our radiological and intraoperative findings. Dural plate erosion mainly leads to the temporal lobe abscess and sinus plate erosion is mainly associated with a cerebellar abscess. In most of our cases, a bony wall of the middle ear cleft and mastoid cells are intact, but still there is a complication. These points toward the venous thrombophlebitis, which is an important cause for a cerebellar abscess. This is also in consistence with the radiological and intraoperative findings, where both dural and sinus plates are intact in most of the cases, in our study. Normal sinus plate is bluish and shiny, and if it is infected it becomes dull and lusterless. In 12 cases, sinus plate was bluish in color and in 5 cases (all of cerebellar abscess) it was lusterless and dull looking and eroded [Figure 4]. Thick sinus wall with perisinus abscess was seen in 7 cases. Semicircular canal erosion is associated with positive fistula test and vertigo. The lateral semicircular canal was eroded in 4 cases intraoperatively and intact in 13 cases. Incus was most commonly eroded ear ossicle, followed by malleus and suprastructure of stapes. Otogenic complications can occur in noncholesteatomatous ears too, in our study also only in 10 cases cholesteatoma is present in rest 5 cases only granulation tissue is present at the time of surgery in the middle ear cleft.
Figure 4: Intraoperative photographs - cholesteatoma seen in mastoid antrum, erosion seen at sinodural angle, dehiscent lateral semicircular canal with exposed posterior dura and exposed facial nerve in fallopian canal

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  Discussion Top


Brain abscess secondary to otitis media displays a bimodal age distribution with a peak in pediatrics age group and in the fourth decade. Chronic otitis media is much more likely to cause brain abscess than acute otitis media and cholesteatoma accounts for most cases. Most of the authors report that otogenic brain abscess more likely to be located in the cerebrum (temporal lobe) than in cerebellum.[1],[2],[3] On the other hand Murthy et al.[4] and Dubey and Larawin [5] found that otogenic brain abscess more frequently occurred in the cerebellum, this is inconsistent with our study. In our study, we found similar results. Most common finding was hypopneumatization of mastoid cavity present in 78%. This is inconsistent with others. Ragavoodoo et al.[6] found pneumatized mastoid in 96% cases. Cholesteatoma [Figure 5] has bone eroding property, Jackler et al.[7] and O'Donoghue et al.[8] found cholesteatoma to be present in 80% cases, using similar criteria 10 cases of cholesteatoma were found intraoperatively. Incus most common bone to be eroded, this is inconsistent with the findings of Chee and Tan.[9] Lateral semicircular canal is the most common site for the erosion leading to fistula formation between the middle ear and inner ear; this is inconsistent with the findings of Silver et al.[10] and Vanclooster et al. who reported the erosion of semicircular canal is the most common cause for fistula. Spread to the brain occurs because of bone destruction due to cholesteatoma, preformed fracture lines, a haversian system of veins, the periarterial space of Virchow–Robbins, trautmanns triangle, venous thrombophlebitis. Cerebellar spread occurs mainly through trautmanns triangle, the periarterial space of Virchow–Robbins, and retrograde venous thrombophlebitis. Mortality associated with brain abscess in the antibiotic era is on the decline. Bento et al.[11] and Migirov reported 14 cases without mortality; this was similar to our study, that is, there was no mortality. Nalbone reported that the mortality due to brain abscess varies from 7% to 61%.[12] Ludman [13] 25% brain abscess is the otogenic origin in children and 50% in adults. A tripple antibiotic regimen consisting of ceftriaxone, amikacin, and metronidazole was given for 21 days. Twenty percent of mannitol was also given in patients having raised intracranial tension. In 12 cases (1 of cerebral abscess and 11 of cerebellar abscess), aspiration of pus was done. This was followed by mastoidectomy within 10 days. Canal wall down mastoidectomy was the surgical approach of choice in our study. Modified radical mastoidectomy (MRM) with type 3 tympanoplasty was done in 10 cases, MRM with type 2 tympanoplasty in 4 cases, and radical mastoidectomy was done in 3 cases. Sigmoid sinus erosion was packed with abgel [Figure 6]. In remaining 5 cases, aspiration was not needed as abscess resolved under antibiotic cover. Cerebellar abscess has a greater likelihood of a fatal outcome. In our study, however, no permanent neurological sequelae were found. This can be further substantiated as at operation bony walls of the middle ear and mastoid cells are intact in many cases. The average period of hospital stay was 4 weeks, and postoperatively patients were followed by CT scan.
Figure 5: Erosion at siodural angle due to cholesteatoma

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Figure 6: Sigmoid sinus packed with abgel

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  Conclusion Top


Although as par various literatures temporal lobe abscess is more common, but in our study of 1-year we found that there is increased the incidence of cerebellar abscess, which is more than that of temporal lobe abscess incidence. As we know that cerebellar involvement is mainly because of venous thrombophlebitis and erosion of sinus plate. In our study, in most of the cases bony wall is intact, therefore, retrograde venous thrombophlebitis and periarterial space of Virchow–Robbins involvement seems to be an important mechanism. This becomes more predominant in acute exacerbations of chronic diseases.

A multidisciplinary approach is needed consisting of otorhinolaryngology, radiology, neurology, and neurosurgery is needed. Fortunately, the incidence is in decline.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Samuel J, Fernandes CM, Steinberg JL. Intracranial otogenic complications: A persisting problem. Laryngoscope 1986;96:272-8.  Back to cited text no. 1
    
2.
Stuart E, O'Brien F, McNally W. Some observations on brain abscess. Arch Otolaryngol Head Neck Surg 1955;104:542-3.  Back to cited text no. 2
    
3.
Samuel J, Fernandes CM, Steinberg JL. Intracranial otogenic complications: A persisting problem. Laryngoscope 1986;96:272-8.  Back to cited text no. 3
    
4.
Murthy PS, Sukumar R, Hazarika P, Rao AD, Mukulchand, Raja A. Otogenic brain abscess in childhood. Int J Pediatr Otorhinolaryngol 1991;22:9-17.  Back to cited text no. 4
    
5.
Dubey SP, Larawin V. Complications of chronic suppurative otitis media and their management. Laryngoscope 2007;117:264-7.  Back to cited text no. 5
    
6.
Ragavoodoo S, Agarwal MK, Srivastava A. A comparative study between preoperative CT scan findings and operative findings in cholesteatoma of middle ear. J Otolaryngol Head Neck Surg 2005; (Special issue 2).  Back to cited text no. 6
    
7.
Jackler RK, Dillon WP, Schindler RA. Computed tomography in suppurative ear disease: A correlation of surgical and radiographic findings. Laryngoscope 1984;94:746-52.  Back to cited text no. 7
    
8.
O'Donoghue GM, Bates GM, Anslow P. Can CT scan detect labyrinthine fi stula preoperatively. Acta Otolaryngol [Stockh] 1988;106:40-5.  Back to cited text no. 8
    
9.
Chee NW, Tan TY. The value of pre-operative high resolution CT scans in cholesteatoma surgery. Singapore Med J 2001;42:155-9.  Back to cited text no. 9
    
10.
Silver AJ, Janecka I, Wazen J, Hilal SK, Rutledge JN. Complicated cholesteatomas: CT findings in inner ear complications of middle ear cholesteatomas. Radiology 1987;164:47-51.  Back to cited text no. 10
    
11.
Bento R, de Brito R, Ribas GC. Surgical management of intracranial complications of otogenic infection. Ear Nose Throat J 2006;85:36-9.  Back to cited text no. 11
    
12.
Nalbone VP, Kuruvilla A, Gacek RR. Otogenic brain abscess: The Syracuse experience. Ear Nose Throat J 1992;71:238-42.  Back to cited text no. 12
    
13.
Ludman H. Complications of suppurative otitis media. Scott Brown's Otolaryngology. 5th edition. London: Butterworths; 1987. p. 264-91.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]



 

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Introduction
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