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Year : 2017  |  Volume : 23  |  Issue : 2  |  Page : 121-124

Enterococcus brain abscess with lateral sinus thrombophlebitis as a complication of chronic otitis media

Department of Otolaryngology and HNS (ENT), AIIMS, Rishikesh, Uttarakhand, India

Date of Web Publication14-Jun-2017

Correspondence Address:
Manu Malhotra
Department of Otolaryngology and HNS (ENT), AIIMS, Veerbhadra Marg, Rishikesh, Uttarakhand - 240 201
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-7749.208018

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With widespread use of antibiotics, the occurrence of brain abscess and lateral sinus thrombosis together is rare these days, especially with enterococcus as the causative organism. We here present a case of pediatric case of brain abscess and lateral sinus thrombosis which developed an additional complication of postoperative cerebrospinal fluid leakage. The case was successfully treated by excision of the abscess, canal wall down mastoidectomy with partial obliteration of cavity, and Type III tympanoplasty with umbrella graft.

Keywords: Brain abscess, chronic otitis media, complications, lateral sinus thrombophlebitis

How to cite this article:
Malhotra M, Gupta S, Varshney S, Joshi P, Malhotra R. Enterococcus brain abscess with lateral sinus thrombophlebitis as a complication of chronic otitis media. Indian J Otol 2017;23:121-4

How to cite this URL:
Malhotra M, Gupta S, Varshney S, Joshi P, Malhotra R. Enterococcus brain abscess with lateral sinus thrombophlebitis as a complication of chronic otitis media. Indian J Otol [serial online] 2017 [cited 2020 Aug 13];23:121-4. Available from: http://www.indianjotol.org/text.asp?2017/23/2/121/208018

  Introduction Top

Chronic otitis media (COM) is a leading cause of health care visits to an otologist. Its incidence rate has been reported as 4.76%, which means about 31 million cases worldwide. Each year 21,000 people die due to complications of COM.[1],[2] The disease is potentially serious because of its capacity to develop extra- and intra-cranial complications, whose incidence has come down from 2.3%–4% to 0.15%–0.04% with the widespread use of antibiotics.[3] After meningitis, brain abscesses (BAs) represent the second most common intracranial complication of COM followed by lateral sinus thrombophlebitis (LST).[4] BA is a focal, intracerebral infection that develops into a collection of pus surrounded by well-vascularized capsule, can evolve rapidly, causing a devastating outcomes.[5] LST may be associated with septic cardiomyopathy, acute respiratory distress syndrome, anacusis, and seizures.[6] Although both of the complications have been reported separately several times in literature, their simultaneous occurrence is rare in postantibiotic era.

We here report a rare case of COM with large otogenic temporal lobe abscess and LST.

An 11-year-old female patient presented in outpatient department, with the chief complaint of fever with chills, right-sided earache for 15 days. She had decreased hearing with recurrent, purulent, foul smelling, and scanty ear discharge since early childhood. These symptoms were accompanied by 2–3 episodes of vomiting in the last 15 days. There was no history of swelling in neck, facial asymmetry, blurring of vision, neck rigidity, seizures, loss of consciousness, and weakness of limbs. Patient's left ear was operated in same department 2 years earlier, for squamous variety of COM and had recovered well with dry cavity. In general examination, the patient appeared drowsy and irritable though she was oriented to time, place, and person. Vital parameters such as pulse and respiratory rate were within normal range although temperature fluctuated between 98°and 101°F. On otoscopy of the right ear, a bulge in posterosuperior canal wall skin and a retraction in posterior half of pars flaccida with pus discharge and cholesteatoma were seen [Figure 1]. There was tenderness present in cymba concha and postaural region, which was also edematous (Griesinger's sign). Mild papilledema was present in fundus of ipsilateral eye. On suspicion of impending complications, a cocktail regime of intravenous antibiotics (co-amoxiclav, garamycin, and metronidazole) was started. Hematology revealed macrocytic anemia with 8 g % hemoglobin. A high-resolution computed tomography (CT) scan of temporal bone was done which revealed clouding of mastoid antrum and middle ear space, dissolution of septa of air cells, erosion of ossicles and dural plate was seen [Figure 2]. Contrast-enhanced magnetic resonance imaging (MRI) scan revealed encapsulated right temporal lobe space occupying lesion (abscess) in temporal lobe shifting the midline and compressing the ventricle [Figure 3]. Venogram revealed blockage of drainage through sigmoid sinus [Figure 4]. The patient was operated by a team of a neurosurgeon and an otologist. Emergency burr hole drainage of abscess was done, about 30 ml pus was aspirated and sent for culture sensitivity. In the same sitting, canal wall down mastoidectomy was performed. The cholesteatoma was seen in attic, aditus, and antrum. Scutum, posterior canal wall, and a part of sinus plate were also found to be eroded. About 2.5 ml of thick pus and thrombus was aspirated from lateral sinus with a wide gauge needle, which was followed by free blood flow. All ossicles were found to be absent. Autologous total ossicular replacement prosthesis or umbrella graft [7] was prepared using cortical bone and placed over stapes footplate. Inferiorly based osteoperiosteal flap was used for partial obliteration of the mastoid cavity which was finally covered with temporalis fascia. The patient recovered well in the wards though a little torticollis was noted and her head was turned to right side.
Figure 1: Right ear otoscopy showing a bulge in posterosuperior canal wall skin and a retraction in posterior half of pars flaccida with pus discharge and cholesteatoma

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Figure 2: (a) Computed tomography scan of temporal bone showing clouding of mastoid antrum and middle ear space, dissolution of septa of air cells, erosion of ossicles and dural plate was seen (thick white arrow); (b) Pneumocephalus

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Figure 3: Magnetic resonance imaging scan showing encapsulated right temporal lobe space occupying lesion in temporal lobe shifting the midline and compressing the ventricle

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Figure 4: Venogram showing blocked sigmoid sinus on right side

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Enterococcus species was the organism isolated from pus culture which was sensitive to vancomycin and ceftriaxone, which were continued for 1 week along with oral epileptics. After 1 week, repeat CT of head revealed mature abscess in the right temporal lobe region. Furthermore, the patient again started having complaint of high-grade fever and vomiting. Patient became drowsy and irritable. Hence, right temporoparietal craniotomy with complete excision of brain abscess was performed. Unfortunately, the patient also developed postoperative cerebrospinal fluid (CSF) otorrhea which did not stop even when ventricular drain was put to decrease CSF pressure. Repeat CT scan with three-dimensional reconstruction was performed which showed defects in sinus plate and dural plate as probable cause of leakage. CT scan also revealed slight subluxation of atlanto-occipital joint which was the probable cause of postoperative torticollis [Figure 5]. Reexploration of the wound was done and leakage site was found where dural mesh was used to repair the dural defect formed after excision of abscess. The site was repaired with double reinforcement (inlay and onlay) of fascia lata sutured to the edges of defect. The patient was kept in left lateral position and neck was maintained in neutral position with a pillow to avoid dislocation of cervical joints. Postoperative period was uneventful and the gentle cervical traction was used to restore subluxated cervical joints. Patient was discharged in a stable condition with no neurological defects after 3 weeks after a repeat CT scan [Figure 6]. Four weeks after surgery, the operated cavity was cleaned and pure tone audiogram was performed which showed 15 dB average gain in hearing.
Figure 5: Three-dimensional reconstruction of computed tomography scan showing postoperative holes in temporal bones

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Figure 6: Computed tomography scan before discharge showing craniotomy site and no brain abscess

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  Discussion Top

Otogenic BAs are often located adjacent to the temporal lobe and cerebellum. The infection spreads intracranially through bony defects in the tegmen tympani or Trautmann's triangle or through spread of an infected clot within small emissary veins of the skull to the venous sinuses.[8],[9] The most common organisms causing otogenic BA source include Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae,  Escherichia More Details coli, Proteus, and Pseudomonas species. Very few studies have reported Enterococcus species as one of the causative agents of BAs in India. Kurien et al. reported Enterococcus faecalis as one of the causative agents of BAs in India.[10] In the year 2002, Park et al. reported a case of otogenic brain abscess due to Enterococcus faecium.[11]

LST occurs due to the propagation of infection from the small venules of the mastoid to the sigmoid sinus. Spread could also result directly from bone erosion be coalescent mastoiditis or cholesteatoma. Subsequently, adherence of fibrina, blood cells, and platelets can produce a mural thrombus. At least two clinical pictures, related to LST, are described: the septic form and the aseptic form. The first is associated with clear signs of mastoiditis and is rarely complicated by cerebral abscess. The aseptic form is often associated with endocranic hypertension and ocular signs. In LST anaerobic organisms, Proteus spp., Pseudomonas aeruginosa, beta-hemolytic Streptococcus, and S. aureus have been reported as causative agents while in one-third of patients, no germs could be found.[6] The case described is of the first clinical type. The most important clinical feature of picket fence pattern of fever was, however, not present.

In the case under discussion, CT scan facilitated the diagnosis of a brain abscess associated with underlying ear disease while a subsequent MRI (T1 and T2 images) with venogram provided additional information regarding the location of the abscess, the degree of mass effect, the presence of a midline shift, and blockage of lateral sinus. The organism isolated was Enterococcus which is a rare species to be isolated with otogenic BA.

The treatment of LST as complication of COM is mastoid exploration with exposure of the sinus with removal of the clot or abscess while BA is removed by burr hole or craniotomy and excision. Use of anticoagulants in LST is controversial as some authors find it unnecessary fearing rupture of the thrombus and septic dissemination.[6],[11]

The case discussed was unique because of four reasons: first, LST and a large BA occurred simultaneously without any prominent neurological and systemic feature of the same; second, the organism isolated was enterococcus; third, partial mastoid obliteration with Type III tympanoplasty was successfully attempted in the same stage; four, there was an additional postoperative complication of CSF leakage.

  Conclusion Top

Although incidence of intracranial complications has declined, we need to maintain high index of suspicion in the patients with COM. Prompt antibiotic coverage and surgical removal of disease can avert serious morbidity and mortality associated with the disease. Partial obliteration of cavity with osteoperiosteal flap and autologous total ossicular replacement can be considered if the surgeon is certain of total eradication of disease.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Chronic Suppurative Otitis Media Burden of Illness and Management Options. Available from: http://www.who.int/pbd/publications/Chronicsuppurativeotitis_media.pdf. [Last accessed on 2016 Dec 26].  Back to cited text no. 1
Monasta L, Ronfani L, Marchetti F, Montico M, Vecchi Brumatti L, Bavcar A, et al. Burden of disease caused by otitis media: Systematic review and global estimates. PLoS One 2012;7:e36226.  Back to cited text no. 2
Sharma N, Jaiswal AA, Banerjee PK, Garg AK. Complications of chronic suppurative otitis media and their management: A single institution 12 years experience. Indian J Otolaryngol Head Neck Surg 2015;67:353-60.  Back to cited text no. 3
Miranda JA, Martins LL, Borges MH, Solcia Filho N, Mendes Ede A. Lateral sinus thrombosis and brain abscess as a complication of cholesteatoma. Braz J Otorhinolaryngol 2009;75:159.  Back to cited text no. 4
Lee TH, Chang WN, Su TM, Chang HW, Lui CC, Ho JT, et al. Clinical features and predictive factors of intraventricular rupture in patients who have bacterial brain abscesses. J Neurol Neurosurg Psychiatry 2007;78:303-9.  Back to cited text no. 5
Bianchini C, Aimoni C, Ceruti S, Grasso DL, Martini A. Lateral sinus thrombosis as a complication of acute mastoiditis. Acta Otorhinolaryngol Ital 2008;28:30-3.  Back to cited text no. 6
Malhotra M, Varshney S, Malhotra R. Cortical bone total ossicular replacement prosthesis. Indian J Otol 2014;20:173.  Back to cited text no. 7
  [Full text]  
Osma U, Cureoglu S, Hosoglu S. The complications of chronic otitis media: Report of 93 cases. J Laryngol Otol 2000;114:97-100.  Back to cited text no. 8
Penido Nde O, Borin A, Iha LC, Suguri VM, Onishi E, Fukuda Y, et al. Intracranial complications of otitis media: 15 years of experience in 33 patients. Otolaryngol Head Neck Surg 2005;132:37-42.  Back to cited text no. 9
Kurien M, Job A, Mathew J, Chandy M. Otogenic intracranial abscess: Concurrent craniotomy and mastoidectomy – Changing trends in a developing country. Arch Otolaryngol Head Neck Surg 1998;124:1353-6.  Back to cited text no. 10
Park SY, Min JH, Ryu JW, Ko YS. Enterococcal otogenic brain abscess. Korean J Otolaryngol Head Neck Surg 2002;45:1188-92.  Back to cited text no. 11


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


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