|Year : 2022 | Volume
| Issue : 2 | Page : 181-185
Otogenic cerebellar abscess with cholesteatoma
MK Vybhavi, V Srinivas, V Prashanth, Dechu Muddaiah, M Lavanya
Department of Otorhinolaryngology, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka, India
|Date of Submission||15-Feb-2022|
|Date of Acceptance||25-Mar-2022|
|Date of Web Publication||21-Sep-2022|
Dr. M K Vybhavi
Department of Otorhinolaryngology, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Otogenic brain abscesses are the second-most common intracranial complication observed in patients of chronic otitis media, more frequently occurring with cholesteatoma. Due to the availability of antibiotics and advanced imaging techniques, the incidence and mortality of otogenic brain abscesses has reduced. Nevertheless, we still come across cases of otogenic brain abscess in modern times. Here, we report a case of the left ear chronic otitis media, squamosal type with intracranial complication of the left cerebellar abscess in a 14-year-old girl. Magnetic resonance imaging of the brain showed a thick-walled cystic lesion in the left cerebellar hemisphere measuring 41 mm × 28 mm × 26 mm suggestive of brain abscess. High-resolution computed tomography of the temporal bone showed soft-tissue density in the left mastoid air cells, in epitympanum, and mesotympanum encasing the left middle ear ossicular chain, suggestive of chronic otomastoiditis with possible underlying cholesteatoma. The patient underwent left retromastoid suboccipital craniotomy and excision of brain abscess followed by the left modified radical mastoidectomy 1 month later. Follow-up scan at 6 months showed no recurrence or any residual disease. Hence, timely surgical intervention for complicated chronic otitis media gives satisfactory results.
Keywords: Cerebellar abscess, cholesteatoma, chronic suppurative otitis media, intracranial complications
|How to cite this article:|
Vybhavi M K, Srinivas V, Prashanth V, Muddaiah D, Lavanya M. Otogenic cerebellar abscess with cholesteatoma. Indian J Otol 2022;28:181-5
| Introduction|| |
Chronic suppurative otitis media (CSOM) is an inflammatory process of the mucoperiosteal lining of the middle ear space and mastoid, characterized by persistent drainage from the middle ear through a perforated tympanic membrane, with or without cholesteatoma. It is frequently seen in developing countries among people of low-socioeconomic strata of society. Complications secondary to chronic otitis media are more commonly seen in squamosal type along with cholesteatoma due to its bone eroding properties. Intracranial complications secondary to chronic otitis media are not unusual.
Brain abscesses are considered the second-most frequently occurring intracranial complication of chronic otitis media after meningitis. Twenty-five percent of brain abscesses in children and 50% of brain abscesses in adults are otogenic in origin. The development of antibiotics and the availability of imaging techniques have curtailed the morbidity and mortality related to otogenic brain abscesses. Early diagnosis with relevant investigations followed by appropriate surgical treatment with a multidisciplinary approach is crucial for positive outcomes. Here, we report a clinical case of the left chronic otitis media, squamosal type with intracranial complication of the left cerebellar abscess and its management and review of the literature.
| Case Report|| |
A 14-year-old girl from a rural district presented to ear, nose, throat (ENT) outpatient department (OPD) with complaints of left earache and left reduced hearing for 2 months. Previously, she had a history of left ear discharge, on and off since childhood for the past 6 years. Ear discharge was intermittent, mucopurulent in nature, nonfoul smelling, and nonblood stained. She noticed foul-smelling discharge from the left ear for 2 months. Two months back, she had developed left earache which was acute in onset, dull aching type, and was associated with fever. Two days later, she developed headache and vomiting. Headache was continuous, throbbing type and was associated with 4–5 episodes of vomiting; she also had neck pain during that time. There was no history of giddiness, loss of consciousness, seizures, and facial weakness. She consulted a local pediatrician in a nearby hospital and was advised hospitalization with brain imaging.
She underwent magnetic resonance imaging (MRI) of the brain (plain and contrast) which showed thick-walled cystic lesion in the left cerebellar hemisphere measuring 41 mm × 28 mm × 26 mm with moderate perilesional edema and wall thickness measuring 2.5 mm suggestive of brain abscess [Figure 1] and [Figure 2]. The lesion was causing mass effect over the cerebral peduncles, midbrain, and fourth ventricle. The contents of the lesion were hyperintense on T2 and hypointense on T1 with the wall showing hypointensity on T2 and hyperintense on T1-weighted images [Figure 3] and [Figure 4]. The contents showed restricted diffusion on diffusion-weighted images [Figure 5]. The lesion showed thick rim enhancement on postcontrast study. Thickening and enhancement of the tentorium were noted on the left side. A diagnosis of the left cerebellar abscess was made and she was advised to undergo immediate surgery and was referred to a higher center for neurosurgical treatment of the abscess.
|Figure 1: Magnetic resonance imaging of the brain showing left-sided cerebellar abscess in the sagittal plane|
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|Figure 2: Magnetic resonance imaging of the brain showing left-sided cerebellar abscess in axial plane|
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|Figure 3: Magnetic resonance imaging of the brain (T1 image) showing left-sided cerebellar abscess in axial plane|
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|Figure 4: Magnetic resonance imaging of the brain (T2 image) showing left-sided cerebellar abscess in axial plane|
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|Figure 5: Magnetic resonance imaging of the brain (diffusion-weighted imaging) showing left-sided cerebellar abscess in axial plane|
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Her medical records showed that she was hospitalized in a tertiary neurosurgical center where she underwent left retromastoid suboccipital craniotomy and excision of lesion 1 month ago. Whitish pearly abscess was evacuated. Patient tolerated the neurosurgical procedure well. Post-operatively, patient was conscious and oriented with vitals stable. She was also treated with antibiotics, analgesics, and antiemetics. She was referred to ENT surgeon for the management of ear complaints.
The patient presented to ENT OPD 1 month after neurosurgical treatment with complaints of left earache and left ear discharge which was scanty, purulent, foul-smelling, and nonblood stained. She also complained of the left side reduced hearing. On examination of the left ear, presence of scanty, purulent discharge was noted in the external auditory canal along with cholesteatoma flakes. The left ear tympanic membrane showed Grade 4 retraction and the scutum was eroded. Mastoid tenderness was absent. Among the tuning fork tests, Rinne's test was negative on the left side; Weber's test was lateralized to the left and absolute bone conduction test was normal. Fistula test was negative. Facial nerve examination was normal.
High-resolution computed tomography (HRCT) of the temporal bone showed soft-tissue density in the left mastoid air cells, attic area with destruction/erosion of the trabeculae, minimal fluid/soft-tissue density in epitympanum, and mesotympanum encasing the left middle ear ossicular chain, suggestive of chronic otomastoiditis with possible underlying cholesteatoma [Figure 6] and [Figure 7]. Partial erosion of the head of the malleus and the incus was noted. Pure-tone audiometry revealed mild conductive hearing loss on the left side.
|Figure 6: High-resolution computed tomography of the temporal bone showing soft-tissue density in the left middle ear and mastoid cavity|
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|Figure 7: High-resolution computed tomography of the temporal bone showing soft-tissue density in the left middle ear and mastoid cavity|
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The patient underwent left modified radical mastoidectomy through post aural approach under general anesthesia. Intraoperatively, a huge cholesteatoma sac was seen occupying the mastoid cavity, antrum, and attic area [Figure 8]. On inspection of the ossicular chain, the incus was completely eroded and the head of the malleus was found to be partially eroded. Remnant of malleus was removed to clear the disease from the anterior attic area. Following removal of cholesteatoma from the mastoid and middle ear, stapes were identified and were mobile. Tympanic segment of the facial nerve was visualized and on palpation, was found to be dehiscent. Myringostapediopexy was done followed by meatoplasty and wound closure. Postoperative recovery was uneventful. The patient was on follow-up. Repeat HRCT of the temporal bone was done at 6-month follow-up visit which showed no recurrence or residual disease [Figure 9]. No neurological sequelae were seen.
|Figure 8: Intraoperative picture showing cholesteatoma in the left mastoid cavity|
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|Figure 9: High-resolution computed tomography of the temporal bone taken postoperatively at 6-month follow-up visit showing no recurrence or residual disease|
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| Discussion|| |
Chronic otitis media is much more likely to cause brain abscess when associated with cholesteatoma in most of the cases due to its bone eroding property. The route of spread to the brain can follow venous thrombophlebitis, bone destruction due to cholesteatoma, preformed fracture lines, periarterial space of Virchow‒Robbins, and Trautmann's triangle. Based on the review of literature, otogenic brain abscesses are more likely to be located in the cerebrum (temporal lobe) than in the cerebellum. According to a systematic review of otogenic brain abscesses by Duarte et al., 55% were found in the temporal lobe and 28% were in the cerebellum. However, contradictory findings have been observed in relation to the location of brain abscess. Few authors, on the contrary, Murthy et al., Dubey and Larawin, Borgohain et al., Kurien et al., and Parmar et al. have found that otogenic brain abscess occurred more frequently in the cerebellum. Primarily, the route of spread to the cerebellum occurs through Trautmann's triangle, the periarterial space of Virchow‒Robbins, and retrograde venous thrombophlebitis.
According to the literature review, otogenic brain abscess was frequently seen in children and young adults. In a study by Vishwanathan and Naseeruddin from 2008 to 2013, higher incidence of the cerebellar abscess was reported in patients below 20 years. Based on a study by Modak et al., among 106 cases of intracranial complications, 87% were below 20 years. A systematic review by Duarte et al. showed that most of the patients with otogenic brain abscesses were pediatric patients. The various reasons for the occurrence of complications in young patients could be a delay in the diagnosis due to miscommunication by the child or as a result of the nature of the disease since cholesteatoma can erode the soft bone. Another reason could be misconception and lack of awareness leading to delay in surgical treatment with cholesteatoma going unnoticed for many years.
Previous studies have mentioned the prevalence of cholesteatoma in patients with otogenic brain abscess to be ranging from 21% to 100%., According to Jackler et al. and O'Donoghue et al., cholesteatoma was detected in 80% of cases. A study by Kangsanarak et al. and Kurien et al. demonstrated cholesteatoma in 100% of patients. Incus was the most common bone to be eroded. The most frequent presenting symptoms constitute chronic ear discharge, decreased hearing, fever, headache, nausea, vomiting, and altered mental status. Brain abscess is a serious clinical condition which may result in severe morbidity and mortality without prompt diagnosis. Appropriate investigations and early treatment should be made in every patient suspicious of otogenic brain abscess.
The availability of advanced imaging techniques has helped in early and improved diagnosis of complications. HRCT is a reliable diagnostic approach for evaluating CSOM with complications. MRI is the imaging modality of choice for locating otogenic brain abscesses. If an abscess is detected on imaging, neurosurgical, and otolaryngology consultations are required for deciding early surgical treatment. The treatment of otogenic brain abscess consists of intravenous antibiotics and surgical intervention. The duration of antibiotic treatment for brain abscess requires at least 4 weeks.
Neurosurgical treatment of the abscess is suggested for lesions 2.5 cm or larger. In case of superficial brain abscesses, encapsulated abscesses, or abscesses of the cerebellum, removal of the abscess through excision is the preferred surgical technique.,, Depending on availability, convenience, and patient stability, coordination and cooperation between otology and neurosurgical teams are important in the treatment of otogenic abscesses where source control must be attained through mastoidectomy, in a single staged or delayed fashion. The surgical procedure preferred for cholesteatomatous ears in cases involving otogenic brain abscess is modified radical mastoidectomy or radical mastoidectomy depending on the extension of disease.
Oftentimes, patients with intracranial complications secondary to chronic otitis media are generally referred from other departments and do not primarily present to ENT, suggesting circumstances that the treatment was obtained for the complication and not for chronic otitis media. Delay in seeking surgical treatment of chronic otitis media is the major reason for patients developing complications. Lack of awareness that chronic otitis media is a disease that can result in life-threatening complications leads to delay and postponement of surgery. Hence, the patients should be educated and sensitized in regard to the dangerous clinical features of complicated chronic otitis media and motivated to seek early surgical treatment.
| Conclusion|| |
Otogenic brain abscess as an intracranial complication of CSOM continues to occur despite the availability of modern antibiotics and advanced imaging modalities. However, incidence and mortality associated with it have decreased over the years. We must create awareness among people regarding the importance of early surgical treatment for chronic otitis media as delay in surgery can lead to complications. Early diagnosis of otogenic brain abscess and prompt treatment for the same followed by canal wall down mastoidectomy for source control in the ear gives fairly good results.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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