International Journal of Pediatric Otorhinolaryngology Extra
Volume 5, Issue 1 , Pages 32-38, January 2010

Bilateral concurrent mastoidectomy: A rare indication in the treatment of otitis media

ENT Department, Victoria Hospital, Bangalore Medical College & Research Institute, # 716, 10th Cross, 5th Main, M.C. Layout, Vijayangar, Bangalore - 560 040, Karnataka, India

Received 4 January 2009; received in revised form 13 January 2009; accepted 14 January 2009. published online 24 February 2009.

Article Outline

Summary 

A 12 years old female patient who had bilateral attico antral type of ear disease and intracranial complication was brought to tertiary care centre for further management. Initially patient had unilateral intracranial complications and later developed intracranial complications on the opposite side. Patient was first treated for neurological complications and later bilateral concurrent mastoidectomy was done to eradicate the source of infection and to prevent further complications due to bilateral ear disease. Patient recovered well and patient was free from any problem during follow up period of 1 year.

Bilateral complications occurring simultaneously in a patient are not reported in the literature.

Keywords: Otitis media, Mastoidectomy, Intracranial complications, Management

 

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1. Introduction 

The complications of chronic otitis media are divided into intracranial and extracranial complications. Extracranial complications are further divided in to extratemporal and intratemporal complications [1].

The occurrence of chronic suppurative otitis media and its complications have reduced considerably with the use of better antibiotics [2]. Despite the advent of antibiotics and advancement in our knowledge and skills in managing otitis media, serious complications still exist. The probable reason why these complications are still encountered may be related to the ignorance about the seriousness of persistent and sometimes offensive ear discharge. However, in the developing countries, these infections still are major challenges with respect to diagnosis and management [2]. They can be lethal if they are not identified and treated properly [1].

Bilateral complication occurring simultaneously in a patient is not reported in the literature. Here a case of bilateral attico antral otitis media with bilateral complication is reported along with the review of literature.

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2. Case report 

A 12 years old female patient, who had continuous bilateral ear discharge for the past 5 years, was referred from a rural hospital for the management of fever and headache which she had for the past 15 days. She was treated with parentaral antibiotics at the rural hospital. Patient had no relief from fever, head ache and developed left facial nerve palsy and blurring of vision. Hence she was referred to tertiary care centre.

On examination patient was febrile. Bilateral mucopurulent foul smelling scanty ear discharge was present. In both the ears middle ear was filled with granulations and tympanic membrane was not seen. Over the left mastoid area tenderness was present. Cerebellar signs were positive. Left facial nerve was paralyzed (Figure 1). CT scan showed cerebellar abscess on the left side (Figure 2). Bilaterally ossicles were destroyed and both mastoids were sclerotic. Ventricles were dilated (Figure 3). Ear pus culture showed pseudomonas aeruginosa and proteus organisms. Cerebrospinal fluid pressure was high. Fundoscopic examination showed papilloedema.

Through left retro sigmoid craniectomy approach cerebellar abscess was drained (Figure 4) and patient was medically treated for elevated cerebrospinal fluid pressure. There was no improvement in patient's condition and cerebrospinal fluid pressure was not controlled satisfactorily with medical therapy. Patient underwent ventriculo peritoneal shunt procedure (Figure 5, Figure 6) and cerebrospinal fluid pressure was reduced. As patient had intermittent pyrexia, repeat CT scan and MRI scans were done. Patient had recollection in the left cerebellum and MRI showed an evolving abscess near the right petrous apex and features of mastoiditis on the right site (Figure 7). Cerebellar abscess was aspirated again.

Patient had septic focus in tympanomastoid region on both the sides. Decision was taken to do concurrent bilateral mastoidectomy under general anesthesia. On the left side middle ear and mastoid were filled with cholesteatoma and granulation. Left fallopian canal was eroded by the cholesteatoma and facial nerve was exposed. All the ossicles were eroded and only foot plate of stapes was present. Right middle ear and mastoid were filled with granulation and cholesteatoma. Except for stapes foot plate all the ossicles were eroded. As there was extensive cholesteatoma on both the sides with bilateral complications, radical mastoidectomy was done on both the sides (Figure 8).

Patient's condition started improving after 24h. Patient was given broad spectrum antibiotics for 3 weeks. At the first month of follow up, patient's facial nerve had recovered completely and vision was normal. Both mastoid cavities were free from discharge. Otoscopic examination at the third month showed well epithelialised mastoid cavity on both the sides. Patient was free from any problem during follow up period of 1 year.

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3. Discussion 

The proximity of the middle ear cleft and mastoid air cells to the intratemporal and intracranial compartments places structures located in these areas at increased risk of infectious complications [1].

In the pre antibiotic era, intracranial complications secondary to ear disease occurred in 2.3–6.4% of cases. Once a patient developed an intracranial complication such as brain abscess, mortality rates as high as 75% were commonly reported. With the introduction of antibiotics, sophisticated imaging techniques, and new, more refined surgical techniques, intracranial complication rates have been reduced to 0.04–0.15% [3]. Even in the 21st century, otogenic brain abscess is still reported as a life threatening complication [4]. The development and appropriate use of antibiotics have led to a decrease in these potentially devastating complications. However, they continue to occur and clinical vigilance is required to early detection and treatment. Further more, with the continued development of multi drug resistant pathogens, these complications may become more prevalent as over current antibiotics becomes less effective [1], [5].

There are many reports of multiple intracranial complications and concurrent intracranial complications and extracranial complications of chronic otitis media. But all the reported cases had unilateral complications [2], [6], [7].

In the present case patient had brain abscess, otitic hydrocephalus, facial palsy and evolving abscess near the petrous apex. In the present case patient had bilateral complications as a result of bilateral attico antral disease.

In a large series by Osama et al. [8], 78% of subjects who had complications secondary to chronic otitis media found to have cholesteatoma [1]. In study of otogenic intracranial abscess by Kurien et al. 100% of their patients had cholesteatoma [9].

In the present case also patient had cholesteatoma on both the sides.

Brain abscess is the second most intracranial complication of otitis media after meningitis, but it perhaps the most lethal and they almost exclusively result from chronic otitis media. Brain abscesses are located on the same side as the diseased ear. The temporal lobe and cerebellum are the two locations for otogenic brain abscess. Cultures from these abscesses are often sterile [10].

Our patient had cerebellar abscess and culture from the abscess was sterile.

Murthy et al. [11] are of the opinion that cerebellar abscess is more common in children and cerebellar abscess was 4 times more common than temporal lobe abscess. A study of otogenic intracranial abscess by Kurien et al. [9] showed that cerebellar abscess was the most common intracranial abscess.

For brain abscess MRI is superior. Although MRI gives better details regarding the abscess itself, a CT scan gives valuable information about bony erosion of the mastoid, and can help in determining the cause of the abscess and the most appropriate treatment options [1]. Imaging is required to rule out concomitant intracranial complications, or evidence of increased intracranial pressure [1].

Otogenic brain abscesses due to otitis media are usually located adjacent to temporal bone [6]. In the present case also, CT scan showed cerebellar abscess adjacent to the temporal bone and showed evidence of raised intracranial tension. MRI showed an evolving abscess near the right petrous apex.

The presenting symptoms and signs of intracranial complications found in this study were malodorous otorrhea, headache, otalgia, spiking fever, vertigo, and vomiting [3].

In the present case patient had otorrhea, headache and continuous low grade fever. Before coming to our hospital patient had received antibiotic treatment at a rural hospital. Previous antibiotics therapies are known to cause change in presentation of intracranial complications.

The high mortality rates associated with the intracranial complications of otitis media, particularly brain abscesses are undoubtedly the reason why definitive surgical intervention is advocated [3].

Otitic hydrocephalus is described as signs and symptoms indicative of increased intracranial pressure with normal cerebrospinal fluid studies on lumbar puncture, which can present as a complication of acute otitis media, chronic otitis media, or otologic surgery [1].

Otitic hydrocephalus is a rare complication of otitis media [12], [13]. It is commonly associated with lateral sinus thrombophlebitis; however, not all patients with sigmoid sinus thrombophlebitis develop otitic hydrocephalus [14]. Cases have been reported without thrombosis of the dural sinuses [1].

The clinical picture is very consistent; the patient has the sign of raised intracranial pressure; headache, drowsiness, vomiting, blurring of vision, and diplopia [14], [15]. Papilloedema and ipsilateral abducent palsy are usually evident. Optic atrophy can eventually develop [14].

In the present case patient never had a classical picture of otitic hydrocephalus and she had only headache, blurring of vision and papilloedema. This case did not have any lateral sinus infection.

The petrous apex comprises the anterior, medial portion of the temporal bone, and has been reported to be pneumatised in 30% of the individuals [1]. These air cells communicate with the middle ear cleft. They are thought to be the route of infection from the middle ear, which lead to the development of petrous apicitis [16]. The infectious agents most commonly responsible for petrous apicitis are staphylococcus aureus and pseudomonas aeruginosa [5], [17].

In the present case also ear swab culture showed pseudomonas aeruginosa and proteus organisms.

Petrous apicitis is a spectrum of disease and can involve anything from an asymptomatic effusion to coalescence and abscess formation. Infection of the petrous apex is a dangerous entity because of its proximity to the middle and posterior cranial fossa and their contents [1]. Petrous apicitis becomes evident only after failure to control chronic suppurative otomastoiditis with prolonged medical and surgical treatment [1].

In the present case also patient had an evolving abscess near the petrous apex and it became evident at a later stage..

Chronic otitis media with or without cholesteatoma can result in facial paralysis through involvement of a dehiscent nerve, or through bone erosion [1]. Chronic otitis media causing facial nerve paralysis is most frequently due to cholesteatoma [18]. The usual mechanism of facial nerve paralysis due to cholesteatoma has been suggested to be direct pressure on the nerve [18], [19]. Djeric and Savic [20] are of the opinion that facial nerve paralysis occurs when the inflammatory process specifically involves the facial nerve trunk.

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4. Treatment 

Once the diagnosis of brain abscess is made, surgical intervention is the treatment and a mastoidectomy is required to eradicate the source of infection. Patient must be stabilized before neurosurgical intervention. Immediate initiation of broad spectrum antibiotics that cover gram positives, gram negatives, and anaerobes is necessary because of the severity of the infection and its poly-microbial nature [1].

In suppurative with intracranial complications, it is accepted practice to treat the neurological complication first, followed by mastoidectomy at a later date after the patient has been stabilized [9].

Abscess is drained either through an open craniotomy with drainage or excision, or by steriotatic aspiration through a burr hole. This procedure not only drains the abscess, but provides culture, enabling antibiotics therapy to be tailored. Drainage should be performed within 24h of presentation, if the patient is stable [1].

There are conflicting reports in the literature on how to prioritize the treatment of patients with brain abscess secondary to otologic disease. Some authors recommend that intracranial surgery should be done first and otologic surgery should be scheduled several days to several weeks later [10].

Murthy et al. [11] stated that first neurosurgical drainage and later ear operation should be done. Macky et al. [3] recommended that treatment of ear disease be performed at the same time as drainage of the brain abscess. By doing this, the necessity for a second operation can be avoided, and the infected ear can be eliminated as a source of intracranial sepsis, thus preventing further seeding of organisms to the brain.

According to Kurien et al. [9], craniotomy with concurrent mastoidectomy is not only safe, but also removes the source of infection at the same time the complication is being treated, thus avoiding reinfection while the patient is awaiting the ear surgery. In addition, the treatment is completed in single, shorter stay, which is economical for the patient.

In the present case patient was first treated for cerebellar abscess and otitic hydrocephalus. Later she also developed an evolving abscess near the opposite side petrous apex. As the patient had bilateral complications concurrent mastoidectomy was done to remove the source of infection from both the sides.

Current recommendations, however, are to perform a mastoidectomy at the time of abscess drainage to remove the infectious focus, assuming the patient is stable enough to tolerate this additional surgery. Regardless the type of surgical intervention, intravenous antibiotics should be continued for several weeks, and CT scan with contrast followed to assure resolution of the abscess [1].

The aims of otitic hydrocephalus treatment are to eradicate any underlying ear disease, to decrease the intracranial pressure and to prevent the potentially devastating complication of optic nerve atrophy [1].

Medical therapy includes acetazolamide, mannitol, diuretics and corticosteroids to decrease intracranial pressure and cerebral edema [1], [14]. If aggressive medical treatment does not normalize the intracranial pressure, lumbar drainage of cerebrospinal fluid pressure can be performed serially or by a lumbar drain. If prolonged drainage is required because of recalcitrant papilloedema, a shunt may be required [1]. Some authors recommend optic nerve decompression [4]. The mechanism by which optic nerve sheath fenestration helps is by reducing the transmitted pressure on the optic nerve. The cerebrospinal fluid pressure is reduced locally over the nerve, and the vision improves and does not deteriorate further [21].

In the present case cerebrospinal fluid pressure was not satisfactorily controlled by medical therapy and patient underwent ventriculo peritoneal shunt procedure.

When facial paralysis is associated with cholesteatoma, a mastoidectomy is performed to remove the cholesteatoma or granulation tissue that is contacting the facial nerve. If there is no nerve sheath involvement, it need not be incised [1]. Minoru et al. [18] in their study on facial paralysis due to middle ear cholesteatoma found that treatment outcome is good.

In the present case cholesteatoma had eroded the fallopian canal and nerve sheath was not involved. Facial nerve recovered completely at the end of 1 month.

Before the wide spread use of antibiotics, surgical intervention for petrous apex abscess and petrous apicitis was relatively common. Because of the difficult surgical approach and response rate to antibiotics, intravenous antibiotics are often the first line of treatment for petrous apicitis [1]. Surgical debridement is reserved for those patients unresponsive to intravenous antibiotics [16].

In the present case patient showed dramatic improvement with after removal of septic foci from the mastoid and resolved completely with intravenous antibiotics therapy.

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5. Conclusions 

Otological complications are still a major problem in developing countries. This is due to lack of public health awareness and inadequate facilities in the rural areas. Otitis media with multiple complications pose a big challenge to the treating physicians. Early diagnosis and timely surgical interventions are essential for good results.

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References 

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PII: S1871-4048(09)00008-2

doi:10.1016/j.pedex.2009.01.004

International Journal of Pediatric Otorhinolaryngology Extra
Volume 5, Issue 1 , Pages 32-38, January 2010

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