Transmastoid and Transtemporal Drainage of Petrous Apicitis with Otitis Media.

BACKGROUND: Petrous apicitis (PA) is a serious infection involving the apical portion of the petrous temporal bone. The classic triad of purulent otorrhea, ipsilateral abducens nerve palsy and retroorbital pain is rarely seen due to early detection and widespread use of antibiotics. Medical management is the primary treatment modality with surgery reserved for cases of recalcitrant petrous apex abscess. METHODS AND RESULTS: We presented a case of PA with previously untreated otitis media. After multidisciplinary evaluation, the patient was initially treated with intravenous antibiotics followed by drainage of the abscess using a combined transmastoid and middle cranial fossa (MCF) approach. The patient recovered well with no recurrence of the infection based on imaging and symptoms. DISCUSSION: While a variety of different surgical approaches can be used in treatment of PA, we recommend the MCF approach in cases where access to the anterior petrous apex may be challenging via transcanal or transmastoid approach.

Tuberculous otitis media with osteomyelitis of the regional craniofacial bones.

Tuberculosis is an uncommon cause of chronic suppurative otitis media. Delay in diagnosis can lead to delayed treatment, resulting in significant complications. We describe a case of tuberculous otitis media with osteomyelitis of the craniofacial bones in a 44-year-old woman with chronic painless suppurative otorrhea, not responding to antibiotics, hearing loss, and facial palsy. Chest X-ray was normal. Computed tomography of the temporal bone showed the destruction of the left zygomatic bone, clivus, and petrous part of the temporal bone. Polymerase chain reaction was positive for Mycobacterium tuberculosis (MTB), and histopathological findings showed caseous necrotizing tissues. Sputum culture was negative for MTB. The patient was successfully treated with surgery and anti-tuberculosis drugs. The polymerase chain reaction is a sensitive, rapid diagnostic tool used to diagnose TB. Surgical approaches and operative biopsy should be considered when the cause of the chronic purulent discharge is still unknown.

Implantation of bone-anchored hearing device using a three-dimensional template in a child.

BACKGROUND: Implantation of bone-anchored hearing devices is performed to improve hearing in patients with chronic suppurative otitis media who cannot wear a conventional hearing aid. The surgical procedure can be safely performed in children aged over five years. CASE REPORT: A 15-year-old patient with bilateral chronic suppurative otitis media and conductive hearing loss underwent the procedure to implant a bone-anchored hearing device but was found to have skull thickness of less than 2.5 mm and the procedure was abandoned. A computed tomography scan of the skull was undertaken and a three-dimensional template was reconstructed to identify appropriate thickness of the skull to implant the abutment during a second procedure. CONCLUSION: Bone-anchored hearing devices can be implanted by prior imaging and using a template to identify the area of appropriate skull thickness to implant the abutment safely.

The Value of Diffusion-Weighted MRI in the Long-term follow-up After Subtotal Petrosectomy for Extensive Cholesteatoma and Chronic Suppurative Otitis Media.

OBJECTIVE: To report the long-term follow-up with diffusion-weighted magnetic resonance imaging (DW MRI) after subtotal petrosectomy (SP) with blind sac closure of the external auditory canal for extensive cholesteatoma and chronic suppurative otitis media. STUDY DESIGN: Retrospective clinical record study. SETTING: Tertiary referral center. PATIENTS: Thirty-one patients (31 ears) with extensive cholesteatoma and 17 patients (19 ears) with chronic suppurative otitis media without cholesteatoma who underwent SP between July 1995 and December 2015. INTERVENTIONS: All 48 patients were followed clinically and with DW MRI to rule out residual cholesteatoma. MAIN OUTCOME MEASURE: Residual cholesteatoma, indicated by a marked hyperintensity on non-echoplanar (non-EP) DW MRI. RESULTS: In the cholesteatoma group the mean interval between surgery and the latest DW MRI was 3.9 years. Seven patients presented with a residual cholesteatoma pearl. The mean interval between surgery and detection of residual disease was 3.7 years. In the chronic suppurative otitis media group the mean interval between surgery and the latest DW MRI was 5.3 years. Residual cholesteatoma was found in three patients. Mean interval between surgery and the detection of disease was 4.5 years. CONCLUSIONS: This study shows the importance of DW MRI in the follow-up after SP for cholesteatoma and chronic suppurative otitis media. A little higher residual cholesteatoma rate was found compared with earlier studies, where patients were followed only clinically. One may wonder whether reintervention is always needed or whether in selected cases with small pearls, one may still observe these by a watchful waiting policy with DW MRI.

A case of multiple empyema caused by Streptococcus intermedius.

We report the case of a patient with multiple empyema present throughout his body, including chronic sinusitis and chronic suppurative otitis media, as well as subsequent epidural empyema, all caused by Streptococcus intermedius. A 38-year-old man presented with chief complaints of headache, left ear discharge, and nasal congestion. Imaging studies revealed pansinusitis, soft tissue signs in the mastoid cells, and otitis media. The patient was treated with meropenem hydrate, 6g/day. While clinical findings indicated improvement of the sinusitis, his headache did not improve. Further examination with contrast computerized tomography (CT) 'a chest radiography' blood cultures were performed, and the patient was diagnosed with multiple empyema (with an epidural empyema, pulmonary suppuration) caused by S. intermedius. Subsequent burr hole drainage was implemented to drain the epidural empyema. Long-term administration was required to treat pulmonary suppuration. While they remain rare, there has been a recent upward trend in the frequency of cases in which a young, previously healthy patient has developed multiple empyema throughout their body despite the absence of complicating diseases that pose an immune deficiency risk, such as diabetes or infection with the human immunodeficiency virus (HIV). In order to properly diagnose and treat patients presenting with multiple empyema infection with S. intermedius should be included in the differential diagnosis.

The evaluation of eustachian tube paratubal structures using magnetic resonance imaging in patients with chronic suppurative otitis media.

Conclusion Eustachian tube (ET) dysfunction, which plays a role in the pathogenesis chronic suppurative otitis media (CSOM), does not seem to be due to differences in paratubal structures. Objective The aim of this study was to compare the magnetic resonance imaging (MRI) findings of the paratubal structures of the ET between normal ears and ears in patients with CSOM. Methods The MRI records of 40 patients who underwent tympanomastoidectomy for a diagnosis of CSOM were reviewed retrospectively. The healthy ears served as the control group. The length, diameter, surface area and volume of the tensor veli palatini muscle (TVPM) and levator veli palatini muscle (LVPM) were measured, in addition to the diameter of the pharyngeal orifice of the ET, volume of the Ostmann fat pad, bimucosal thickness of the lumen of the ET, and mucosal thickness. Results In the pathological ears, the mean length of the TVPM and LVPM was 22.6 mm and 19.3 mm, the mean diameter was 3.2 and 5.3 mm, and the mean volume was 1.75 and 3.2 cm(3), respectively. In addition, the mean diameter of the pharyngeal orifice of the ET was 1.9 mm. There were no significant between-group differences in the paratubal structures (p > 0.05).

Radiologic and surgical findings in chronic suppurative otitis media.

Our aim in this study was to evaluate the efficiency of preoperative temporal bone computed tomography (CT) in detecting pathologic conditions in patients with chronic suppurative otitis media (CSOM). The intraoperative findings and temporal bone CT results of 350 patients who were diagnosed with CSOM between September 1, 2010, and June 1, 2013, were compared. Comparison parameters were as follows: the presence of cholesteatoma, erosion of the outer ear bone canal, erosion of the middle ear chain, erosion of the dural plate, erosion of the lateral semicircular canal, erosion of the sigmoid sinus wall, and dehiscence of the facial canal. The contribution of CT was limited in showing the outer ear canal destruction, dural plate destruction, facial canal destruction, lateral semicircular canal destruction, and destruction of the sigmoid sinus wall. However, CT was more sensitive in detecting cholesteatoma and erosion of the ossicular chain. These results indicate that preoperative CT of patients with CSOM serves as an important guide for otolaryngologists, although there are limitations in the evaluation of the CT results.

[The use of cone beam computed tomography for diagnostics of chronic suppurative otitis media].

The objective of the present study was to estimate the potential of cone beam computed tomography of the temporal bone as a diagnostic tool for chronic suppurative otitis media. This method was employed to study the temporal bones of 33 patients presenting with chronic suppurative otitis media (18 cases of one-sided and 15 cases of two-sided inflammatory process). The results of the total of 48 sessions of beam computed tomography of the temporal bones were available for analysis. The age of the patients varied from 16 to 80 years. Seven of them presented with chronic suppurative otitis media in combination with cholesteatoma. The clinical symptoms of chronic suppurative otitis media were revealed by cone beam computed tomography in conjunction with the peculiarities of visualization of bone tissue destruction using this technique (both in the presence of cholesteatoma and without it). The rationale has been developed for the use of cone beam computed tomography in diagnostics of chronic suppurative otitis media.

A comparison of three MDCT post-processing protocols: preoperative assessment of the ossicular chain in otitis media.

The aim of this study was to examine and assess comparative values of HRCT-based multiplanar reformation (MPR), volume rendering (VR) and virtual endoscope built on three-dimensional (3D) shaded-surface display (SSD-based CTVE) for detections of ossicular chain's damage in patients with otitis media. 70 human ears from 70 patients suffering by chronic otitis media or cholesteatoma, who were examined with a preoperative multi-slice computer tomography (MSCT) examination and tympanoplasty in our hospital were collected. The patients ossicular chains were reconstructed with the aforementioned three protocols and assessed via a three-point scoring system by three radiologists. Then, all the patients ossicular chains were reviewed by a surgeon and a radiologist via the same three-point scoring system used during surgeries at same time. By calculation, the Youden's index and coincidence rate were acquired without a significant difference for display of malleus. With regard to the incus, the Youden's index and coincidence rate of VR and MPR did not show any difference, however, both were higher than CTVE. For representation of the stapes, the accuracy of these three modalities is very low; especially, for the CTVE. In conclusion, both MPR and VR are relative robust, and CTVE is not effective for evaluation of small ossicular structures, particularly the stapes. Furthermore, the VR images are real 3D ones. Therefore, it could be the more valuable protocols for detection of the damage of ossicular chain in the patients with otitis media, and should be further applied in the future work.

[Clinical and roentgenological diagnostics of the severity of mucositis in the patients presenting with chronic suppurative otitis media].

The objective of the present study was to determine the prevalence of mucositis and its roentgenological manifestations in the patients presenting with chronic suppurative otitis media (CSOM). A total of 390 patients with CSOM (mesotympanitis) and 85 ones suffering CSOM with concomitant mucositis were available for the observation. The signs of mucositis were evaluated based on the patients' complaints, results of otomicroscopy, and computed tomography (CT) of the temporal bones. This randomized clinical study involving 390 patients presenting with CSOM revealed the signs of mucositis in 44.6% of the cases. Analysis of the results of temporal bone CT performed in 85 patients with CSOM and mucositis in the absence exacerbation has demonstrated the possibility of detecting mucositis and evaluating its severity from the changes in the airness of the tympanic cavity, attics, and antrum due to the presence of the pathological substrate in these regions.

[Destructive mastoiditis with thrombosis of the sigmoid sinus in a 8 year-old child presenting with concomitant chicken pox].

The specific clinical feature of mastoidities that developed in a patient presenting with chicken pox was the rapid progress in temporal bone destruction with partial thrombosis of the sigmoid sinusis in the absence of typical manifestations of mastoiditis. The pronounced destructive changes found in a series of CT images were regarded as the indications for urgent antromastoidotomy with the puncture of the sigmoid sinusis.

Management of otogenic lateral sinus thrombosis.

OBJECTIVE: To evaluate the changing clinical course and trends in management of otogenic lateral sinus thrombosis (OLST), in view of the rarity of the said lesion and antibiotic abuse. METHODS: A retrospective case study was done in 6 patients referred to our tertiary care centre with OLST over a period of three years from May 2007 to May 2010: Department of Otorhinolaryngology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - a tertiary care university teaching hospital under central government of India. Medical records of all the patients were scrutinized and data pertaining to patient profile, type of chronic suppurative otitis media (CSOM), clinical course with any other complication and management were tabulated. The said data was scientifically analyzed w.r.t. current medical literature on the subject. RESULTS: Clinically, it was observed that all patients had protracted CSOM - attico antral type, with history of rampant misuse of antibiotics. The attack of OLST in each case was triggered off by an acute attack of suppurative otitis media. Moreover, in all the cases OLST was masquerading as an intra-cranial complication, with no specific clinical features thereby causing missed diagnosis initially. All these patients were diagnosed by CT scan, and underwent modified radical mastoidectomy (MRM) with needle aspiration of sinus under antibiotic cover. The said treatment protocol resulted in excellent prognosis with no morbidity or mortality whatsoever. Pathologically, cholesteatoma was detected in 5 of the six cases with one case having only granulations. CONCLUSIONS: In this era of antibiotic abuse, the clinical presentation of OLST has altered substantially, and mimics other intra-cranial complication with vague signs and symptoms. There are conflicting views in contemporary medical literature regarding management of OLST. In our experience, MRM with needle aspiration under antibiotic cover is the treatment of choice for all cases of OLST associated with CSOM attico antral disease/cholesteatoma disease.

Temporal bone erosion in patients with chronic suppurative otitis media.

OBJECTIVES: To analyse temporal bone erosion sites (including scutum, labyrinth, facial canal, mastoid tegmen, posterior fossa dural plate and sigmoid sinus plate) in patients with chronic suppurative otitis media (CSOM). METHODOLOGY: Retrospective case review in a tertiary referral centre. Medical records were reviewed from 905 patients (121 complicated; 784 non-complicated) who received a mastoidectomy as a minimum intervention for the treatment of CSOM. RESULTS: All types of temporal bone erosion were found to be more frequent in patients with complicated CSOM. Erosion in the scutum, mastoid tegmen, posterior fossa dural plate and labyrinth was observed significantly more frequently in complicated-CSOM patients with a cholesteatoma. Granulation/polyp tissue invaded the sigmoid sinus and facial canal at a rate similar to cholesteatoma. CONCLUSIONS: Our study demonstrates that bone erosion is more frequent in complicated-CSOM patients. Temporal bone erosion can be seen in both cholesteatomatous and non-cholesteatomatous CSOM patients. Granulation/polyp tissue was as important as cholesteatoma in the erosion of the facial canal and sigmoid sinus plate.

CT two-dimensional reformation versus three-dimensional volume rendering with regard to surgical findings in the preoperative assessment of the ossicular chain in chronic suppurative otitis media.

PURPOSE: To assess the role of three-dimensional volume rendering (3DVR) in the preoperative assessment of the ossicular chain in chronic suppurative otitis media (CSOM). MATERIALS AND METHODS: Sixty-six patients with CSOM were included in this prospective study. Temporal bone was scanned with a 128-channel multidetector row CT and the axial data was transferred to the workstation for multiplanar reformation (MPR) and 3DVR reconstructions. Evaluation of the ossicular chain according to a three-point scoring system on two-dimensional reformation (2D) and 3DVR was performed independently by two radiologists. The evaluation results were compared with surgical findings. RESULTS: 2D showed over 89% accuracy in the assessment of segmental absence of the ossicular chain in CSOM, no matter how small the segmental size was. 3DVR was as accurate as 2D for the assessment of segmental absence. However, 3DVR was found to be more accurate than 2D in the evaluation of partial erosion of segments. CONCLUSION: Both 3DVR and 2D are accurate and reliable for the assessment of the ossicular chain in CSOM. The inclusion of 3DVR images in the imaging protocol improves the accuracy of 2D in detecting ossicular erosion from CSOM.

[Efficacy of high-resolution CT in differential diagnosis of chronic suppurative otitis media and cholesteatoma otitis media by soft-tissue shadows].

OBJECTIVE: To evalute the efficacy of high-resolution CT(HRCT) in differential diagnosis and treatment of chronic suppurative otitis media and cholesteatoma otitis media by soft-tissue shadows. METHODS: HRCT scanning was performed in 120 cases, 153 ears, with chronic otitis suppurative media and cholesteatoma otitis media, of which original data were processed with multi-planar reconstruction (MPR) and maximum intensity projection (MIP), the characteristics of the soft-tissue shadows' growth, window width or window leveling and bony destruction were respectively observed, as well as compared with the surgery findings. RESULTS: In 120 patients (153 ears), 109 ears were diagnosed as cholesteatoma otitis media, and 44 ears were diagnosed as chronic suppurative otitis media, among which 33 ears had granulation tissue and 11 ears had secretion. One hundred and seven ears were postoperatively diagnosed as cholesteatoma otitis media, among which 25 ears had granulation tissue. Among 46 ears of chronic suppurative otitis media, 35 ears had granulation tissue, and only 11 ears had secretion. A 98.6% diagnostic accuracy can be reached with HRCT in diagnosing cholesteatoma otitis media and chronic suppurative otitis media. The Youden's index was 0.98, 0.98 and 1.00 respectively with HRCT in diagnosing cholesteatoma, granulation tissue and secretion. CONCLUSIONS: Combination of the three different imaging methods, axial images, coronal MPR images and MIP images, can improve the efficacy of the HRCT diagnosis and definite chronic otitis media, which can be routinely used for surgery plan.

The value of preoperative CT scan of tympanic facial nerve canal in tympanomastoid surgery.

CONCLUSIONS: The combined analysis of axial, coronal, and sagittal planes can increase the positive rate of diagnosis for dehiscence of the facial nerve canal. OBJECTIVE: The aim of this study was to evaluate the diagnostic value of high resolution computed tomography (HRCT) scanning of the condition of the tympanic portion of the facial nerve canal in patients with chronic otitis media. METHODS: A total of 76 ears of 72 inpatients with chronic suppurative otitis media and with cholesteatoma or granulation tissues in the attic were examined by routine HRCT. The condition (including dehiscence) of the tympanic portion of the facial nerve canal observed by CT on multi-planar images and surgical findings were recorded. RESULTS: The condition of the tympanic portion of the facial nerve canal observed by CT could be confirmed by surgical findings in 67/76 ears, but was not confirmed in 9/76 ears. Axial-transverse images could clearly show the position and length of dehiscence on the lateral wall of the facial nerve, while coronal images were superior to axial-transverse images in showing the bony circumference of the facial nerve, and sagittal images could show the inferior wall of the facial nerve canal more clearly than images on the former planes.

Bezold's abscess in the setting of untreated HIV infection.

INTRODUCTION: Reports of Bezold's abscess are rare. Classically, Bezold's abscess is described as a complication of mastoiditis in which infection spreads deep to the sternocleidomastoid muscle and throughout the fascial planes of the neck. Antibiotic treatment of suppurative otitis media has considerably decreased the incidence of complications resulting from this disease. We present a unique case report of Bezold's abscess in the setting ofa patient with untreated HIV. To our knowledge, this is the first reported case of Bezold's abscess and HIV. Despite its rarity, clinicians must have a high suspicion for Bezold's abscess in the setting of complicated otitis media and HIV; it must be recognized early in immunocompromised patients and treated aggressively due to its potentially fatal outcome. STUDY DESIGN: Case report and review of the literature. METHODS: We review the clinical course of a thirty five year old male HIV patient with a chronically draining ear and progressive neck stiffness, found to have a Bezold's abscess on CT. The incidence, pathogenesis and treatment of Bezold's abscess are discussed with special reference to the clinical presentation in the setting of an immunocompromised host. RESULTS: After broad-spectrum intravenous antibiotic therapy, mastoidectomy and surgical incision and drainage of the neck abscess, the patient recovered and had begun antiretroviral therapy at six-month follow-up. CONCLUSIONS: Bezold's abscess should be considered in the setting of complicated otitis media with neck stiffness and immunocompromised, specifically untreated HIV. The diagnosis and prompt, aggressive treatment of Bezold's abscess is necessary for an optimal clinical outcome