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CASE REPORT
Year : 2022 | Volume
: 28
| Issue : 4 | Page : 317-319
A camouflaged brain abscess with zygomatic Abscess – A bizzare presentation in chronic suppurative otitis media
Priti S Hajare, Yashita Singh, Keerthana Veenish, Salonee S Das
Department of ENT, Head and Neck Surgery, J.N. Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
Correspondence Address:
Dr. Yashita Singh
Department of ENT, Head and Neck Surgery, J.N. Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/indianjotol.indianjotol_65_21
Intracranial complications of chronic suppurative otitis media (CSOM), even though rare, can have a simultaneous occurrence of multiple complications. An 8-year-old child, a case of CSOM (squamosal) with zygomatic abscess, was referred to us with HRCT temporal bone showing left otomastoiditis and 7 days of higher intravenous antibiotics. The patient was treated with modified radical mastoidectomy and incision and drainage of the abscess. On the 4th postoperative day, he developed focal neurological deficits which confirmed a brain abscess on magnetic resonance imaging on the same side. It was further managed by neurosurgeons. Here, we report this unusual presentation of multiple complications of CSOM.
Keywords: Brain abscess, chronic suppurative otitis media complications, zygomatic abscess
With the arrival of antibiotics, there has been a significant decline in the complication rates of chronic suppurative otitis media (CSOM). However, the current scenario has reciprocated with the surfacing of antibiotic resistance which has diversified the diagnosis and treatment of CSOM along with its complications.[1]
The complications of CSOM can be broadly categorized into extracranial (intratemporal) and intracranial complications.[2] The incidence of intracranial complications in the preantibiotic era was 2.3%; however now, there is a significant decline which is estimated to be between 0.02% and 1.97%.[3] The most common complications is otogenic brain abscess and meningitis with the mortality rate being 7%-61%.[3] In the Indian scenario, 8% of intracranial lesions are brain abscesses. Its proportions in adults and children are 50% and 25% for each, respectively.[3] One of the most significant causes for brain abscess is cholesteatoma. The infection can have many routes of spread, the preformed pathways or the normal anatomical landmarks, there can be direct extension through the perivascular extension of disease or retrograde thrombophlebitis.[4] The neurological symptoms can vary from headache, profound dizziness, altered sensorium, fever to gait disturbance, and visual disturbance.[3] These symptoms can be life-threatening, but their presentation is masked due to the overuse of antibiotics.[5] CT scan of the temporal bone is the preferred imaging modality; however, magnetic resonance imaging (MRI) of the brain is one of the most useful diagnostic tools for the identification of otogenic intracranial complications.[6] Bezold in 1908 reported a very rare complication where the purulence of mastoid can elude to erode the root of zygoma resulting in a zygomatic root abscess. The zygomatic root abscess is extremely rare and unlikely as the root of the zygoma drains well owing to its high position.[7] Here, we present an interesting case with an unusual presentation of both complications camouflaging each other.
Case ReportAn 8-year-old male child was referred to our outpatient department with complaints of left ear discharge for 2 years which was mucopurulent, nonfoul smelling, nonblood tinged. There was history of swelling above the left ear for 8 days and headache. The patient was initially treated at a private children's hospital for 8 days where he received high dose IV antibiotics (piperacillin and tazobactam) and was referred to us for further surgical management because of increasing swelling over the zygomatic area [Figure 1].
Examination
The swelling was seen extending from the mastoid tip inferiorly to two cm above the superficial temporal line superiorly. Anteriorly, it extended till the root of the zygoma. The swelling was tender with a local rise of temperature and was firm in consistency.
Ear examination
On otoscopic examination of the left ear, profuse mucopurulent discharge was seen and the tympanic membrane was partially visible due to posterior canal wall bulge. There was no mastoid or tragal tenderness seen.
Routine blood investigations were normal except for a white blood cell count of 23,500 cells/mm3.
A diagnosis of zygomatic abscess secondary to CSOM (squamosal) was made.
The patient's computed tomography (CT) scan of the temporal bone was done 2 weeks before, and it showed otomastoiditis. Mastoid exploration was planned. Intraoperatively, a subperiosteal pathway was created to trace the abscess, and approximately 20 ml of pus was expressed by milking from the zygomatic area. Inside out, mastoidectomy was done where an extensive cholesteatoma sac was seen occupying the attic, antrum, and sinodural angle along with the erosion of the posterior wall of the external auditory canal. The disease was eroding the tegmen, and frank pus was seen coming out of the tegmen plate which was covered using the remnant graft [Figure 2]. Diseased incus and malleus were removed. Modified radical mastoidectomy with type 3 tympanoplasty was done.
The patient withstood the procedure well and was planned for discharge on the 3rd day but at the time of discharge, the patient developed altered sensorium and drowsiness. An emergency neurosurgery opinion was taken. MRI of the brain with venogram was advised which revealed brain abscess in the left temporal region measuring 4.5 (AP) × 3.8(ML) × 3.5 (CC) cm with perilesional edema [Figure 3]. MR venogram was within normal limits. Decompressive craniotomy with temporal lobe abscess excision was done by them. The excised tissue was sent for histopathological examination which was suggestive of an acute chronic inflammatory lesion [Figure 4]. Injectables were given for 3 weeks. Postoperative follow-up was done for 6 weeks. Healing mastoid cavity and healed craniotomy site were seen.
Figure 3: Magnetic Resonance Imaging of Brain showing brain abscess in the left temporal region (White arrow) Discussion The zygomatic abscess is extremely rare. The possible routes of spread are via the petrotympanic fissure or glaserian fissure, the preformed track of cells, the petrosquamous sinus which arises from the dorsolateral part of the transverse sinus, and direct invasion of the bone secondary to cholesteatoma.[7] It is more commonly reported in the pediatric population owing to plentiful zygomatic air cells in childhood in comparison to adults. The patient will usually present with otorrhea, reduced hearing, and facial swelling which need to be managed with IV antibiotics, incision and drainage of abscess, and mastoidectomy in the same setting,[7] as done in our case.
The most common location of the otogenic brain abscess is the temporal lobe or the cerebellum at the ratio of 2:1.[8] The symptoms are often insidious and slowly progressive in presentation. Headache and low-grade fever are the predominant symptoms in the early stage, as seen in our patient. This occurs due to localized encephalitis and edema. Convulsions, vomiting, and drowsiness with lethargy are present in the later stages due to raised intracranial tension.[9]
The MRI of the brain is considered superior to the CT scan due to the lower toxicity of the contrast used and higher resolution.[6] It helps in assessing the midline shift and the mass effect.[10],[11] As in our patient, the CT scan done in early stage did not reveal any findings concerning brain abscess. MRI has higher specificity and sensitivity.[2]
Mukherjee et al. reported that cholesteatoma or granulation tissue is underlying for brain abscess.[3] The commonly cultured organisms in CSOM include Gram-negative microorganisms which include Pseudomonas aeruginosa, Proteus mirabilis, and Enterococcus.[12] However in our scenario, the bacteriological culture was negative owing to the administration of large doses of IV antibiotics previously.
Management of brain abscess begins with stabilization of the patient and often requires a multidisciplinary team. Initiation of supportive therapy includes high-dose IV antibiotics for 4–6 weeks, with third- or fourth-generation cephalosporins with vancomycin, metronidazole, aminoglycosides, and chloramphenicol are usually endorsed.[12] The surgical methods of an abscess include either aspiration through a burr hole or craniotomy and open drainage.[3]
ConclusionAlthough the incidence of complications of CSOM has declined due to the availability of higher antibiotics in recent decades, it is still seen in routine clinical practice. Complications such as brain abscess remain silent due to antibiotics in the early stages, but rare complications such as zygomatic abscess present with significant symptoms and need urgent intervention. More than one complication in CSOM patients are not commonly seen. Furthermore, the role of repeat imaging modality such as High Resolution Computed Tomography (HRCT) temporal bone by ENT surgeons just before ear exploration needs to be considered in patients with intracranial complications of CSOM to look for fresh changes if any.
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Conflicts of interest
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References
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