A CASE OF BRAIN ABSCESS SECONDARY TO MIDDLE-EAR CHOLESTEATOMA
Introduction
Despite the benefits of antibiotics and computed tomography (CT) examinations, chronic otitis media with cholesteatoma is sometimes accompanied by brain abscess. We report a case of brain abscess due to incomplete treatment for meningitis secondary to middle-ear cholesteatoma.
Case report
A 55-year-old man was referred to our hospital with high fever, nausea, persistent right otorrhea and right hearing loss. A white debris was observed (Fig. 1A). CT revealed bony destruction in the right tegmen (Fig. 1B). Magnetic Resonance Imaging (MRI) revealed the existence of epidural abscess (Fig. 1D). Audiogram showed right mixed hearing loss (Fig. 1C). The examination of spinal fluid obtained by lumbar puncture showed marked elevation of the white blood cells count. He was therefore diagnosed with otogenic bacterial meningitis.
After he was treated using intravenous antibiotics for about one month, the epidural abscess had disappeared. A surgery for middle-ear cholesteatoma was then planned, however, he refused the surgery and was discharged.
As a result of incomplete treatment to his middle-ear cholesteatoma, the patient was admitted to our hospital by ambulance three weeks later, suffering from high fever, headache, right otalgia and disordered consciousness. CT (Fig. 2A) and MRI (Fig. 2B) revealed a brain abscess in the right temporal lobe in addition to right middle-ear cholesteatoma.
Pseudomonas aeruginosa which was sensitive to cephem series and carbapenem series antibiotics was detected in the right otorrhea at second admission. Meropenem (MEPM) and vancomysin (VCM) were administered because anaerobic bacteria and methicillin-resistant Staphylococcus aureus could not be ruled out. Pseudomonas aeruginosa was detected again one month later at second admission, however, it was resistant to MEPM. MEPM was therefore replaced by ceftriaxone (CTRX).
After the brain abscess reduced and the patient’s condition had improved, the surgery was then performed to remove the cholesteatoma, using canal-wall-down procedure. Since a dehiscence in the tegmen was observed (Fig. 3A), it was covered with bone tips and bone paste (Fig. 3B).
The brain abscess was cured conservatively with a course of antibiotics for as long as seven months (Fig. 4A). The patient has been under observation as an outpatient for seven months already and has presented no signs of recurrence of a cholesteatoma (Fig. 4B).
Fig. 1. A. A white debris was observed. The swelled posterior wall of the external auditory canal (arrow). B. Coronal section CT. Bony destruction in the right tegmen (arrow). C. Audiogram showed right mixed hearing loss. D. Axial section MRI. Epidural abscess in front of the right cerebellar hemisphere (arrow).
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Fig. 2. A. Axial section CT at second admission. Brain abscess in the right temporal lobe (arrow). B. Axial section MRI at second admission. Brain abscess in the right temporal lobe (arrow).
Discussion
Nowadays, otogenic brain abscesses are rarely encountered in the ENT clinic in developed countries. Osama et al. has reported that the most frequent intracranial complication of chronic otitis media was meningitis (1.4%), followed by brain abscesses (0.35%).1 In our institute, 251 patients with suppurative otitis media underwent tympanoplasty during an eight-year period (2003–2010). Two patients presented with meningitis (0.79%) and only one patient (reported in this article ) presented with brain abscess (0.39%).
Fig. 3. A. A dehiscence in the tegmen (circle). B. A dehiscence was covered with bone tips and bone paste (circle).
Fig. 4. A. Axial section MRI. Brain abscess has disappeared. B. No recurrence of a cholesteatoma.
It is controversial when to operate for a cholesteatoma with intracranial complications. In this case, the patient presented with brain abscess after he denied to undergo middle-ear surgery at first admission. Penido et al. have reported two patients who did not take surgery for a cholesteatoma and died from brain abscess. Therefore, the procedures concerning a cholesteatoma with intracranial complications should be performed sooner, preferably before or concomitantly with neurosurgical intervention.2 Regarding treatment for brain abscess, Rosenblum et al. have proposed that a patient with otogenic brain abscess with severe disordered consciousness should be operated as soon as possible. However, if the patient is alert or lethargic, antibiotics would be administered for two weeks to maximize the chance for a well-formed abscess wall to develop.3
In this case, the brain abscess was cured conservatively with antibiotics for seven months. On the other hand, Morwani et al. have reported that transmastoid drainage of intracranial abscess and concurrent treatment of the otogenic pathology is an effective treatment for otogenic intracranial abscesses.4
It is important to have appropriate conservative therapy using antibiotics, appropriate neurosurgical or otological procedures with neurosurgeons and neurologists.
References
1.Osma U, Cureoglu S, Hosoglu S. The complications of chronic otitis media: report of 93 cases. J Laryngol Otol 114:97–100, 2000
2.Penido Nde O, Borin A, Iha LC, Suguri VM, Onishi E, Fukuda Y, Cruz OL. Intracranial complications of otitis media: 15 years of experience in 33 patients. Otolaryngol Head Neck Surg 132:37–42, 2005
3.Rosenblum ML, Hoff JT, Norman D, Edwards MS, Berg BO.Nonoperative treatment of brain abscesses in selected high-risk patients. J neurosurg 52:217–25, 1980
4.Morwani KP, Jayashankar N. Single stage, transmastoid approach for otogenic intracranial abscess. J Laryngol Otol 123:1216–20, 2009
Address for correspondence: Yasuhiro Arai, MD, Yokohama City University, 3–9 Fukuura, Kanazawa-ku, Yokohama, Japan. yasuarai@ yokohama-cu.ac.jp
Cholesteatoma and Ear Surgery – An Update, pp. 425–428
Edited by Haruo Takahashi
2013 © Kugler Publications, Amsterdam, The Netherlands