Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.

The existence and treatment of the intracranial complications of suppurative ear disease can be traced to the European Neolithic period. It is well-known that prehistoric man performed trephining, or the surgical opening of the skull with primitive instruments, for such infections. Until the 1940s the outlook for these patients remained grim, with a mortality of 75%. However, the introduction of penicillin by Fleming drastically changed this, decreasing mortality to 10%.

There are four well-known infectious otitic intracranial complications:

1. Epidural abscess
2. Subdural abscess
3. Meningitis
4. Brain abscess
The signs and symptoms of these complications can often be difficult to detect initially. Impending complications should be suspected when: 1) otologic infection recurs two to three weeks after initial treatment; 2) fetid aural discharge is present; 3) headache or subtle mental status changes in the presence of otologic disease; and 4) otalgia in the setting of chronic ear disease. These warning signs should prompt further investigation.

The most useful initial study is computerized tomography (CT) with contrast. If the CD findings are equivocal and the index of suspicion remians high, this should be followed by magnetic resonance imaging (MRI) with and without contrast. Therapy is tailored to each specific complication but should include intravenous antibiotics, medical management of elevated cerebrospinal fluid pressure, and neurosurgical consultation. Once the patient is neurologically stable, attention should be focused on definitive otologic intervention.

The pathogenesis, microbiology, and treatment of each otitic intracranial complication were discussed in detail.

Case Presentation

A 20-year-old white woman with an extensive otologic history including left mastoidectomy in 1984 with revision in 1991, presented to another hospital with a five-day history of right-sided fetid aural discharge, otalgia, headache, and fever. She had been placed on oral antibiotics three days earlier by a private physician. On admission she was noted to be lethargic with neck rigidity, vomiting, and photophobia. Her aural exam was significant for the discharge and a posterior, superior deep retraction pocket. CT scanning revealed right mastoiditis and probable posterior fossa bony erosion. A lumbar puncture was consistent with meningitis, with the CSF fluid growing staphylococcus, proteus, and pseudomonas species.

The patient was transferred to BTGH on broad spectrum antibiotics. A right modified radical mastoidectomy with removal of a cholesteatoma was performed. A bony defect was found over the lateral sinus, but the sinus was patent. Postoperatively, DM had persistent headaches and neck pain. She developed somnolence, ataxia, and dysdiadochokinesia. CT and MRI imaging showed an infratentorial subdural empyema. A suboccipital craniotomy was performed by the neurosurgical team with removal of a sterile empyema. DM then made steady progress with only mild residual ataxia.

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