0:01

We are continuing to discuss the potential

0:03

complications of otomastoiditis.

0:06

So far we've seen otomastoiditis

0:10

causing labyrinthitis,

0:11

we've seen otomastoiditis causing ossicular lysis

0:15

with absence of the long process of the incus.

0:19

We've seen otomastoiditis with a Bezold's abscess

0:24

eroding through the mastoid and having a very large

0:27

collection along the occipital skull base.

0:30

And this is another patient who got into trouble

0:33

with otomastoiditis. So here on the CT scan,

0:38

what we see is complete opacification of the mastoid

0:42

air cells as well as the middle ear cavity on the

0:45

left side. Again, malleus, incus, aditus, antrum,

0:49

mastoid opacification.

0:52

See a little bit of the cochlea as well

0:55

as the vestibule and the round window.

0:58

Now,

0:58

one of the things to note on this particular case

1:02

is how ragged it looks in the mastoid air cells.

1:06

Where is that bony wall,

1:08

the lateral bony wall of the mastoid on the

1:12

left side compared to the right side?

1:13

We've lost that.

1:15

And you have what looks like erosion of the septa

1:20

extending to the soft tissues just adjacent

1:23

to the ear as the pinna of the ear.

1:27

Similarly,

1:27

even here we have what looks like air cells of the

1:33

mastoid just being able to freely collect

1:35

into the adjacent soft tissues.

1:37

And this comes very close to the external canal,

1:41

which is also pacified in this patient.

1:45

So very concerned about the potential for erosive

1:50

coalescent mastoiditis with an adjacent inflammatory

1:55

process. So if we look at these soft tissue windows,

1:58

we can see that indeed there is inflammation around

2:01

the mastoid tip and extending to behind the ear.

2:06

And for this,

2:07

we would of course want to do either post-gadolinium

2:11

MRI scanning or CT scanning to better characterize

2:15

the nature of this inflammatory process.

2:18

So on the flare scan, once again,

2:20

similar findings as previously,

2:22

opacification of the mastoid middle ear cavity

2:25

with high signal intensity secretions,

2:28

suggesting infection.

2:30

And there is some element of soft tissue

2:33

thickening along the mastoid tip,

2:35

but this is much better identified on

2:37

our post-gadolinium fat sat scan.

2:40

So here we are at post-gadolinium fat sat.

2:42

We have opacification of the mastoid air cells,

2:45

some of which are showing contrast enhancement.

2:48

And we also see here a ring-enhancing collection

2:54

just below the mastoid tip, which

2:56

we would call a Bezold abscess.

3:00

With adjacent inflammation extending to the parotid

3:03

gland as well as the subcutaneous

3:05

fat with cellulitis,

3:06

as well as the external auditory canal

3:09

which has soft tissue in it.

3:11

Here's a portion of the external auditory canal.

3:13

And here's all this soft tissue inflammation.

3:15

If we look at the muscles of mastication,

3:18

including the temporalis muscle and the masseter

3:22

muscle and the pterygoid musculature

3:24

on the left side,

3:26

we see that they're all enhancing more than the

3:29

contralateral right side because of this myositis

3:33

cellulitis abscess from the mastoiditis.

3:38

Looking at the transverse sinus,

3:40

it doesn't look so bad.

3:42

The sigmoid sinus doesn't look so bad,

3:43

but we kind of have this filling defect in the

3:47

jugular bulb, and then we lose the jugular

3:51

vein below. Here's our internal carotid artery.

3:55

It's got some inflammation around it as well,

3:58

but we're also missing the jugular vein.

4:02

So here is our MR venogram.

4:08

And while we see the full extent

4:12

of the jugular vein,

4:13

jugular bulb, and sigmoid sinus,

4:16

and transverse sinus on the right side,

4:18

on the left side we're left with the

4:20

sigmoid sinus and then this gap.

4:23

And then we pick up the jugular vein here.

4:26

So this is an example of thrombophlebitis

4:31

of the jugular vein,

4:32

jugular thrombophlebitis secondary to the

4:36

mastoiditis with the cellulitis myositis

4:39

and bezold abscess. Again,

4:42

it may be useful to see the pre-gadolinium-enhanced

4:46

scan and try to identify the jugular

4:49

flow void not seen here.

4:52

We got some slow flow that we're identifying in

4:55

the sigmoid sinus and transverse sinus,

4:58

but that could just be normal.

5:01

But now we know that indeed the

5:03

jugular vein is thrombosed.

5:06

I want to just move over and show

5:09

you the diffusion-weighted scans.

5:12

And the diffusion-weighted scans again are useful in

5:16

identifying that there is indeed a bright signal

5:19

intensity area in the space just

5:23

below the mastoid tip,

5:24

which identifies it as purulent material

5:27

and likely to be an abscess.

5:29

So,

5:29

yet another example of complications

5:33

of mastoiditis. In this case,

5:35

not just the Bezold's abscess,

5:36

but also jugular thrombophlebitis leading to

5:40

narrowing and obstruction of the jugular vein and occlusion of

5:45

the jugular vein in association

5:47

with myositis cellulitis.

5:50

Let's look quickly for any inflammation of the

5:54

meninges. So no meningitis in this case.