0:01

When we consider other potential

0:03

complications of otomastoiditis,

0:05

we have to consider the entity of a

0:08

Bezold abscess or mastoid abscess.

0:12

This is a case where the patient had hearing loss

0:17

on the left side as well as a neck mass.

0:21

This was done as a soft tissue examination

0:24

of the neck rather than a temporal bone.

0:27

So as you can see, the slice thicknesses were 2 mm.

0:30

So we can't do a reconstruction here.

0:33

And this was done, as I mentioned,

0:34

with post-contrast imaging.

0:36

So on this CT scan we immediately start to see that

0:39

there is inflammation present posteriorly in the

0:43

neck along the posterior margin of the sternocleidomastoid

0:46

and we are still below the level of the

0:49

mastoid tip. As we come further superiorly,

0:54

we arrive at the mastoid tip and we have this large

0:58

fluid collection which is seen

1:00

posterior to the mastoid tip.

1:01

And there's also inflammation that's extending to

1:04

the arc of the ear as well as the

1:07

parotid gland on the left side.

1:09

There's a little bit of infiltration of the

1:11

subcutaneous fat and thickening of the

1:13

skin suggestive of cellulitis.

1:15

We continue further superiorly again, large fluid

1:19

collection posterior to the mastoid.

1:22

There's inflammation along the posterior aspect

1:25

of the ear with this soft tissue

1:27

thickening of cellulitis.

1:30

And you can see that there is opacification

1:33

of the middle ear cavity and mastoid.

1:35

And we would have to convert this to the bone window

1:40

to see the degree of opacification of the middle ear

1:44

cavity around the middle ear ossicles

1:46

as well as the mastoid.

1:48

And you can see the fluid level here in the mastoid.

1:52

So this is acute otomastoiditis with an abscess

1:59

which is relatively large in size,

2:03

as you can see continuing up

2:05

along the occipital bone.

2:09

What you want to look at is to make sure that the

2:12

sigmoid sinus and the jugular bulb are patent.

2:16

So on this post-contrast scan that looks good,

2:19

we can look at the transverse sinus which looks

2:21

just fine. There is some erosion of bone here.

2:24

I'm not sure whether that was post

2:25

op or was due to the infection.

2:28

But you would imagine that there's likely going to

2:30

be some meningitis along here, a little bit concerned

2:34

by the collection that appears to be posterior to

2:38

the transverse sinus on the edge of the film here.

2:41

So for this, we would recommend getting an MRI scan.

2:45

Again, looking at the nasopharynx, not too bad,

2:49

no masses there.

2:50

The patient does have chronic sinusitis.

2:52

So let's look at the associated MRI scan

2:56

on this case, and we can look at the

3:00

FLAIR images,

3:01

as well as the post-gadolinium scans to help

3:06

us the most. So, here is the FLAIR scan,

3:10

and the FLAIR scan shows this

3:11

large fluid collection.

3:12

Looks like they've already put a drain in it, coming

3:15

from posteriorly, so it's smaller in size.

3:18

Again, we have the opacification of the mastoid air cells

3:22

and the middle ear cavity in signal intensity,

3:25

which is not that of CSF.

3:27

Remember, CSF would be dark on the FLAIR scan,

3:30

similar to the vitreous of the eye.

3:32

So this is brighter than expected.

3:35

And when we look at the post-

3:36

gadolinium enhanced scan,

3:38

you can see that there is enhancement of this tissue

3:42

as well as the collection that has been partially

3:45

drained. So, the big abscess-looking here,

3:49

it looks like the jugular vein is open, but an MRI.

3:54

Venogram was performed, identifying that, indeed,

3:58

transverse sigmoid sinuses and

4:00

jugular vein are okay.

4:03

And the other thing we want to

4:04

do is look at the brain MRI,

4:09

post gadolinium, to look for any evidence

4:12

of meningitis. So, on these scans,

4:17

it doesn't look like there's enhancement of the

4:20

meninges associated with the mastoid infection.

4:25

There is some value in looking

4:27

at the diffusion-weighted scan.

4:29

The diffusion-weighted scan may be useful in this

4:31

scenario to see where there's a pocket of high

4:34

signal intensity on the diffusion-weighted scan,

4:36

which might suggest an abscess that's

4:38

still able to be drained.

4:40

We see a little bit of bright signal intensity in

4:42

those posterior soft tissues, but by and large,

4:44

it doesn't look all that bad.

4:47

So, no discernible abscess that has

4:50

not been previously drained.