0:01

The vast majority of cases of middle ear

0:03

inflammation do not require imaging.

0:06

This is usually a diagnosis that's made

0:09

at pediatrician's office,

0:11

usually associated with just an uncomfortable ear,

0:17

and there may be several bouts of this otitis media,

0:22

middle ear inflammation,

0:23

that occurs during one's childhood.

0:26

However, when it fails to

0:30

clear, you may again see that entity known

0:34

as chronic otitis media or COM.

0:37

And one of the complications, potentially, of chronic

0:40

otitis media is a cholesteatoma,

0:42

which we'll talk about shortly.

0:44

When the middle ear inflammation extends to

0:48

the mastoid air cells, it's termed otomastoiditis.

0:54

If the mastoid air cells start to have irregularity

1:00

and destruction of the septa between

1:03

the various mastoid air cells,

1:05

we call that coalescent mastoiditis and we treat it as

1:08

if it is a form of osteomyelitis and therefore

1:12

often requiring aggressive antibiotic use,

1:16

sometimes even intravenous antibiotics.

1:19

Now unfortunately,

1:21

when you have mastoiditis you may have some of the

1:24

complications of mastoiditis which include

1:27

thrombophlebitis of the sigmoid sinus or transverse

1:32

sinus or you can have adjacent inflammation of the

1:36

meninges and the patient presenting with meningitis.

1:40

So here we have a CT scan

1:44

through the middle ear cavity and mastoid air cells

1:48

and as you can see there is opacification on the left

1:51

side of the middle ear cavity as

1:53

well as the mastoid air cells.

1:55

And in point in fact you can even see an air-fluid

1:57

level identifying this as acute otitis media.

2:02

Here however is a patient who has a little bit

2:06

different appearance and that is that we have lost

2:10

the septa within the mastoid air cells.

2:14

Bilaterally there still is opacification

2:16

of the middle ear cavity,

2:18

but with this loss of the normal septa of the

2:22

mastoid air cells we would call this coalescent

2:25

mastoiditis or coalescent otomastoiditis because

2:28

there's inflammation in both locations.

2:31

Similarly,

2:31

here we have a patient who has otitis media with

2:36

opacification around the middle ear ossicles,

2:39

but in addition there has been erosion and expansion

2:42

of that anterior epitympanic space.

2:45

So again some coalescent expansion that would lead

2:50

to the diagnosis of coalescent otomastoiditis.

2:56

Here we have a patient who has a flare scan.

3:00

Showing high signal intensity in the mastoid

3:03

air cells. Now, two points to make here.

3:05

The first point is that it is very unusual for the

3:09

fluid that occurs in the mastoid air cells to

3:14

be the same signal intensity as that of CSF.

3:19

So whatever it is that is within the mastoid

3:22

air cells, it's not just pure fluid,

3:25

it is usually inflammatory disease.

3:26

And that's why you see it as bright in

3:29

signal intensity on the flare scan.

3:32

Now,

3:32

this applies also to patients who have nasogastric

3:35

tubes or have been irradiated,

3:38

where you see fluid in the mastoid air cells

3:43

even though it's not likely to be infected.

3:45

In other words,

3:45

it's just an obstructive phenomenon when you have

3:48

nasogastric tubes or it's a weeping

3:52

with radiation therapy.

3:54

It still does not show CSF signal on the flare scan,

4:01

so it's going to be bright in

4:03

signal intensity, it allows you to see mastoid effusions very easily.

4:08

So even though we might call it a mastoid effusion,

4:10

we know that it's not the same fluid as CSF.

4:13

The second main point to make is that

4:16

this is a patient who is an adult.

4:18

And in an adult that has mastoid fluid or chronic

4:23

otitis media or recurrent bouts of otitis media,

4:26

you better look at the nasopharynx.

4:29

So otomastoiditis in an adult is due to nasopharyngeal

4:34

carcinoma until proven otherwise.

4:36

And for those of you who had good eyes,

4:40

you may have noticed that there was this mass in the

4:43

nasopharynx which is obliterating the normal fat space

4:49

between the tensor veli palatini muscles.

4:52

And instead we have this soft tissue that would

4:55

be obstructing the eustachian tube orifice,

4:58

the torus tubarius eustachian tube orifice.

5:01

And you see that it's narrowed and probably displaced

5:04

by this mass, which also, it looks like,

5:07

is infiltrating the longus colli

5:10

muscle on the right side.

5:11

So when you see a patient presenting with chronic

5:15

otitis media or episodes of otitis

5:17

media or otomastoiditis,

5:19

we have to always be cognizant of the potential for

5:23

a nasopharyngeal carcinoma that is

5:26

obstructing the eustachian tube.

5:29

Here is one of the complications of otomastoiditis,

5:32

and that is an abscess.

5:33

In this case,

5:34

we see a peripheral enhancing mass

5:37

which is in the cerebellum.

5:39

You see the displacement of the fourth

5:40

ventricle from right to left.

5:42

And we're also seeing the superficial

5:44

enhancement of the meninges,

5:47

suggesting that this is meningitis

5:49

with a cerebellar abscess.

5:51

And we can see the enhancing soft tissue in the

5:54

mastoid cells representing the inflammatory process.

5:58

The next thing to look for

6:00

is the venous sinuses,

6:02

the transverse and sigmoid sinuses and jugular

6:04

vein to ensure that there is not

6:08

thrombophlebitis.

6:10

I spoke about the entity of malignant otitis externa

6:14

when we were talking about the external auditory canal

6:16

because by and large that's where it's

6:18

thought that the infection resides.

6:20

Remember that this is a Pseudomonas infection which

6:23

typically occurs in an elderly diabetic patient and

6:28

there is inflammation which extends to the skull base

6:32

and gets there via the fissures of Santorini which are

6:37

the fissures that occur between the cartilaginous

6:40

and bony portion of the external auditory canal.

6:44

However,

6:45

it's not unusual for that malignant otitis externa to

6:49

extend into the middle ear cavity

6:51

as well as the skull base.

6:53

And you may see the cortical

6:54

bone erosion of the clivus,

6:56

a soft tissue mass at the skull base usually extending

6:59

into the parapharyngeal space and then either osteolysis

7:02

or increased bone thickening at the clivus.

7:07

So here, for example,

7:08

is our case that I showed on the talk on the external

7:12

auditory canal where we have

7:14

soft tissue in the external

7:17

auditory canal cartilaginous portion thickening along

7:20

the wall of the bony portion of the external auditory

7:23

canal with erosion infiltration into the middle ear

7:26

cavity, which you can see also on the MRI scan.

7:30

And then the MRI scan nicely demonstrates

7:32

on this post gadolinium fat scan,

7:35

the inflammation around the carotid artery,

7:37

the enhancement of the clivus. Here's

7:39

the normal fat-suppressed clivus.

7:41

This is abnormally enhancing clivus from the

7:45

osteomyelitis associated with the malignant otitis externa.

7:48

You have enhancement of the longus muscle. Here's the

7:51

contralateral normal longus muscle, and then the

7:53

parapharyngeal space inflammation

7:55

adjacent to the nasopharynx.

7:58

So this is going from the external canal into the

8:01

middle ear cavity and from the middle

8:02

ear cavity into the vascular space,

8:04

the mastoid air cells as well as the skull base.