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| CASE REPORT |
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| Ahead of print publication |
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Temporal lobe abscess – as a result of COVID pandemic
Rahul Naga1, Tejpal Singh Bedi2
1 Department of ENT, INHS Asvini, Mumbai, Maharashtra, India
2 Department of ENT, 151 BH, Guwahati, Assam, India
| Date of Submission | 28-Jun-2022 |
| Date of Decision | 23-Jul-2022 |
| Date of Acceptance | 24-Jul-2022 |
| Date of Web Publication | 20-Oct-2022 |
Correspondence Address:
Tejpal Singh Bedi,
Department of ENT, 151 BH, Guwahati - 781 029, Assam
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jmms.jmms_103_22
Complications of chronic otitis media have reduced substantially in the postantibiotic era. The complications are described as being intracranial and extracranial. Intracranial complications are rarer epidemiologically; however, the recent COVID pandemic has led to widespread delay among the general populace from seeking therapy. We present a case where a 22-year-old male failed to seek timely intervention for otorrhea and developed a temporal lobe abscess. The patient was subsequently managed through an intact canal wall mastoidectomy and tympanoplasty with drainage of pus through the transmastoid approach. On follow-up, there was an adequate resolution of the abscess with a well-healed tympanic cavity.
Keywords: Abscess, complication, drainage, intracranial, otological
| Introduction | |  |
Over 65–330 million individuals suffer from chronic otitis media (COM) worldwide, and the maximum burden is borne by the African continent and South-East Asian region.[1] There has been a major shift in the associated morbidity and mortality associated with COM owing to the advent of antibiotics and improving health-care facilities.[2] However, the COVID-19 pandemic led to a generalized delay in seeking medical therapy. We present a case of COM which developed an otogenic temporal lobe abscess.
| Case Report | | |
A 22-year-old male presented with an episode of a generalized tonic–clonic seizure. The patient gave a past history of foul-smelling, scanty, mucoid, intermittent, and nonblood stained otorrhea, which had recently become viscous and continuous with associated febrile episodes preceding the seizure by 1 week. The individual did not seek medical attention for his ailments owing to the COVID pandemic.
Clinical evaluation revealed no signs of meningeal irritation and a raised total leukocyte count and polymorphonuclear cells in the CSF tap.
ENT evaluation revealed a retraction of the pars flaccida (TOS grade IV) with erosion of the posterior wall of the external auditory canal (EAC) as well as conductive hearing loss of the left ear. No focal neurological deficits were seen and higher mental functions were intact. The right ear examination revealed a grade IV retraction of the pars tensa, while the nose and throat examinations were unremarkable.
Magnetic resonance imaging (MRI) revealed an intracranial left temporal lobe peripherally enhancing lesion of approximately 2.1 cm × 2.5 cm × 1.7 cm with surrounding edema and evidence of mastoiditis in continuity with this abscess [Figure 1]. | Figure 1: MRI axial image revealing intracranial abscess with ipsilateral mastoiditis. MRI: Magnetic resonance imaging
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High-resolution computed tomography (HRCT) temporal bones revealed soft-tissue densities in the epitympanum, mesotympanum, hypotympanum, and aditus ad antrum with involvement of Prussak's space and complete engulfment by soft-tissue density of the ossicular chain. A tegmen defect was also noted in continuation with the intracranial lesion in the temporal lobe [Figure 2] and [Figure 3]. | Figure 2: CT scan axial image showing left otomastoiditis. CT: Computed tomography
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 | Figure 3: CT scan coronal image showing left tegmental defect. CT: Computed tomography
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The individual was initially managed with antibiotics and supportive therapy, planned for a tympanomastoid exploration with the aim of draining the abscess and repair of the tegmen defect.
Intraoperative findings revealed an eroded posterior wall of EAC and a cholesteatoma sac lateral to the ossicles involving the Prussak's space, epitympanum, and aditus ad antrum with polypoidal middle ear mucosa; partially eroded head of the malleus with intact ossicular continuity; scutum erosion; and a 0.5-cm diameter tegmen defect.
An intact canal wall mastoidectomy was performed and the cholesteatoma sac was excised in toto. About 3–4 ml of pus was drained through the tegmen defect and repair was undertaken using muscle, fascia, and fibrillar oxidized cellulose sheets. The posterior wall of the EAC was reconstructed using conchal cartilage. The patient had an unremarkable postoperative period and started on a month-long antibiotic cover.
Follow-up imaging after 4 weeks of surgery, the patient had resolution of the intracranial lesion with minimal signs of inflammation and no frank abscess noted within the temporal lobe. The otoscopic examination revealed a well-healed posterior wall of EAC and a well-healed tympanic membrane. There was mild conductive hearing loss noted on audiometry in the left ear [Figure 4]. | Figure 4: MRI image revealing well-healed left temporal abscess. MRI: Magnetic resonance imaging
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| Discussion | | |
COM was a major cause of mortality in the preantibiotic era causing 1 in 40 deaths; however, post the introduction of sulfonamides, 1 in 400 deaths are attributed to COM.[3]
The complications of COM have seen a massive decline in the postantibiotic era.[4] Squamous COM has a higher propensity for complications in comparison to the mucosal variety.[5]
Otogenic intracranial abscess is a recognized complication of COM, and over 50% of said abscesses are located in the temporal region of the intracranial cavity.[6]
On the microbiological front, the Western literature attributes Proteus mirabilis to be the leading causative agent for otogenic intracranial abscess while an Indian study of about 75 cases found streptococci to be a leading isolate in its population.[6],[7]
The characteristic triad was described in the pre-CT era times which comprised headache, focal neurological deficits, and fever. However, patients more commonly present with nausea, headache, and fever in the post-CT era.[3],[6] Change in the nature of discharge often serves as warning signs for impending or ongoing complications.[3] Otogenic temporal lobe abscesses may also present with complaints of headache, fever, nausea, altered mental status, and signs of meningeal irritation along with a preceding history suggestive of or diagnosed COM.
Radiologically, an intracranial abscess on CT imaging is seen as a hypodense area with surrounding edema, referred to as a “ring sign.” MRI is superior to CT in detecting subtle changes in the brain parenchyma and early detection of the spread of abscess to subarachnoid or ventricular spaces; however, its inability to delineate detailed bony anatomy often makes a CT scan imperative.[5],[8]
Temporal lobe abscesses carry a mortality rate of 8%–10% even in the present era. There are multiple complications following otogenic temporal lobe abscess – one-third of individuals are left with permanent neurological deficits (most commonly aphasia) and about one-fourth are left suffering with epilepsy.[6]
Management of temporal lobe abscess is an area surrounded by debate. However, all patients after diagnosis must be started on intravenous antibiotics. A third-generation cephalosporin alongside metronidazole is indicated and an additional agent for MRSA is desirable. The minimal duration of therapy is 4 weeks; however, one would do well, to take into account the condition and follow-up imaging before resorting to one approach fits all dictum.[6]
The basis of management lies in abscess drainage and source control. There are multiple studies quoting drainage of abscess through the burr hole approach or open craniotomy, even multiple drainages at the time with antibiotic washes and subsequent tympanomastoid approach.[6]
On the other hand, two studies have described mastoid surgeries in conjugation with abscess drainage.[9],[10] The most important factor here remains the clinical situation of the patient, and in the case of neurological deterioration, early drainage through the quickest route must be undertaken.[6]
In this case, we offered transmastoid drainage of the temporal lobe abscess in conjunction with an intact canal wall mastoidectomy for the patient in view of his age and tegmen defect allowing for surgical drainage. This approach allowed us to drain the abscess and control the disease while simultaneously allowing us to reconstruct and preserve the external auditory canal, thus avoiding the lifelong morbidity of a mastoid cavity as well, with good postoperative results.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | World Health Organization. Chronic Suppurative Otitis Media; Burden of Illness and Management Options. Geneva, Switzerland: World Health Organization; 2004. p. 2-83.  |
| 2. | Smith JA, Danner CJ. Complications of chronic otitis media and cholesteatoma. Otolaryngol Clin North Am 2006;39:1237-55. |
| 3. | Gulya AJ, Minor LB, Poe DS, editors. Glasscock-Shambaugh Surgery of the Ear. 6 th ed. USA: People's Medical Publishing House; 2003. p. 444-7. |
| 4. | Kangsanarak J, Fooanant S, Ruckphaopunt K, Navacharoen N, Teotrakul S. Extracranial and intracranial complications of suppurative otitis media. Report of 102 cases. J Laryngol Otol 1993;107:999-1004. |
| 5. | Yorgancılar E, Yildirim M, Gun R, Bakir S, Tekin R, Gocmez C, et al. Complications of chronic suppurative otitis media: A retrospective review. Eur Arch Otorhinolaryngol 2013;270:69-76. |
| 6. | Duarte MJ, Kozin ED, Barshak MB, Reinshagen K, Knoll RM, Abdullah KG, et al. Otogenic brain abscesses: A systematic review. Laryngoscope Investig Otolaryngol 2018;3:198-208. |
| 7. | Menon S, Bharadwaj R, Chowdhary A, Kaundinya DV, Palande DA. Current epidemiology of intracranial abscesses: A prospective 5 year study. J Med Microbiol 2008;57:1259-68. |
| 8. | Muzumdar D, Jhawar S, Goel A. Brain abscess: An overview. Int J Surg 2011;9:136-44. |
| 9. | Sennaroglu L, Sozeri B. Otogenic brain abscess: Review of 41 cases. Otolaryngol Head Neck Surg 2000;123:751-5. |
| 10. | Samuel J, Fernandes CM, Steinberg JL. Intracranial otogenic complications: A persisting problem. Laryngoscope 1986;96:272-8. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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