Otomastoiditis complicated with meningitis

Case contribution: Dr Radhiana Hassan


  • A 66 years old man
  • No known medical illness
  • Presented with left ear pain and discharge, associated with high grade fever
  • Treated for acute suppurative otitis media and on oral antibiotic for 2 weeks
  • Subsequently had abnormal behaviour with slurred speech and right sided hemiparesis
CT scan brain in axial planes; brain window non-contrast (upper row), contrast-enhanced (middle row) and bone window (lower row).

CT scan findings:

  • Increased meningeal enhancement at left temporoparietal region (yellow arrow).
  • Presence of subdural collection at left parietal region measuring 0.3 cm thickness. There is associated cerebral oedema with effacement of the cerebral sulci on the left side.
  • No mass effect or midline shift. No acute intracranial haemorrhage.
  • No hydrocephalus. Normal grey white matter differentiation.
  • Basal cisterns are not effaced.
  • Fluid is noted at left mastoid air cells and left middle ear (red arrow).

MRI findings:

  • Continuous smooth enhancement of the meninges are noted in the left cerebral hemispheres (yellow arrows).
  • It is associated with mild effacement of the left cerebral hemisphere sulci and cortical thickening which is mainly seen at left temporo-occipital lobes; suggestive of cortical oedema.
  • Grey white matter junction differentiation is however remains preserved. No internal brain herniation.
  • No area of restriction diffusion demonstrated in DWI/ADC.
  • No blooming artefact seen in hemo sequence to suggest of bleed.
  • No enhancing brain lesion is seen.
  • The previously seen minimal left subdural collection at left parietal region (at previous CECT) is no longer visualized in this study.
  • No hydrocephalus. Basal cisterns are not effaced.
  • Left mastoid air cells are filled with fluid signal intensity, suggestive of left mastoiditis.
  • Right mastoid air cells are well aerated.
  • Mucosal thickening of bilateral maxillary sinuses are noted.

Diagnosis: Left otomastoiditis with meningitis.


  • Intra cranial complications from mastoiditis is well recognized.
  • Pathways of intracranial spread from infective focus include anatomical contiguity between meninges and mastoid, hematogenous spread, thrombophlebitis of the blood vessel, and bone dehiscence.
  • Computed tomography and MRI scan play an important role in diagnosing mastoiditis and its intracranial complications, but sensibility and specificity of these techniques are not definitively established.
  • The most common complications in MR imaging were intratemporal abscess, subperiosteal abscess and labyrinth involvement.
  • Children had a significantly higher prevalence of total opacification of the tympanic cavity and mastoid air cells, intense intramastoid enhancement, outer cortical bone destruction, subperiosteal abscess and perimastoid meningeal enhancement.

Progress of patient:

  • During current admission, patient was newly diagnosed DM and hepatitis B.
  • Treated as meningits and mastoiditis with antibiotics.
  • Reassessment prior to discharge showed resolved dysphasia with normal neurological examination
  • Patient was able to ambulate independently


Author: radhianahassan