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ORIGINAL ARTICLE

Transmastoid approach to otogenic brain

abscess: 14 years experience
V R Borade, S A Jaiswal, H O Nemade
Department of ENT, Dr. Vaishampayan Memorial Government Medical College, Solapur, India

Objectives: Objectives of this study were to review our experience in on otogenic brain abscess and its
Abstract
management by transmastoid drainage and compare the results. Materials and Methods: All patients with
brain abscess secondary to CSOM presenting to our department from January 1997 to December 2010
were included in this study. All patients subjected to clinical, neurological, opthalmological examination
and CT scan was done as an imaging modality. All patients managed by radical mastoidectomy or
modified radical mastoidectomy and transmastoid drainage of brain abscess as neurosurgical facility
not available. Results: Seventy-two patients in whom brain abscess secondary to chronic suppurative
otitis media was diagnosed and has been treated since 1997 are presented. 85% of patients were
below 20 years of age. More than 50% patients presented with more than one complication of chronic
suppurative otitis media. 85% of patients were having extensive cholesteatoma and 15% patients were
having extensive granulations in middle ear and mastoid air cells. 83% patients were having cerebellar
abscess while 17% patients were having temporal lobe abscess. 80% of the pus culture was sterile while
in 20% patients various microorganisms such as Proteus spp., Escherichia coli, Pseudomonas aeruginosa,
Staphylococcus spp., and Streptococcus spp were cultured. Overall mortality in this series was 4.4%.
Conclusion: In diagnosis of otogenic brain abscess CT scan with constrast is of immense help. Transmastoid
drainage of brain abscess is a safe and effective method that can be performed by otologists in cases
of otogenic brain abscess.

Keywords: Otogenic brain abscess, Transmastoid drainage, Complications of CSOM

Introduction Morand reported a successful operation for brain abscess.

Chronic suppurative otitis media (CSOM) with cholesteatoma
has the potential for intracranial spread of infection.
Although there has been a marked decrease in the incidence
of otogenic intracranial complications because of early
diagnosis and prompt treatment of ear infection, availability
of higher antibiotics, and advances in otological surgical
techniques, otogenic intracranial complication persists as a
difficult problem.[1,2] CSOM accounts for 28,000 deaths and
a disease burden of more than 2 million Disability Adjusted
Life Years (DALYs).[3] Over 90% of the burden is borne by
countries in the South-East Asia and Western Pacific regions,
Africa, and several ethnic minorities in the Pacific rim. The
most commonly encountered intracranial complication is
meningitis followed by brain abscess. Brain abscess was the
first complication of otitis media to be recognized and the
first one successfully treated by operation. It was in 1768 that
In 1856, Lebert accurately described the pathology of brain
abscess, confirming the fact that it follows infection of the
ear, not the reverse. The treatment of otogenic brain abscess
consists of medical management in the form of antibiotics
and the agents to lower the intracranial pressure and surgical
management which include burr hole or craniotomy to drain
the brain abscess by neurosurgeon and removal of the ear
and mastoid cholesteatoma by radical or modified radical
mastoidectomy done by otologist. In our setup due to lack
of neurosurgical facility, the otogenic brain abscess patients
were treated by otologists by radical or modified radical
mastoidectomy and approaching the brain abscess through
defect in tegmen antri and Trautmann’s triangle.
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Address for correspondence: Dr. Hemantkumar Onkar Nemade,

Department of ENT, ‘B’ Block, Shri Chhatrapati Shivaji Maharaj General DOI:
Hospital and Dr. VMGMC, Solapur-413005, India. 10.4103/0971-7749.94493
E-mail: honemade@gmail.com

Indian Journal of Otology | October 2011 | Vol 17 | Issue 4 | 155

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Borade, et al.: Transmastoid approach to otogenic brain abscess: 14 years experience

The objectives of this study were to review our experience Results

on treating otogenic brain abscess transmastoid route with
particular reference to symptoms, signs, intraoperative From the total of 72 patients, 40 patients were male and 32
findings, and results. were female. Ages of patients ranged from 6 years to 54 years
with the mean age of 16 years. 85% patients were below 20
Material and Methods years of age. Otological diagnosis revealed that 62 (85%)
patients were having cholesteatoma while 10 patients were
This article will review our experience with 72 patients having granulations in middle ear and mastoid air cells
of otogenic brain abscesses treated from January 1997 [Table 1]. Cerebellar abscess was found in 60 patients (83%)
to December 2010 in our hospital. All cases of CSOM while temporal lobe abscess was found in 12 patients [Table 2].
with suspected intracranial complications were subjected
to clinical examination, neurophysicians opinion, In all, 48 patients were having more than one intracranial
fundoscopy by ophthalmologists, and imaging by computed complication. Lateral sinus thrombosis was found in 15
tomography (CT) scan. Brain abscesses from other origins patients, meningitis in 4 patients, and epidural empyema in
and extradural abscesses were excluded from this study. 20 patients. Intratemporal complications such as labyrinthine
According to the severity of the disease, modified or radical fistula was found in 36 patients and facial nerve palsy seen in
6 patients [Table 3].
mastoidectomy was performed under general anesthesia. In
temporal lobe abscess, the dural plate was carefully examined
to look for erosion. If granulations were present on dura, Table 1: Otological diagnosis
the tegmen antri was removed till healthy dura was seen. Otological diagnosis Cholesteatoma Granulations
Brain cannula was inserted into the abscess cavity through Patients (n) 62 10
the healthy portion of the dura and the pus was aspirated off Percentage 86 14
[Figure 1]. The abscess cavity was irrigated with antibiotic
solution. In cerebellar abscess, the sinus plate examined for
Table 2: Brain abscess location
erosion, presence of granulation, perisinus abscess, and sinus
Location Temporal Cerebellar
was palpated for signs of thrombosis, and aspiration of sinus
Patients (n) 12 60
was done. If no free flow of blood, sinus was exposed from
Percentage 83 17
sinodural angle up to mastoid tip and sinus was incised and
thrombus was removed till there was free flow of blood.
Aspiration of cerebellar abscess was done through the Table 3: Associated intracranial and intratemporal
Trautman’s triangle [Figure  2]. Hemostasis was achieved, complications
and antibiotic pack was kept in operated cavity. Postaural Complication Patients (n) Percentage
wound was not sutured. Repeated aspiration of brain abscess Lateral sinus thrombosis 15 20.83
was done after every 48 hours. Clinical status of patient was Meningitis 4 5.56
assessed and abscess was also assessed by repeat CT scan, Epidural empyema 20 27.78
when satisfactory secondary suturing of postaural incision Menigocoele 2 2.78
was done at a later date. Antibiotics continued for almost 1 Facial palsy 6 8.33
month after surgery. Labyrinthine fistula 36 50

Figure 1: Transmastoid drainage of temporal lobe abscess through Figure 2: Transmastoid drainage of cerebellar abscess through the
the dural plate Trautmann's triangle posterior fossa dura

156 Indian Journal of Otology | October 2011 | Vol 17 | Issue 4 |

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Borade, et al.: Transmastoid approach to otogenic brain abscess: 14 years experience
Figure 3: CT scan of cerebellar abscess
Out of 12 cases of temporal lobe abscess, morbidity was seen in
one patient in the form of persistence of hemiplegia. Mortality
was seen in two patients of temporal lobe abscess and in three
patients of cerebellar abscess.
All patients of facial nerve palsy had undergone facial nerve
decompression and two patients showed partial improvement.
Pus was sent for Gram staining and culture sensitivity. In
80% of patients, pus was sterile on culture. Remaining 20%
showed variable causative organisms, e.g., Escherichia coli,
Pseudomonas aurugenosa, Proteus spp., Staphylococcus spp.,
and Streptococcus spp.
Discussion
A brain abscess is a focal suppurative process within the brain
parenchyma surrounded by a region of encephalitis. The risk
for a patient with chronic otitis media to develop a cranial
abscess is of 1 in 10,000 patients per year, but in adults who’s
had the disease since the childhood this risk may increase to
1 in 200 patients per year.[4,5] Yen and associates’ recent series
of 122 consecutive patients seen in a Taiwan hospital between
1981 and 1994 revealed that otitis was the third most common
cause of intraparenchymal brain abscess, exceeded only by
those associated with cyanotic congenital heart disease and
those secondary to head injury or neurosurgery.[6]
According to Nalbone et al., otogenic brain abscess carry
a mortality rate ranging from 7% to 61%.[7] According to
Ludman, 25% of all brain abscesses were otogenic in children,
whereas in adults 50% brain abscesses were otogenic.[8] For
some unknown reasons, otogenic intracranial complications
occur predominately in males. As a rule, otogenic brain
abscesses are single and multiple only in rare cases.[9] The
mortality associated with brain abscess of otogenic origin
in the antibiotic era is about 25%. Patients who present with
altered mental status have more advanced disease and have a
higher mortality rate.[10]
Indian Journal of Otology | October 2011 | Vol 17 | Issue 4 |
Figure 4: CT scan cerebellar abscess
Spread beyond middle ear cleft can occur due to destruction
by cholesteatoma, through fracture lines, preformed pathways,
through the Haversian system of veins or through the
periarterial space of Virchow Robin. In this era of antibiotics,
incidence of complications is reduced due to awareness of
disease, advances in diagnostic, and treatment modalities.
The clinical diagnosis of intracranial complication and brain
abscess are not reliable and must be confirmed by CT scan
[Figures  3  and  4]. This is also not an invasive, quick, and
reliable method of preoperative and postoperative assessment
of patients of otogenic brain abscess. HRCT temporal bone
sometimes misses the temporal bone abscess, so CT brain plain
plus contrast must be complimented by the HRCT.
All patients presented with headache more than 7 days and
associated with the nausea and vomiting, fever, and variable
alteration in consciousness. All patients gave history of
purulent and foul smelling discharge through the ear. Radical
mastoidectomy is considered as the surgery of choice in event
of the presence of intracranial complications.[11,12]
Open cavity mastoidectomy was used as a method of
choice in our series. In modified radical mastoidectomy,
hearing preservation was attempted by ossiculoplasty and
myrigostapedopexy.
The mean follow-up period was 1 year and seven patients
required revision surgery. Hence, recurrence rate was 12%
which was comparable to the existing series. The mean
duration of hospitalization was 15 days. Postoperative follow-
up was kept with serial CT scans in clinically suspicious cases.
Conclusion
Otogenic brain abscess is a challenging condition to manage.
High degree of suspicion is indicated for diagnosis for which
CT scan with contrast is of immense help.
Transmastoid drainage of otogenic brain abscess is equally safe
157
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Borade, et al.: Transmastoid approach to otogenic brain abscess: 14 years experience
and efficient modality of treatment of otogenic brain abscess in
the area where neurosurgical facilities are not available. It deals
with primary focus of infection with the secondary intracranial
complication in single setting avoiding two-stage procedure.
Acknowledgement
Dr. Shinde Dean, Dr. VMGMC Solapur for permission for
publication.
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How to cite this article: Borade VR, Jaiswal SA, Nemade HO.
Transmastoid approach to otogenic brain abscess: 14 years
experience. Indian J Otol 2011;17:155-8.
Source of Support: Nil. Conflict of Interest: None declared.
Indian Journal of Otology | October 2011 | Vol 17 | Issue 4 |