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A rare case of otomastoiditis complicated by pneumocephalus, meningitis and cerebritis

Case presentation: A 71-year-old male patient presented in the Emergency Department with decreased consciousness, speech disturbance, febrility and 2 months history of otitis media, for which he was administered antiobiotics. Physical examination was besides hyperemic tympanic membrane normal. Laboratory tests showed elevated inflammatory markers (C-reactive protein, procalcitonin). Non-enhanced computed tomography (NECT) revealed fluid content in the mastoid cells and middle ear on the left side with cortical erosion of petrous apex and clivus. Intracranial air inclusions were seen in left temporal lobe. On brain magnetic resonance imaging (MRI) there was restriction of diffusion in left mastoid suggesting suppurative process. Spread of the inflammation was noticed on post-contrast T1-weighted images (T1WI) with strong enhancement of temporal lobe dura as well as left carotid space and epipharynx. On fluid-attenuated-inversion - recovery (FLAIR) sequence high signal intensity was present in the temporal lobe. Discussion: Infectious otitis media has many complications. Inflammatory effusion often spreads into mastoid cells causing otomastoiditis. Involvement of the petrous apex results in petrous apicitis with bony erosions seen on CT. Spontaneous otogenic pneumocephalus is rare condition as air enters from middle ear into cranial cavity through cortical defect caused by temporal bone osteomyelitis. Meningitis is the most common intracranial complication and best visualized with MRI that shows dural thickening and enhancement. Inflammation can affect brain parenchyma causing cerebritis and abscess. Conclusion: Despite wide use of antibiotics, middle ear infections still remain life-threatening condition in which urgent neuroradiological analysis proves the diagnosis and determines spread of the primary inflammatory process and its complications.

otitis, pneumocephalus, meningitism, cerebritis

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