Intracranial Infection Complicating Chronic Ear Disease

Abstract

SU_Ml\1A~Y: A case of ext radural and l'crchellar absces.o,; complicating chronic car disease iu an 18 year old C hmese grr) IS reported. The case hi!!o1ory illustrates the difficulties experienced in makinJ,; the diagnosi,,_ Case ReportAn 18 year old Chinese girl was admitted with a one week history of fever, headache, constipation and pain in her left ear. She gave a history of recurrent ear problems during cruldhood. On examination temperature was 39.3 QC with a pulse rate of 1.00 per minute. Pus discharged through a perforation of her left tympanic membrane. The ESR was 100 mm in the first hour, haemoglobin 11.4 Gms / 100 mls. white cell co unt 11.7 x 10 3 C.m m with 79 % polymorphonuclear leucocytes. C hest X-ra y_ urea a nd electrolytes and a Denco were all normal. Swabs from the thoat and left ear, and blood and urine <.:ultures were negative. X-rays of her skull showed a large bon y defect in the left mastoid, which was otherwise scJeroti<.: and poo rly pneumatised.She was sLa rt ed on benzylpenicillin and continued on cotrimoxazole. Two hours a fter admission she su!fered a generalised convulsion which lasted 3 m inu tes. Immediat~l y after this she \\'a5 delirious and had an axillary te mperature of 42°C. She was cha nged from intramuscular to intravenous benzylpenicillin.On the se~ond da y of admission hcr temperature was 38~C .. She was lethargic and had a slight degree of menmgIsm but there were no other neurological abnormalities. There was evidence of acute on chronic ear disease but there was no evidence of acute masto iditis.On the morning of the fourth day of admission she was apyrexial, lethargic and mentally dulled. She had early left sided papilloedema but there were no other neuro logical abnormalities. A CAT scan was arranged for the next day. That evening, however, ~hc became pyrcxia J and was found to ha ve left Sid ed cerebellar signs, n ystagmus. bi latera l extensor planta r and absent abdominal reflexes Emergency mastoidec tomy revealed extensive cholesteatomatous di~ea~e invading the mastoid . The fl oor of the temporal fossa over the atric was removed and norm a l dura found . The bony plate over the sigmoid sinus was removed and a large extradural co llection of pus was found . A modi fied radi cal (;aVil y was formed . Streptococc us Group C wa ... cultured from the left mastoid cavity and Streptococcus pneumoniae from the extradural absces~. Dexamethasone was started postoperatively.She slowly improved over the next week and tbe cerebellar signs gradually disappeared. The drowsiness. however. did not improve and on the fourlct:nth day of admission she agai n developed gross signs suggesling a left sided cerebeHar lesion.