A 64-year-old man presented to the tertiary referral hospital with a 1-month history of severe otalgia, constant otorrhea, and a 1-week history of facial weakness on the left side. He also complained of painful mastication on the same side. He had no previous history of ear infection, diabetes mellitus, or tuberculosis. The patient had a history of excessive alcohol consumption.
At arrival, his temperature was 37.2 C. A blood test revealed leukocytosis (12.3 x 109/L) and normal glucose level. On physical examination, the patient had a facial paralysis grade IV according to the House-Brackmann scale. Otoscopically, there was edema with granulation tissue in the EAC and an eardrum perforation in lower quadrants on the left side. Pus and granulations were also detected in the tympanic cavity on that side.
Radiologically, mastoiditis was diagnosed (Figure 1(a)). CT scans also showed erosion of the anterior-inferior walls of the middle ear cavity and external auditory canal (Figure 1(b)). Air bubbles in the prestyloid compartment and TMJ were also detected.
From the geniculate ganglion to the stylomastoid foramen, no obvious facial nerve bony canal destruction was detected. Multiple biopsies showed highly vascularized granulation tissue with leukocytic infiltration and foci of necrosis. They did not reveal any neoplasm or granulomatous inflammation. A culture showed a growth of alpha-hemolytic Streptococci.
Treatment with intravenous antibiotics (Cefuroxime 750 mg three times daily, Metronidazole 500 mg twice daily, and Ciprofloxacin 200 mg twice daily), aural suction, and topical Ciprofloxacin and Dexamethasone drops was started immediately. However, conservative management and intensive aural toilet were ineffective, and the patient underwent surgery. Canal wall down mastoidectomy was performed. Removal of the incus was required to reestablish the patency of the blocked aditus ad antrum and attic. A dehiscent facial nerve in the tympanic portion was observed intraoperatively. Ossiculoplasty with repositioning of the incus was performed at the same procedure. However, after a short improvement, purulent otorrhea and pain in the preauricular pain reoccurred. New massive granulations in the anterior part of the tympanic cavity were observed. Pus in the canal appeared with closure of the mouth and clenching. Repeated CT scan of the temporal bones and temporomandibular joint (TMJ) revealed a bony sequestrum and defect in the anterior middle ear cavity and external auditory canal walls (Figure 2(a)). MRI with intravenous contrast was carried out; in the left infratemporal fossa, an abscess (30 x 9 mm) enhanced on the periphery with the irregular contours was detected (Figure 2(b)). The abscess extended from the external auditory canal towards the jugular fossa, carotid, and parapharyngeal compartments. Debris in the mastoid on the left was described as well. Altered intensity of the lateral pterygoid muscle on the left as well as thrombosed internal jugular vein and partially thrombosed transversal and sigmoid sinuses were detected on the left (Figures 2(b) and 2(c)).
A final clinical diagnosis of temporal bone osteomyelitis complicated by infratemporal abscess coexisting with mastoiditis and necrotizing external otitis was made on the basis of medical signs and imaging data. The second operation was carried out in collaboration with a neurosurgeon (S. R.). Lateral petrosectomy was performed, and a drain was inserted into the abscess cavity (Figure 3(a)). Granulations were removed from the middle ear cavity. A defect in the anterior wall was identified (Figure 3(b)). The tympanic part of the temporal bone was drilled out, and a large sequestrum was removed (Figure 3(c)). Next, tympanoplasty type III using temporal muscle fascia was performed (Figure 3(d)).
The patient continued to use Ciprofloxacin 500 mg twice a day for six weeks after surgery. On follow-up, six months postoperatively, the tympanic membrane was intact, and the mastoid bowl was noncompletely epithelized (Figure 4).
Grade V House-Brackmann facial paresis persisted at the last follow-up.