Case contributed by Mostafa Elfeky
Diagnosis almost certain


Right otorrhea and hearing loss.

Patient Data

Age: 60 years
Gender: Male

Right middle ear

  • the right middle ear cavity shows near total opacification with associated with attico-antral opacity creating mass effect in the form of widened aditus and lost figure of eight configuration, as well as opacified sinus tympani, facial recess, anterior epitympanic recess, as well as both window niches
  • the mastoid air cells are opacified and hypocellular
  • the tegmen shows few frank full thickness defects
  • suspected incudo-stapedial disconnection with attenuated thinned out lenticular process; also the incus bony shows multiple erosions of the body and short process consistent with ossicular erosions
  • the malleus is yet intact with hardly visualized stapedial super-structures among tympanic opacification
  • the facial nerve canal shows dehiscence at inferior wall tympanic segment
  • the lateral epitympanic recess is opacified with blunted scutum

Left middle ear

  • the left middle ear cavity is opacified including sinus tympani, facial recess, anterior epitympanic recess, as well as both window niches
  • normal alignment and configuration of the ossicular chain, showing intact malleus-incus complex and intact stapes
  • the tegmen sows few minute dehiscences
  • the facial nerve canal shows thinned out wall with no definite dehiscences
  • opacified hypocellular mastoid air cells  

Hypocellular mastoid bilaterally.

Retained secretions involving middle ear cavities bilaterally reflecting bilateral otomastoiditis.

Small T2 hyperintense right middle ear cavity structure averaging 1.5 x 0.7 cm showing diffusion restriction with no enhancement after contrast administration in keeping with cholesteatoma.

Case Discussion

​This case represents MRI imaging features of bilateral otomastoiditis. Right sided chronic suppurative otitis media (CSOM) with mass effect, bony wall dehiscences and ossicular erosions as well as the presence of a focus of diffusion restriction, best seen on HASTE diffusion-weighted (non echo-planar) sequence in keeping with right middle ear cholesteatoma.   


Case courtesy: Prof. Dr. Mohamed Eid, professor of radiology, Alexandria university, Egypt.          

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