Presentation
Chronic left ear discharge with neck pain
Patient Data
Soft tissue is seen filling up the left middle ear cavity with air fluid levels in left mastoid air cells. Diffuse edema and post gadolinium contrat hyperenhancement is seen involving >60% of clivus with surrounding posterior nasopharyngeal wall edema, enhanement around left Eustachian tube, involving left occipital condyle, left jugular foramen and left hypoglossal canal.
Absent flow voids in mid superior sagittal sinus, entire left transverse sinus, left sigmoid sinus, left jugular vein. Meningeal thickening and hyperenhancement seen in the posterior margin of left middle cranial fossa floor.
Inflamed left maxillary and the sphneoid air cells.
Lytic permeative bony destruction of clivus, left occipital condyle, left hypoglossal canal, tympanic wall of left jugular foramen. Eroded tegmen tympani. Whilst encased by middle ear soft tissue, the ossicles appear preserved.
Case Discussion
The long standing left middle ear / mastoid inflammation can lead to a multitude of complications, the severe one being skull base osteomyelitis. The initial inflammation has now eroded the tegmen tympani inflaming the dural lining, eroded the jugular foramen, resulting the venous sinus thrombosis. extended into clivus and occipital bone resulting in skull base osteomyelitis.
Whilst the MRI is excellent for soft tissue involvement delineation, CT correlation is recommended to assess the extent of bony loss.
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