PMC5401737_01
(a) Mastoiditis on the left side. There is diffuse debris throughout the mastoid. (b) An erosion of the anterior-inferior wall of the middle ear cavity (arrow) with air bubbles in the left prestyloid compartment (asterisk).
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fig1
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)).
(a) CT scan of the left temporal bone:a bony sequestrum in the tympanic part is shown by the arrow. (b) An abscess in the left infratemporal fossa appears as a contrast-enhanced mass on the periphery, with irregular contours (arrows). A trismus was explained by inflammatory infiltration of the lateral pterygoid muscles (asterisk). (c) A thrombosed sigmoid sinus is seen on the left side (arrow).
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fig2
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)). 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) A 3D volume rendering scan shows the amount of bone removed during lateral petrosectomy. The drain was inserted into the abscess cavity through the defect in the anterior EAC wall (arrow). (b) Intraoperative image: a defect in the anterior wall of the tympanic cavity (arrow). Pus under the pressure appeared when the granulations were removed from the tympanic cavity. (c) After the tympanic part of the temporal bone was partially drilled, a large bony sequestrum was removed with microforceps. (d) Finally, the third type of tympanoplasty was carried out.
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fig3
Lateral petrosectomy was performed, and a drain was inserted into the abscess cavity (Figure 3(a)). 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)).
Six months postoperatively, a partially epithelized mastoid bowl (asterisk) with an intact tympanic membrane was seen.
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fig4
On follow-up, six months postoperatively, the tympanic membrane was intact, and the mastoid bowl was noncompletely epithelized (Figure 4).
PMC5401737_02
(a) Inflammatory infiltration at the level of the prevertebral and superior pharyngeal constrictor muscles (asterisk). Arrows show the massive erosion of the tympanic part of the temporal bone. (b) Inflammatory changes at the level of the jugular fossa and parotid compartment (asterisks). (c) A soft tissue lesion in the parapharyngeal and parotid spaces.
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fig5
Advanced inflammatory infiltrate at the central skull base was observed that involved the parapharyngeal, retropharyngeal, carotid, parotid, retroparotid, and prevertebral compartments, as well as extending to the jugular foramen (Figures 5(a)-5(c)).
(a) The 3D volume rendering technique shows the lateral surface of the temporal bone: the destruction of the base of the styloid process (vaginal process) is clearly seen. Anterior dislocation of the mandible with subluxation of the condyle is shown with arrows. Note slight cortical erosion of the mastoid process of the right side. (b) Inferior view of the skull base: massive destruction of the petrous and tympanic parts of the temporal bone is marked with arrows. (c) The most severe bone lytic changes were observed around the carotid foramen (arrows). (d) A destruction of the carotid plate is clearly seen on this coronal reformat (arrow). (e) The other possible infection-spreading pathway was from the external auditory canal. Asterisk shows a defect in the anterior wall of the latter. Additionally, arrows show erosion of the mandibular fossa roof as well as auricular tubercle. Note an anterior dislocation of the mandibular condyle. (f) Axial CT scan shows the destruction of the cortical layer of the occipital bone (arrows).
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fig6
PMC5401737_03
(a) The asterisk shows erosion of the temporal bone around the carotid canal (peritubal mastoiditis). The arrow shows a widened TMJ cavity. (b) Defect in the anterior tympanic cavity wall (asterisk). (c) A 3D volume rendering technique shows the same defect from the fossa mandibularis perspective (arrow).
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fig7
CT scan revealed an osteolytic lesion of the petrous apex of the temporal bone with loss of clear bony margins of the carotid foramen (Figure 7(a)). In this case, an infection extended directly through the defect in the anterior wall of the tympanic cavity into the surrounding spaces: mandibular fossa and temporomandibular joint (Figures 7(b) and 7(c)).