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Have chronic mastoiditis. No discharge or ear pain. What is the white spot seen on CT scan?

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Radiologist
Practicing since : 2007
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Hi,
I am suffering from chronic mastoiditis for last 1 year. There is no discharge from my ear and no ear pain. However, I have pain in my jaws. I had a series of CTs. I have a few questions regarding those:

Here is a description of my CTs:
1. ms-00.jpeg - taken 2 months after the infection started. Red arrow shows fluid in one air cell.
2. ms-01.jpeg - taken 7 months after the infection started. Red arrow shows fluid in the same air cell and a new white spot there.
3. ms-02.jpeg - taken 10 months after the infection. I had mastoidectomy 2 months before this. Red arrow still shows some fluid (doctor said it is post surgery fluid). But that white spot is still there.

Now here are my questions:

1. What is that white spot which has developed over time? Is it bone erosion or bone growth?
2. My SPECT scan shows some high uptake in my mastoid. What does that signify? Is it bone erosion in minor level or bone sclerosis?
3. Has this bone abnormality not been removed during mastoidectomy or is it that such a thing can't be removed?
4. Radiologist notes in all my CT does not mention any bone erosion. Has it gone undetected ?
5. Is that white spot focus of osteomyelitis?

Regards,
XXXXXXX
Posted Sat, 5 Jan 2013 in Ear, Nose and Throat Problems
 
 
Answered by Dr. Ganesh Sanap 2 hours later
Hi, welcome XXXXXXX

I have gone through all your CT scan images. It is mastoiditis. First, I want to tell you that there are high variations in air spaces in mastoid in between persons. In same person, it may be of different sizes on both sides.

The white spot is not erosion at all. Erosion causes destruction of bones and not the new bone formation.

Now there are two choices about white spot.

1. In first scan, it was there but the section was not given on film.
2. It may be due to reactive sclerosis to infective process.

Now about SPECT scan. High intake is seen is any active process whether it is infection or malignant. It significance is correlated with CT scan. In your case, high intake is due to infection. Such a small bone sclerosis will not cause identifiable uptake on SPECT.

It is not necessary to remove such a small lesion every time. It may be possible that it is not amenable for operating field.

Finally, it is not osteomylitis, because it is highly destructive process. You can see that your mastoids are not in that phase.

Hope I have answered your all doubts. Any further queries are welcome in follow up.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Have chronic mastoiditis. No discharge or ear pain. What is the white spot seen on CT scan? 9 hours later
Hi Dr. XXXXXXX

Thanks for your answers. A few more questions:

1. As you can see (in ms-01.jpeg) which was done before my mastoid surgery, only one air cell shows haziness. However, after surgery all my left mastoid air cells became hazy. Is it due to post surgery changes or a true mastoiditis? My mastoid surgery was done 3 months ago.

2. Should I undergo another mastoid surgery to properly remove the accumulation? My CT report for ms-01 which was done just before surgery says - "Subtle soft tissue opacification in left mastoid air cells - posterio-inferior aspect". My CT repost for ms-02 which was done after mastoidectomy says - "Minimal fluid intensity noted in mastoid air cells".

3. Is it possible for radiologists to find the amount of fluid that is present in the air cells? I mean is it low minimum or high. I am asking this in relation to the CT report which says - "Minimal fluid intensity"

4. Is it possible for radiologist to distinguish normal not infected fluid from infection in the air cells?

5. As you said SPECT scan showed infection. However, my air cell structures are not much harmed. Is it a slowly progressing infection and there is reactive bone growth due to this? Can this also be slow bone erosion? My mastoid structure is not much changes after 1 year.

6. Fluid culture was done after my mastoid surgery. This did not show any aerobic bacterial growth. Does that mean there was no infection there? In such a case why was the SPECT positive?

7. Assuming that white spot is new bone growth, is it not necessary to remove such additional growth or is it a harmless entity sitting there or is it that the surgeon has missed that place?

Regards,
XXXXXXX


 
 
Answered by Dr. Ganesh Sanap 3 hours later
HI, Welcome back XXXXXXX

We will discuss accordingly your questions

1) I want to tell you that your interpretation about images is quite wrong. There is near same opacity in both the scan with a white spot, which we have discussed already. Therefore, after operation same changes mean it is the mastoiditis, which is not resolved.
2) If you have done the all scan from same radiologist then he/she had approximately quantified the amount as subtle and minimal. If the scan is at different doctors then forget it, as it is a subjective term used by doctors (unless and until it is clearly stated like- as compared to previous scan there is change in amount.......).
3) 3rd question is discussed above.
4) Radiologist cannot distinguish between infected or sterile, he can only comment on fluid.
5) Any high activity due to either bacterial infection or sterile process will give hot spot on SPECT.
6) Bacterial growth was not there, means it is serous type of collection. Serous collection is like our nasal secretions. It is secreted everywhere in body. When drainage system gets affected, it starts collecting like sinusitis.
7) White spot is completely harmless, no need to operate only for that.

Hope I have answered your all doubts.
Thanking you.
Above answer was peer-reviewed by
 
Follow-up: Have chronic mastoiditis. No discharge or ear pain. What is the white spot seen on CT scan? 4 hours later
Hello Dr. XXXXXXX

Thanks for your explanation.

I have attached a new set of images which are more clear. In those you will see the mastoid air cells are now all hazy after surgery. Before surgery they were black. I assume black means air/normal.

Here is a brief description of the images.

1. ms-03.jpeg - taken 2 months after the infection started. Red arrow shows fluid in one air cell.
2. ms-04.jpeg - taken 7 months after the infection started. Red arrow shows fluid in the same air cell and a new white spot there.
3. ms-05.jpeg - taken 10 months after the infection. I had mastoidectomy 2 months before this. Red arrow still shows some fluid in all cells post surgery. But that white spot is still there.

Now some more questions:

1. Here you can see fluid in all cells after surgery. Does that mean the infection is still there or it is probably fluid from surgery.

2. Now you can clearly see the white spot in on air cell. That is the cell which has fluid in it for 1 year. According to you it is sclerosis. Is it different from bone lesion?

3. Can sterile fluid produce high activity in SPECT scan?

4. Is the radiology software able to give any idea about the amount of fluid in the air cells?

5. How long does it usually take for such a fluid to disappear on its own after mastoid surgery?

6. The affected air cell was on the posterio-inferior side. Can this give rise to pain in the jaw just beneath the TMJ?

Regards,
XXXXXXX
 
 
Answered by Dr. Ganesh Sanap 45 minutes later
Hi,

Welcome back XXXXXXX

We will discuss as per previous one. I have seen your new images.

1) Post surgical fluid means infection is still there. It may be due to re-infection or incomplete procedure.
2) Sclerosis is response of bone to chronic stimulation only. It is part of bone only.
3) Definitely sterile fluid can produce high activity on SPECT scan.
4) Sorry to say, but there is no such software for measuring fluid.
5) Posterio-inferior side is most dependent and difficult to drain. So it will take long time to fluid to disappear. It is difficult to say it in exact months.
6) Such condition can cause referred jaw pain. As mandibular head is normal in scan pain is referred only.

Any further doubts are always welcome.

Regards
Above answer was peer-reviewed by
 
Follow-up: Have chronic mastoiditis. No discharge or ear pain. What is the white spot seen on CT scan? 1 hour later
Hi

A few more questions:

1. By any chance can that white spot be an infection?

2. Does mastoid infection lead to TMJ disorder? I am having pain in my jaw, temple and neck region.

3. Is it not possible at all to remove that fluid from posterio-inferior portion with/without surgery?

4. Please suggest what should be my next step - another surgery or antibiotics?

5. Last surgery did more harm to me than good. Now all my air cells are filled with fluid. Prior to surgery only one or two cells were filled. So I want to know is there any long term complication of such fluid staying there?

6. Since I did not have any noticable bone erosion in 1 year (as per my 3 CTs) can I be sure that I will not have any in future?

Regards,
XXXXXXX
 
 
Answered by Dr. Ganesh Sanap 3 hours later
Hi welcome back,
1) white spot is not infection, but you need not to worry for the same . It is definately benign, no doubt about that.
2) TMJ disoreders will involve the joint proper. Reffered pain means pathology is at one place and pain at other place. Pain at TMJ joint may be referred.
3 and 4) Just continue with antibiotic and do follow up. If it increases then think for surgery again.
5) There is no complication if continue on antibiotics. It will cause mild pain at that mastoid region only.
6) There is no chance that it will cause erosion. You can be sure about that.

Hope now you have all doubts answered.
Regards.
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