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Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection?

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Hi
I have been suffering from chronic mostoiditis for a year. My left mastoid is affected. There is no discharge from my ear.
I tried all sorts of antibiotics (around 10) and also had a mastoidectomy. Fluid culture from mastoid did not reveal anything. Had 6 CTs in 1 year before and after mastoidectomy. All of them showed little fluid collection in mastoid. However there is no bone destruction. I have one sided headache and pain in my left temporal scalp (side of the affected ear). I don't have any pain at back of the ear.
I have a few questions -
1. What are the consequences of a chronic mastoid infection?
2. How long does it take to resolve on its own? I tried all sorts of antibiotics but nothing helped. Is it not curable by antibiotics/mastoidectomy? That little mastoid fluid is always there in my mastoid continuously what ever I do.
3. Now since I have done 6 CTs in 1 year I also have the fear of radiation. Am I at risk of any radiation health hazard in my future due to all these 6 CTs that I have done?
4. Can there be any other cause of my temporal scalp headache other than mastoiditis?
5. I had mastoidectomy 3 months ago. How long does it take for the mastoid to heal? I had a CT just 2 days back which again showed little fluid collection. Is it possible that the fluid is there due to mastoidectomy which was done 3 months ago?
6. Can my present one sided headache be due to mastoidectomy?

Thanks,
XXXXXXX.
Posted Sun, 13 Jan 2013 in Ear, Nose and Throat Problems
 
 
Answered by Dr. Naveen Kumar 1 hour later
Hi XXXXXXX

Thanks for the query and a thorough description.

1. What are the consequences of a chronic mastoid infection?
A: The consequences of chronic mastoid infection are many, to mention a few:
a) Persistent ear discharge
b) Deafness due to damage to middle ear ossicles and the sensitive inner ear
c) Dizziness following damage to the labyrinth
d) Cerebral abscess due to extension of the disease into the brain, etc.

2. How long does it take to resolve on its own? I tried all sorts of antibiotics but nothing helped. Is it not curable by antibiotics/mastoidectomy? That little mastoid fluid is always there in my mastoid continuously what ever I do.

A: Resolving of the symptoms depends on the body immunity. In normal individuals it will take around a week or two to resolve completely. If there is any anatomical block, no amount of antibiotic will help in reducing the problem. Mastoidectomy is the treatment of choice in chronic mastoiditis. Presence of small amount of fluid is common in many individuals, many a times; it could be a fluid trapped mastoid air cell.

3. Now since I have done 6 CTs in 1 year I also have the fear of radiation. Am I at risk of any radiation health hazard in my future due to all these 6 CTs that I have done?

A: I am surprised at the number of CT scans performed on you. If it were to be a low dose CT scan, then no need to worry. But, if it was a normal CT then you will definitely be under risk category and have to avoid radiation exposure for at least 2 -3 years.

4. Can there be any other cause of my temporal scalp headache other than mastoiditis?

A: If the headache has been noticed after mastoidectomy then it could be due to cutting of the temporalis muscle. But, if you have noticed it before the surgery then the probable cause of your headache is migraine.

5. I had mastoidectomy 3 months ago. How long does it take for the mastoid to heal? I had a CT just 2 days back which again showed little fluid collection. Is it possible that the fluid is there due to mastoidectomy which was done 3 months ago?

A: It can take at least 6 months to one year for the cavity to heal. Small amount of fluid retention following surgery could be due to missed air pocket or collection of normal fluid.

6. Can my present one sided headache be due to mastoidectomy?

A: Yes, one can present with headache following surgery. This is due to cutting of the temporalis muscle and retraction of the scar tissue.

Hope I have answered your query; I will be available for the follow-up queries.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 1 hour later
Hi

Thanks for your answer. Here are my follow-up questions.

1. What are the consequences of a chronic mastoid infection?
A: The consequences of chronic mastoid infection are many, to mention a few:
a) Persistent ear discharge
XXXXXXX- I don't have. Never had any discharge.
b) Deafness due to damage to middle ear ossicles and the sensitive inner ear
XXXXXXX- Hearing is normal
c) Dizziness following damage to the labyrinth
XXXXXXX- Don't have
d) Cerebral abscess due to extension of the disease into the brain, etc.
XXXXXXX- Don't have.

XXXXXXX- I have popping sound in my ear when I swallow and occassionally slight congestion in the ear. I never had ANY ear problem before this 1 year.

2. How long does it take to resolve on its own? I tried all sorts of antibiotics but nothing helped. Is it not curable by antibiotics/mastoidectomy? That little mastoid fluid is always there in my mastoid continuously what ever I do.

A: Resolving of the symptoms depends on the body immunity. In normal individuals it will take around a week or two to resolve completely. If there is any anatomical block, no amount of antibiotic will help in reducing the problem. Mastoidectomy is the treatment of choice in chronic mastoiditis. Presence of small amount of fluid is common in many individuals, many a times; it could be a fluid trapped mastoid air cell.
XXXXXXX- Can this small amount of fluid be there for so long time? In my case 1 year. I had a mastoidectomy. Even then it is there.

3. Now since I have done 6 CTs in 1 year I also have the fear of radiation. Am I at risk of any radiation health hazard in my future due to all these 6 CTs that I have done?

A: I am surprised at the number of CT scans performed on you. If it were to be a low dose CT scan, then no need to worry. But, if it was a normal CT then you will definitely be under risk category and have to avoid radiation exposure for at least 2 -3 years.
XXXXXXX- Can I do something to reduce the risk? Am I at risk of cancer?

4. Can there be any other cause of my temporal scalp headache other than mastoiditis?

A: If the headache has been noticed after mastoidectomy then it could be due to cutting of the temporalis muscle. But, if you have noticed it before the surgery then the probable cause of your headache is migraine.
XXXXXXX- Does mastoiditis cause temporal headache? Indomethacin helps in my headache.

5. I had mastoidectomy 3 months ago. How long does it take for the mastoid to heal? I had a CT just 2 days back which again showed little fluid collection. Is it possible that the fluid is there due to mastoidectomy which was done 3 months ago?

A: It can take at least 6 months to one year for the cavity to heal. Small amount of fluid retention following surgery could be due to missed air pocket or collection of normal fluid.
XXXXXXX- Does that mean I will have dull pain for a year? What is "collection of normal fluid"? You mean it is not infected? How did it come there?

6. Can my present one sided headache be due to mastoidectomy?

A: Yes, one can present with headache following surgery. This is due to cutting of the temporalis muscle and retraction of the scar tissue.
XXXXXXX- One side of my head feels heavy. It feels inflammed/swollen. Can this be due to mastoidectomy. My doctor says the head is not swollen.

XXXXXXX- two additional question. I have taken 10 different antibiotics. Will there be long term effect of taking so many antibiotics on my body? I am presently on AKT-4 but my mastoid glue culture showed nothing. My blood culture is also negative and TB PCR is negative. My blood reports are - ESR = 10, WBC = 6800, CRP = 10. Is it advisable to stop AKT 4? I have taken it for 1 month with not much benifit.

Thanks,
XXXXXXX
 
 
Answered by Dr. Naveen Kumar 15 hours later
Hi

Thanks for writing back

Q: I have popping sound in my ear when I swallow and occasionally slight congestion in the ear. I never had ANY ear problem before this 1 year.

A: The popping sound in the ear is due to opening and closing of the Eustachian tube (the tube connecting nose and the ear) and this is completely normal. The problems could have all started because of the blockage/dysfunction of Eustachian tube.

Q: Can this small amount of fluid be there for so long time? In my case 1 year. I had a mastoidectomy. Even then it is there.

A: Yes, there can be small amount of fluid retained in the mastoid cavity and this not going to cause any problem. Secondly, the same fluid trapped air cell would not have been effectively removed during mastoidectomy or it could be the normal secretions which are noticed following mastoidectomy. If it is the normal secretions following mastoidectomy, then, it will take 5-6 months for the ear to become dry.

Q: Can I do something to reduce the risk? Am I at risk of cancer?

A: Please consume plenty of fresh fruits and vegetables to boost up your immunity and for detoxification. No, you are not at the risk of cancer. In future, try to avoid any exposure to radiation for at least 2-3 years.

Q: Does mastoiditis cause temporal headache? Indomethacin helps in my headache.

A: It is very unusual for the mastoiditis to cause headache, unless it is associated with complications. I presume, your temporal headache is due to migraine, which is why indomethacin was effective.

Q: Does that mean I will have dull pain for a year? What is "collection of normal fluid"? You mean it is not infected? How did it come there?

A: Dull pain could be due to scar retraction and cutting of the muscle, the pain will remain till the things settle down. Normal fluid is the secretions from the newly forming inner lining of the operated mastoid cavity. I don't think so it is infected; if it is infected, then there will be fever associated with it.

Q: One side of my head feels heavy. It feels inflammed/swollen. Can this be due to mastoidectomy? My doctor says the head is not swollen.

A: Occasionally, there can be swelling over the operated region due to presence of edema at the operated site. But, it is not possible for the entire hemicranium to be swollen. Migraine can give rise to this sort of symptoms.

Q: Will there be long term effect of taking so many antibiotics on my body? I am presently on AKT-4 but my mastoid glue culture showed nothing. My blood culture is also negative and TB PCR is negative. My blood reports are - ESR = 10, WBC = 6800, CRP = 10. Is it advisable to stop AKT 4?

A: Yes, definitely! I wonder why so many antibiotics were prescribed to you. Your body defense mechanism reduces with long term antibiotics and also it gives rise to various other problems such as fungal infection, multi-drug resistance, acidity, etc. I don't know the reason behind starting AKT-4. If it is not necessary, better to stop AKT-4.

I wish you good health.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 5 hours later
Thank you doctor for your answers. A few more questions:

1. How can the Eustachian tube dysfunction be corrected? Do you suggest any medicine or technique to correct it?

2. Is there any medicine to absorb the fluid in the mastoid air cells?

3. I can feel that I have left sided scalp headache. In that case how long to take indomethacin?

4. It began with an abcess on outside my ear drum 1 year ago which bursted within 2 days. I also got blood filled within my middle ear at the same time. Doctor then told it is haemorrhagic otitis media. Now can you get some clue regarding my temple pain? It was never there before this infection. The pain on my hemicranium started around a week after this ear infection.

5. I also had a bone scan which showed some increased activity in my mastoid region. But my CT / MRI did not show any bone erosion. Doctor said it is not osteomyelitis. Is it common in such cases to have an increased bone activity? Is it bone sclerosis ? If so is it different from osteomyelitis? What are the dangers of this type of bone activity?

6. I was also put on a grommet. Latter a different doctor told that the grommet was put in wrong way very close to the ear bone. Can this trigger a TMJ pain? Can this grommet cause bone inflammation? One doctor told me that grommet can cause this type of activity in bone scan. But when the bone scan was done the grommet was out 2 months before it.

7. AKT-4 was started emperically thinking that the fluid is so long there and TB is one of the most common disease in India. However, my TB test came out to be negative and fluid culture from mastoid did not reveal anything. In such a scenario will stopping AKT 4 have any negative impact?

8. Can this be herpes zoster oticus and I am suffering from post-herputic neuralgia on my hemicranium? I just had one blood filled abcess just on my ear drum.

Regards,
XXXXXXX
 
 
Answered by Dr. Naveen Kumar 4 hours later
Hi

Welcome back

Q: How can the Eustachian tube dysfunction be corrected? Do you suggest any medicine or technique to correct it?

A: You need to use saline nasal spray followed by steam inhalation 3-4 times a day; avoid smoking and chilled food/beverages. Alternatively, you can use steroid nasal spray.

Q: Is there any medicine to absorb the fluid in the mastoid air cells?

A: No, there are no medicines to remove the fluid, but; you can try oral decongestant such as pseudoephedrine.

Q: can feel that I have left sided scalp headache. In that case how long to take indomethacin?

A: Indomethacin is a pain reliever; you can use it only when you are having pain. It can be used for any number of days, but, certain side-effects are noticed on prolonged usage.

Q: It began with an abcess on outside my ear drum 1 year ago which bursted within 2 days. I also got blood filled within my middle ear at the same time. Doctor then told it is haemorrhagic otitis media. Now can you get some clue regarding my temple pain? It was never there before this infection. The pain on my hemicranium started around a week after this ear infection.

A: I do agree with the fact that initial episode of headache started with acute mastoiditis. But, it does not remain for so long. Once the infective stage resolves, the headache will disappear. If there were to be persistence of the abscess, it would have been picked up in CT scan or MRI. Hence, I strongly feel the headache could be because of migraine.
Q: I also had a bone scan which showed some increased activity in my mastoid region. But my CT / MRI did not show any bone erosion. Doctor said it is not osteomyelitis. Is it common in such cases to have an increased bone activity? Is it bone sclerosis ? If so is it different from osteomyelitis? What are the dangers of this type of bone activity?

A: Yes, any blockage in the middle ear cleft initiates sclerotic reaction of the mastoid bone. This is in response to the anaerobic environment in the middle ear.

Q: Can this trigger a TMJ pain? Can this grommet cause bone inflammation? One doctor told me that grommet can cause this type of activity in bone scan. But when the bone scan was done the grommet was out 2 months before it.

A: No, insertion of grommet cannot trigger TMJ pain. No, grommet insertion will not cause bone inflammation.

Q: However, my TB test came out to be negative and fluid culture from mastoid did not reveal anything. In such a scenario will stopping AKT 4 have any negative impact?

A: When the fluid culture was showing negative to TB, ESR was normal; then there is no point in starting AKT. No, stopping of AKT will not have any negative impact.

Q: Can this be herpes zoster oticus and I am suffering from post-herputic neuralgia on my hemicranium? I just had one blood filled abscess just on my ear drum.

A: This cannot be Herpes Zoster oticus as it will not be perceived for such a long period. The pain of Herpes will be very severe around the ear and the corresponding area where that particular nerve supplies.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 42 minutes later
Thanks doctor. A few more questions:

1. How XXXXXXX is this sclerosis of bone and what can be done for it? Is it normal or a bone disease?

2. Can this be a nerve pain? A damage to nerve done by my mastoid infection which may be over now?

3. Are the zygomatic air cells usually opened and cleared during mastoidectomy? I had pain in that area and my jaw is tender.

4. Can this be a sudden TMJ pain which has no obvious reason?

5. Can this be just inflammation without infection? If so how long can inflammation stay there without infection?

Regards,
XXXXXXX
 
 
Answered by Dr. Naveen Kumar 3 hours later
Hi

Welcome back

Q: How XXXXXXX is this sclerosis of bone and what can be done for it? Is it normal or a bone disease?

A: Sclerosis of the bone is not a XXXXXXX thing; it is seen in many of the individuals suffering from chronic sinusitis, or Eustachian tube related problems.

Q: Can this be a nerve pain? A damage to nerve done by my mastoid infection which may be over now?

A: Yes, neuralgia is noticed during scar retraction also. This happens because of cutting of the superficial nerves in the skin during surgery.

Q: Are the zygomatic air cells usually opened and cleared during mastoidectomy? I had pain in that area and my jaw is tender. Can this be a sudden TMJ pain which has no obvious reason?

A: If it is infected only then clearing of the zygomatic air cells is required. The pain near TMJ could be due to arthritis of the joint or stretching of the joint following intubation during anesthesia.

Q: Can this be just inflammation without infection? If so how long can inflammation stay there without infection?

A: As I had mentioned before it could be more of a inflammation rather than an any infection.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 36 hours later
Hi

Some more questions:

1. Are the zygomatic air cells usually seen when the surgeon opens the mastoid? So that there is no chance of missing them when they are infected. I felt a pain there so thinking there might be infection.

2. I had a severe bleeding inside my middle ear during the initial infection. That fluid got trapped and caused all these additional trouble. Can germs grow on such blood inside the middle ear?

3. Can this blood/pus which I got during my initial infection travel to my TMJ and cause infection there? I have pain on top roof of the tmj just the place where top point of the outer ear meets the head.

4. I never had migraine pain in my life. Can it suddenly happen like this after an infection?

5. Can this be some auto-immune disease?

6. Doctor said there is lot of fibrosis in my mastoid-tmj junction. Can this give rise to pain?

7. Does a normal fluid in mastoid disappears on its own or stays there forever?

8. You said intubation during anesthesia can cause tmj joint stretching. I suspect such intubation during my grommet insertion surgery which was done around a year ago. Will such a pain remain so long?

Regards,
XXXXXXX.
 
 
Answered by Dr. Naveen Kumar 7 hours later
Hi

Thanks for writing back

1. Are the zygomatic air cells usually seen when the surgeon opens the mastoid? So that there is no chance of missing them when they are infected. I felt a pain there so thinking there might be infection.

A: No, the bone has to be drilled out to visualize the zygomatic air cells. If it is infected only then it will be cleared or else there is no need of clearing the cells. Yes, occasionally, the surgeon might opt to clear those as precautionary measures. Infection can't remain for such a long period.

2. I had a severe bleeding inside my middle ear during the initial infection. That fluid got trapped and caused all these additional trouble. Can germs grow on such blood inside the middle ear?

A: Fluid gets trapped when there is anaerobic environment inside the mastoid air cells. It does not happen within a day or two; it happens over a period. Yes, during an attack of infection there will be micro-organisms feasting over. But, with the appropriate antibiotics the micro-organisms can be taken care of.

3. Can this blood/pus which I got during my initial infection travel to my TMJ and cause infection there? I have pain on top roof of the tmj just the place where top point of the outer ear meets the head.

A: Yes, in complicated situations the infection can travel to the zygomatic region, but, in the rarest of the situations it can get into TMJ. If the infection spreads to TMJ, there will be difficulty in opening the mouth and painful swelling in front of the ear.

4. I never had migraine pain in my life. Can it suddenly happen like this after an infection?

A: Migraine can present at any stage of life. Stress is the main reason for recurrent attacks of headache.

5. Can this be some auto-immune disease?

A: Any sort of auto-immune disease would have been identified by now and it would been substantiated with the investigations performed on you.

6. Doctor said there is lot of fibrosis in my mastoid-tmj junction. Can this give rise to pain?

A: Long-term inflammation of the synovial membrane of the TMJ can lead to inflammation of the joint capsule and to fibrosis. This restricts the mobility of the TMJ. This can happen as a result of surgery over the joint or trauma to the joint. The diagnosis can be confirmed by restricted mobility of the joint.

7. Does a normal fluid in mastoid disappears on its own or stays there forever?

A: The fluid following surgery is normal. It is the same sort of fluid which we see in the nose and the mouth.

8. You said intubation during anesthesia can cause tmj joint stretching. I suspect such intubation during my grommet insertion surgery which was done around a year ago. Will such a pain remain so long?

A: Usually, the grommet insertion is done under local anesthesia. Grommet insertion will not cause such sort of pain. The pain following grommet insertion will be noticed inside the ear and not over temporal region. The pain will subside once the grommet extrudes out.

Regards
Dr. Naveen Kumar N
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 44 minutes later
Thanks for your answers. A few more questions:

1. As I feel it is in the zygomatic region, one more question about it. Will the surgeon get any clue when he opens the mastoid that the infection has spread to the zygomatic region so that he goes and clears them? I am worried about whether everything has been cleared properly.

2. Will CT/MRI pick up any abnormality in the zygomatic region?

3. The pain is centered just above the tmj in front of the ear. From there it radiates to head. That's why I was thinking it is zygomatic mastoiditis. Can it be a chronic case of this? What dangers are there because of this?

4. Can I have a gallium scan / technicium scan done ? I already had 6 CTs as I told you and 1 bone scan.

5. Can mastoid surgery lead to tmj region fibrosis?

6. My grommet insertion was done under general anesthesia. So there might be chances of injury during such a procedure. I could not eat hard food for a month after that. This temple pain/TMJ pain started after that. The grommet was there for 2 months. However, even when it is out for 10 months I still have pain but intensity has decreased. Can there be pus accumulation after grommet insertion which can make matters worse?

7. As I told you I had bleeding inside my ear before the infection. Can this blood/pus directly travel to the zygomatic cells and cause infection there?

8. Do you suggest another surgery for this chronic mastoiditis? I had one. Is there any other way out?


Regards,
XXXXXXX.
 
 
Answered by Dr. Naveen Kumar 2 hours later
Hi

Welcome back

1&2. A surgeon gets an idea about infected zygomatic cells after going through the CT scan. CT scan is the best guide for the surgeon to analyze the extent of the disease and picks up the abnormality in the temporal region.

3. The pain over the TMJ could be due to arthritis of the joint. TMJ arthritis can radiate to the temple on the same side. I doubt the mastoiditis can lead to all these complications.

4. All those investigations are not required.

5. Unless the posterior wall of the joint is not damaged during surgery, the TMJ fibrosis cannot occur. Secondly, this damage can occur very rarely during mastoid surgery.

6. Yes, that could be one reason behind the pain. Excessive stretching of the capsule can cause arthritis of the joint. It is not possible for the pus to accumulate following extrusion of the grommet. You can try a short course of oral steroids, local application of ibuprofen or diclofenac ointment and rest for the affected jpint.

7. Yes, it can happen when appropriate intervention is not done at the right time.

8. Just have some patience and wait for few days till you recover completely from the present surgery.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon




Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 14 hours later
Thanks for your reply. A few more questions:

1. My pain is only in the left scalp. It pains even when touching. I am on indomethacin which gives me some relief. The pain is like some muscle stretched always. There is also slight inflammation on my jaw. As I told you I was very worried about zygomatic mastoiditis. Is there any such thing as chronic zygomatic mastoiditis which stays there in a dormant / masked state and very slowly cause problems?

2. My TMJ joins are clear according to a specialist. There is no joint swelling. Half of my head feels like tight ropes bounded together. There is no jaw clicking on the affected side but there is severe jaw clicking on the opposite side. Can there be TMJ pain even if my TMJ joint is clear in x-ray? I have attached the x-ray for your reference.

3. Can this TMJ stay so long assuming it happened due to muscle stretch during my grommet insertion surgery 10 months back?

4. Can mastoiditis (zygomatic/normal) cause TMJ?

5. My hearing is normal but my ear feels clogged. Can this be due to mastoid problem? I feel there is fluid/inflammation inside my ear but the CT shows there is nothing. Why is this feeling? Can the CT/MRI miss something?

6. You told zygomatic mastoiditis is a complication of mastoiditis.I read that temple pain is a symptom of zygomatic mastoiditis. Is it 100% sure that the CT will catch it? If not then the surgeon might have missed them and I still have the pain. Since the CT films are too large in size (110 MB) I can't send them to you.

7. My CT report says that the attic/tegmen is normal. Is attic/tegmen connected to the zygomatic area and does that mean the zygomatic area is clear? There is no specific mention of the zygomatic area in my report. Is there any possibility of zygomatic area erosion and csf leak and death thereby in long term?

8. Can there be muscle spasm in the head due to healing of the mastoid from inside? My outside scars have healed and there is nothing noticable from outside.

Regards,
XXXXXXX.
 
 
Answered by Dr. Naveen Kumar 27 hours later
Hi

Welcome back

1. I feel, it is more of migraine or TMJ problem rather than mastoiditis, that is the reason for relief in pain following ingestion of indomethacin. Zygomatic mastoiditis is usually an acute condition which is evidenced by swelling and pain over the pre-auricular region

2. X-ray shows sclerosis of the joint on (L) side. The features could be of migraine. Consult a faciomaxillary surgeon for further queries.

3. Yes, it can.

4. No

5. Mastoiditis can cause reduced hearing. The hearing loss is primarily due to either Eustachian tube block or damage to the ossicles in the middle ear or neural loss. In your case I suspect both Eustachian tube block and neural loss. Audiometry can diagnose this problem.

6. Yes, it can be identified by CT scan, more than that, one can identify by general examination and it is of short duration.

7. No CSF leak does not happen in Zygomatic mastoiditis, unless there is erosion of the tegmen plate or floor of the skull.

8. TMJ arthritis can cause spam of the temporalis muscle, scar healing can also cause tightness over the operated area and inside the skin where the temporalis muscle has been cut.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 2 hours later
Thanks for your answers. A few more questions:

1. Do you think the infection spread to the TMJ and caused sclerosis there? What might be the cause of sclerosis?

2. I can feel that it might be TMJ but my mouth opening is not limited and I don't have any pain exactly over the joint. However, both top and bottom(on the parotid) of the joint is painful. Can this be infectious arthritis of TMJ?

3. My ESR is normal but CRP is always high (10-20 range) during the past 1 year. My WBC count is normal. Is this because of infection?

4. The bone scan showed some increased activity in the TMJ/mastoid region. If this is due to sclerosis, what are the dangers of this in long term in the TMJ if this is due to infection?

5. I have taken the following antibiotics - gentamicin, amikacin, pippercillin, ofloxacin, levofloaxcin, augmentin, cephodem XP, ceftrioxone, ciprofloaxcin, AKT-4. Levofloaxcin was of some help but doctor stopped it giving me a course of 7 days saying it might harm in prolonged courses. Not sure what I should take now to remove this bone infection. Can there be bone inflammation and pain without infection for such a long time?

6. What is the best treatment for chronic osteomyelitis, assuming the pain is due to tmj osteomyelitis? Long term antibiotic or tmj surgery?

7. Can there be bone inflammation and pain without infection for so long time (10 months)?

Regards,
XXXXXXX
 
 
Answered by Dr. Naveen Kumar 16 hours later
Hi

Thanks for writing back

1. Sclerosis happens due to repeated trauma to the joint leading to fibrosis and hardening of the joint capsule. This happens when there is excessive stretching of the joint capsule, constant use of one side of the jaw, surgery over the joint, trauma, etc. Joint capsule is a tough covering of the joint which protects against infection. It is almost impossible for the infection to spread from the mastoid to the TMJ.

2. The restriction of the joint movements does not happen in all the cases. Only people having painful joints suffer from restriction of the joint movements. Infection inside the joint happens only in those individuals suffering from immuno-suppression and elderly.

3. CRP is mildly raised, but that does not indicate active infection. CRP raises during active infection and is significant when it is more than 100.

4. Bone scan is indicated in tumors. Increased activity is noticed when there is destruction and regeneration of the bone tissue, sclerosis is one such condition. But, in your case this is not something XXXXXXX

5. Do not take any antibiotics, it is not required at present. Just wait for few more days till you recover from the surgery completely. Yes, there can be inflammation without infection.

6. Do not worry! Osteomyelitis is altogether a different entity. It is nowhere close to your condition. Long term antibiotics will cause depression of the immunity, gastritis, fungal infection, injury to liver and kidney, etc.

7. Yes, there can be joint inflammation and pain without infection.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon




Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 9 hours later
Hi

Thanks again. A few more questions specific to tmj:

1. After grommet insertion I could not chew / open my mouth properly for about a month (not sure whether this is usual???). There was some swelling on my left side (affected ear) near the zygomatic arch. From that time only this muscle tightness on my left side started and is still continuing for 10 months. A doctor told me that the grommet was inserted in the fouth quadrant so it has been wrongly put and put very near to the bone. I also used to close my nose and blow forcefully through the nose so as to pass air through the grommet. I could also feel a very painful inflammed spot at the top roof of my oral cavity, very close to TMJ (this is not there any more after grommet removal). This is a brief history of why I may get TMJ. Given this scenario is there chance of TMJ?

2. In my X-ray sent earlier you will see my right TMJ is bent a bit and it makes sound on my right when I open and close my mouth. But my pain is on left side (the side of prior ear infection). Can you please help me co-relate the whole scenario?

3. I have a constant dull pain every time for the last 10 months (after the grommet insertion). The pain is surrounding the ear and back TOP portion of my left hemicranium. The pain increases once / twice in a day. I mostly feel the pain is outside my skull. There are some pain points also which if I press pains. Are these symptoms of TMJ?

4. A doctor told me that I have skull base osteomyelitis. Is this type of headache which I described above suggestive of skull base osteomyelitis? I am really very worried and concerned.

Kindly let me know if you require any further information.

Regards,
XXXXXXX
 
 
Answered by Dr. Naveen Kumar 3 hours later
Hi

Welcome back

1. Yes, you are right, the pain and swelling in the TMJ could have been due to excessive stretching of the joint capsule following mouth opening during intubation. Even though, grommet insertion causes pain inside the ear, it will not induce any swelling over the joint. Hence it can be only Arthritis of the TMJ.

2. Clicking noise happens when there is dysfunction of the joint. It is not possible to identify the problems related to joint capsule through OPG, it requires MRI of the joint. With OPG only bony abnormalities and the gap in the both joints can be compared.

3. Yes, the pain could be due to TMJ arthritis.

4. I do not understand who tells you all these sort of things. Skull base osteomyelitis is a rare condition. The prevalence of skull-based osteomyelitis is about 1.5% of all osteomyelitis cases. Patients with compromised immune systems, (such as diabetics, those with cancer, or transplant patients) are more prone to the disease.

I would suggest you to consult a good faciomaxillary surgeon to clarify all your doubts regarding the joint. Secondly, stop worrying; the more you worry, the pain worsens due to spasm of the temporalis muscle, hence worsening your symptoms. Don't subject yourself to any sort of unnecessary investigations, most of the practitioners try to give a run for your money.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 2 days later
Hi

I have showed a doctor who suspects it is temporal arteritis as he says such a thing can happen during and after a severe infection.

1. Since my pain is in the scalp and I feel some part of my scalp is swollen (minimal swelling), so it was suggested that I might have temporal arteritis due to my infection which might have gone now. Kindly give me your valuable second opinion about temporal arteritis.

2. Can TMJ affect top of scalp?

3. As you mentioned earlier, any anaerobic environment can give rise to bone sclerosis. I remember when I had the initial infection, there was lot of blood inside my middle ear. Could this blood/pus form an anaerobic environment inside my ear and go to mastoid and start sclerosis there?

4. How long does sclerosis take to settle? Is sclerosis a mild form of osteomyelitis?

5. Should I start on steroids thinking it is temporal arteritis? I heard that steroids destroy immunity so worried about starting it.

6. Is indomethacin which I am taking now sufficient for temporal artheritis?

7. Also I was told that it might be a MRSA ear infection since my initial infection started with an abcess on my eardrum. If it is MRSA which has spread to my scalp what do I need to do now?


Thanks a lot.

Regards,
XXXXXXX
 
 
Answered by Dr. Naveen Kumar 17 hours later
Hi XXXXXXX

Welcome back

1. Temporal arteritis is a disease of older people. The average age of onset is 72, and almost all people with the disease are over the age of 50. Women are more commonly affected than men. I doubt your problems are related to the above condition.

2. Yes, it can; this happens over the area from where the temporalis muscle originates. Temporalis muscle is a fan shaped muscle having its origin over the side of the scalp popularly known as temporal region ( WWW.WWWW.WW and gets inserted into the mandible.

3. Yes, the blood and pus could have been formed due to infection and anaerobic environment in the middle ear. The sclerosis would have been formed before, during or after the infection.

4. Once the anaerobic condition stops the sclerosis stops forming. Let me explain to you about this; mastoid can be of two types, sclerotic and pneumatic. Pneumatic is the one containing air in the honey comb like mastoid bone, which is normal. Sclerotic is a hardened bone replacing the pneumatic bone; the air spaces get obliterated and a hard bone is formed. Osteomyelitis is a different entity wherein the bone gets destroyed and the pus gets accumulated and tracks into the surface of the skin. This does not happen with sclerosis. There is no bone destruction in sclerosis. In fact, sclerosis resists destruction of the bone.

5. Once sclerosis forms it will remain there forever, it will never revert back.

6. Indomethacin is just a pain killer; it can relieve all sorts of pain.

7. MRSA would have been taken care of by now with the number of antibiotics you have taken. It can spread to the brain and skull only if appropriate intervention has not been carried out.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 8 hours later
Hi

Thanks again for your elaborate answers.

A few more questions:

1. Assuming my mastoidectomy did not eradicate my ear infection fully and still there is some masked mastoiditis or anaerobic environment, what do I do now - wait n watch ? What are the symptoms that I should watch for and report immediately?

2. Is masked mastoiditis a XXXXXXX disease? Does it produce sclerosis for ever?

3. During last 1 year there was no observable bone erosion in my HRCT that were done several times. Does this mean there will be no erosion in future also?

4. A doctor also suggested trigeminal neuralgia for me and I was given pregabalin with which I got relief. Please give me your valuable second opinion about this.

5. My jaw line is swollen and painful. This indicates TMJ as you said. Can TMJ give rise to trigeminal neuralgia?

6. I even have difficulty (pain) in combing my hair on the affected side. I can feel that its something related to my scalp. Is this an indication of TMJ or Trigeminal Neuralgia?

7. Should I start on steroids for decreasing inflammation?

8. If that anaerobic environment is not removed from my ear and mastoid, will sclerosis continue for ever or will my body take some action to resolve it automatically and things will become normal with time?

Regards,
XXXXXXX.
 
 
Answered by Dr. Naveen Kumar 2 days later
Hi

Welcome back

I sincerely apologize for the delay in answering your queries as I was out of town.

1. Usually, with mastoidectomy most of the diseased air cells would have been cleared. Seldom has a surgeon left behind the diseased air cells. I would suggest you to wait and watch for another 3-4 months.

2. Yes, masked mastoiditis can be XXXXXXX in children and it can produce sclerosis.

3. Bone erosion does not happen suddenly in any case of mastoid infection, it is a slow process. Bone erosion happens when there is increased pressure and an anaerobic environment created in any tissue. Now, the entire mastoid has been drilled out, hence, there will be no chances of any bone erosion.

4. Pregabalin is used for the treatment of chronic pain, nerve related pain, peri-operative pain and migraine. Trigeminal neuralgia is an inflammation of the trigeminal nerve causing extreme pain and muscle spasms in the face. Attacks of intense, electric shock-like facial pain can occur without warning or be triggered by touching specific areas of the face. I doubt you had any symptoms similar to this.

5. No

6. Few features of TMJ arthritis, migraine and trigeminal neuralgia can have over-lapping symptoms which needs to the differentiated with a thorough history and a complete examination.

7. It is better to start on a short course of low dose oral steroids to reduce the inflammation and pain. This helps in ruling out various causes of pain. Migraine will not subside with steroids, but, TMJ arthritis will reduce completely and trigeminal neuralgia to a certain extent.

8. Whether it is a sclerotic bone or a pneumatic bone, all the cells would have been cleared during mastoid surgery, hence there does not arise any question of sclerosis in the future.

If you have any more doubts you can request the XXXXXXX team to connect to my phone through the portal called “Ask a Doctor on Phone”, so that I can explain to you thoroughly.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 53 minutes later
Hi

I have attached 3 pics of CTs taken at different times:

1. ms-03.jpeg - taken 1 month after initial ear infection. Some air cells in the mastoid tip are filled with fluid.

2. ms-04.jpeg - taken 7 months after infection. 1 air cell is filled. A new white spot has developed in that filled air cell.

3. ms-05.jpeg - taken 10 months after infection and 3 months after mastoidectomy. All my air cells are fluid filled. That white spot is prominent.

4. ms-06.jpeg - taken 10 months after infection and 3 months after mastoidectomy. This is from a different angle. All my air cells are fluid filled. That white spot is prominent.

Now here are my questions:

1. What might be that white spot - infection, sclerotic bone, bone lesion or bone erosion?

2. Many air cells are still visible. Does that mean the surgery had not been done completely?

3. Why are all cells filled with fluid after the surgery?

4. Is some antibiotic fluid injected in all air cells during mastoidectomy? Are all the air cells sterilized?

5. Before mastoidectomy and even after I get jaw pains. Can that be due to this fluid in the air cells?

6. Can mastoid infection give rise to neuralgia which can spread over head and neck?

7. Are all air cells connected in the mastoid so that sucking at one shot during surgery can remove the accumulation without actually drilling and removing the cells?

8. Can sterile fluid in mastoid give rise to high activity in bone scan?

9. Assuming the fluid in those air cells is sterile, is there any chance of them getting infected in future?

10. If it is post surgery fluid, will it stay there for so long as 3 months?

11. Can neuralgia stay even after active infection goes away? If so usually how long?

Regards,
XXXXXXX.
 
 
Answered by Dr. Naveen Kumar 9 hours later
Hi

Thanks for writing back

1. The white spot inside the mastoid bone is the sclerotic air cell.

2. Yes, the air cells have not been completely exenterated.

3. Unless the inner layer of the cells heal completely the fluid will remain in the cells. The fluid is secreted during the process of normal repairing of the cells.

4. No antibiotics are not instilled into the cells, instead, a thorough wash is done using normal saline to remove the bacterial load and the bone dust.

5. No, this is not due to fluid in the cells.

6. No, it cannot.

7. No, this is not possible because of the presence of mucosal lining inside the mastoid air cells.

8. No

9. Yes, the fluid can get infected.

10. Yes, it will remain there till the exenterated cavity gets a normal inner lining.

11. Neuralgia is not directly related to the infection, stress induced during the infection can give rise to neuralgia.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 22 hours later
Hi Doctor,

A few more questions:

1. You said the fluid in the air cells is due to normal repair process. But even those cells which have not been touched by the surgeon are also filled. How can that happen?

2. Before mastoidectomy I had fluid in only posterio-inferior tip cells of the mastoid. Is this area so hard to reach/ so risky to operate that the surgeon did not clear it?

3. Before mastoidectomy I had fluid in only posterio-inferior tip cells of the mastoid. Can this by any chance cause a XXXXXXX jaw pain as this area is very close to the jaw?

4. I have attached a picture (FN-01.jpeg) which shows my approx pain region marked with red lines. Can you now get any clue of my pain? The pain starts just below my mastoid bone tip and goes till my TMJ in line with my mandibular ramus lining. There is pain also at top corner of head which radiates down.

5. I feel my scalp is a little swollen on the infected ear side (left side). Can you tell me the reason?

6. Assuming this is bone sclerosis which has not been treated properly what option do I have other than surgery?

7. My main problem is pain which I want to kill without pain-killer. Is another mastoidectomy the only option?

8. Are you available in India so that if possible I can contact you?

Regards,
XXXXXXX
 
 
Answered by Dr. Naveen Kumar 14 hours later
Hi XXXXXXX

Welcome back

1. Mastoid is a very small area; while drilling the bone the surrounding areas will also be affected by the vibrations caused by the drill. And also, during the reparative process the secretions can be noticed in the normal cells also, but this will gradually clear of.

2. No, it is not hard to reach the mastoid tip, but very few surgeons dare to clear those cells.

3. No, it is not possible unless there is associated complications (such as mastoid tip abscess).

4. & 5. That is area of origin and insertion of the temporalis muscle. When there is any inflammatory process (such as during TMJ arthritis/migraine/mastoid surgery/TMJ surgery), the muscle can becomes edematous and painful.

6. Do not worry! It is a minute sclerotic bone, it is not going to affect you in any way.

7. As mentioned before, try taking short course of oral steroids, give rest for the affected joint, take only soft feeds and chew on the non-affected site.

8. I am in Bangalore at present, you can request the XXXXXXX team to put you on "phone a doctor" portal, they will connect to my local number.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 24 hours later
Hi Doctor,

A few more questions:

1. Is there any occipital nerve damage/cut during mastoidectomy? I have pain radiating from my neck to the top of head in the occipital region.

2. As you saw in my last scans my mastoid tip air cells have not been cleared. These were the cells that had fluid in them and that are showing sclerosis now. The raidiologist note mentioned this as - "Subtle soft tissue opacification in posterio-inferior mastoid air cells". Now assuming this infection is still there, will it remain there forever without correct mastoidectomy and always be a risk of complications?

3. I can feel that my neck muscles are in spasm/inflamed. Can this be related to mastoid infection or mastoid surgery healing? I had mastoidectomy 4 months ago.

4. Are antibiotics not able to reach the tip cells?

5. A question about antibiotic resistance - Can taking a few antibiotics (say 10) produce resistance to ALL known antibiotics? I have taken many antibiotics so fear that I might have developed a superbug which is resistant to ALL antibiotics.

6. Even if I go for mastoidectomy there is no surity that those tip cells will be cleared and if I don't go for it there is always danger for complications. I am really confused and in tension. Please suggest what can be done?

Regards,
XXXXXXX
 
 
Answered by Dr. Naveen Kumar 3 hours later
Hi XXXXXXX

Welcome back

1. No

2. The fluid retained in the mastoid has to clear-off by itself or surgical intervention has to be performed. Do not worry! This is not going to give rise to any complications.

3. Neck muscle spasm could be due to the wrong posture maintained during sleep following mastoid surgery. Yes, mastoidectomy can give rise to neck muscle spasm during severe infection, but not in your case.

4. Antibiotics can reach to the tip of the mastoid cells, but unless the block in the middle ear cleft is not relieved the antibiotics will not be of much value.

5. Yes, taking multiple antibiotic can give rise to multi-drug resistance. Hence, you will require an appropriate antibiotic in a higher dose and for more number of days.

6. If you get the surgery done from a experienced surgeon they will definitely do a good job. As of now, just "wait and watch".

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 4 hours later
Hi

Thanks for your answers.

1. The sample taken during mastoid surgery did not reveal any growth. Since the surgeon has not drilled XXXXXXX enough, I doubt whether the sample collected was proper. Is it possible that sample at different places in the mastoid are different - i.e., some may not be infected and some may be?

2. I often get cold and tonsil problem. But my ear is normal. My CT shows there is no fluid collection in the middle ear. My ear drum is fine according to my ENT. My hearing is normal. But I get a slight popping sound only in the affected ear right from beginning of infection. Given this scenario, do you think I have a middle ear cleft block? If so what can be done to correct it?

3. Initial diagnosis for my ear infection was - "Viral haemorrhagic otitis media". Can such a thing give rise to abcess on the ear drum? Not sure if initial diagnosis was correct.

4. Can there be a chronic inflammation (bone inflammation) due to a chronic infection? If so what can be done for it?

5. My initial infection was from an abcess. It might be MRSA. If so did I take appropriate antibiotic for it? I have tried all these - cipro, augmentin, cephodem xp, gentamicin, amikacin, AKT-4, levofloaxcin, piptaz, oflox, ciftrioxone, ampicillin, doxicycline.

6. Pain around my ear started a week after my initial ear infection. In that 1 week there was just pus/blood filled in my ear. What might be this?

7. Having taken so many antibiotics, I want to try some natural ways. What can be done to reduce inflammation/infection naturally? I am presently taking septilin daily. Is there any such natural remedies?

8. Does a healthy body have capability to fight such bacterial infection without antibiotics?

Regards,
XXXXXXX
 
 
Answered by Dr. Naveen Kumar 14 hours later
Hi

Welcome back

1. After taking antibiotics, if the specimen sample is taken, it will not show any growth. No, the sample taken at different sites in the mastoid will not vary with the bacterial growth.

2. Yes, you could be having a middle ear cleft block, the popping sound is the opening and closing of the Eustachian tube (the tube connecting nose and the ear).

3. 'Viral haemorrhagic otitis media' is a new terminology for me, I have never heard something like this. I presume you were having acute suppurative otitis media which was filled with infected secretions and blood.

4. Yes, it can happen and with appropriate antibiotics it can be taken care of.

5. 1gm of Augmentin for 2 weeks would have been an ideal antibiotic regimen

6. This was typical acute suppurative otitis media.

7. Septilin can be taken; along with that drink plenty of warm water and do steam inhalation 3-4 times a day. Take a mucolytic such as ambroxol or bromhexine which helps in reducing the consistency of secretions and thus clearance from the mastoid cells.

8. Yes, people with good immunity can fight against these sort of infection.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Mastoidectomy done. Having pain in left temporal scalp, no ear pain. Chronic mastoid infection? 36 hours later
Hi Doctor,

1. Since my glue culture was negative can it be safely said that I did not have infection?

2. If I did not have any infection then why was my bone scan positive?

3. What steroid can I take and in what dosage for inflammation?

4. I feel that my scalp is tender. Some blood vessels in my head are inflammed. What does this point to?

5. Assuming there is mucosal thickening in my left mastoid now after surgery, can this produce any referred pain in the top left side of the head?

6. I have pain in my steno-mastoid muscle and neck. Is it only due to sleep posture or can there be some other cause?

7. I heard that Temporal Arteritis is produced after/during a severe infection. Is it true?

8. Is temporal arteritis a part of skull based osteomyelitis?

9. Can abcess on ear drum be produced by bacteria other than MRSA?

Regards,
XXXXXXX
 
 
Answered by Dr. Naveen Kumar 44 hours later
Hi

Welcome back

1. Yes

2. Bone scan will be positive whenever there is some ongoing activity in the bone tissue such as new bone formation, inflammatory changes (sclerosis), cancer, etc. So in your case, it was sclerotic changes which was happening hence there was positive reaction on the scan.

3. You can take prednisolone after getting the prescription from your doctor. As per the online consultation rules I am not supposed to mention the dosage, strength and duration of the medicine.

4. This can happen in various conditions such as Migraine, TMJ arthritis, mastoid surgery, temporal arteritis, etc. In your case, I feel, it could more of TMJ arthritis and associated migraine. I doubt it is Temporal arteritis.

5. No

6. I presume, it could be more of wrong posture attained during sleep in order to avoid the operated area.

7. No

8. No

9. Yes, pseudomonas can also cause middle ear infection, but most of the times it is staphylococcal infection.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
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