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Suffering from Chronic mastoiditis. CT scan shows fluid mastoid. Bone biopsy revealed some mild lymphocytes. Due to infection?

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Hi

I am suffering from Chronic mastoiditis for 2 years. There is no ear discharge. I had never got any ear discharge or fever. My eardrum is normal but CT shows fluid in mastoid. Bone scan shows increased uptake in mastoid. I underwent mastoidectomy 2 times (both cortical). Still I have the following symptoms -
pain in the affected side. Not exactly on the mastoid but in the parietal and occipital scalp and top of head. Sometimes rarely inside the ear and also near the surgery scar.

My questions -
1. I have pain in the upper part of mastoid near the surgery scar. Any idea about the cause? Is there any nerve involvement?
2. Is the pain in the scalp normal after 3 months of surgery?
3. My bone biopsy shows - "Calcification of lamellar mastoid bone". What does that mean? Is it dangerous?
4. My ESR is 5 and CRP is within 10-15 over the last 6 months. Can this indicate infection?
5. My bone biopsy revealed some mild lymphocytes in the mastoid. Is it due to chronic infection or inflammation?
6. I have sharp shooting pain on top of my head near the vertex and also near my eyes. Whole scalp on the affected side seems to be inflammed. Can this be due to infection or surgery?

Thanks,
XXXXX
Posted Thu, 17 Oct 2013 in Ear, Nose and Throat Problems
 
 
Answered by Dr. Sumit Bhatti 2 hours later
Brief Answer:
Unusual. Trigeminal Neuralgia. Review CT, meds

Detailed Answer:
Hi,

Thank you for your query.

1. Pain around the post aural surgical incision may be due to small unnamed cutaneous nerves that may be cut while the incision is taken.

2. Occasional or dull aches and pains in the scalp may occur 3 months after surgery. These should subside over time, otherwise they are unusual.

3. Sclerotic changes in the mastoid bone are usually seen in chronic mastoiditis and are not XXXXXXX However it is unusual for a bone biopsy to be sent during a simple cortical mastoidectomy.

4. A normal ESR is 5 and CRP is within 10-15 does not indicate any infection or inflammation. Other blood tests may be required and symptoms will also be there.

5. Mild lymphocytosis in the mastoid in the bone biopsy may be due to a mild infection via the Eustachian Tube. Do you suffer from frequent colds or sinusitis?

6. The sharp shooting pain on top of your head near the vertex and also near your eyes, with a feeling that the whole scalp on the affected side is inflamed may be due to Trigeminal Neuralgia. These sensation may be referred pains. The source of the irritation may be local infection, inflammation or the surgery itself.

7. I would like to review any CT Temporal Bone images and other test results if you can upload them.

8. Painkillers for neuralgias are different from routine pain medications.

I hope that I have answered your query. If you have any further questions, I will be available to answer them.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Suffering from Chronic mastoiditis. CT scan shows fluid mastoid. Bone biopsy revealed some mild lymphocytes. Due to infection? 17 hours later
Hi

Some more questions:

1. My doctor said that the whole mastoid bone is inflammed. But there was not pus found. So no culture could be done. Is it possible to remove the whole mastoid? If not what to do now?

2. Even after 2 mastoidectomies and grommet insertion my mastoid pain is not going. What next to do?

3. Does sclerosis produce pain?

4. My doctor suggested osteomyelitis of mastoid. What can be done for it? I have taken ciplox for 1 month with no benifit.

5. Can there be bone pain due to surgery even after 4 months?

6. Is there any surgery to remove the whole mastoid bone?

Regards,
XXXXX
 
 
Answered by Dr. Sumit Bhatti 3 hours later
Brief Answer:
As below

Detailed Answer:
Hi,

Thank you for your query.

1. It is not required to remove the whole mastoid bone for mastoiditis.

2. It is common for a second mastoidectomy being done of the first is done conserving bone in the first procedure. By definition, a cortical mastoidectomy leaves no place for a repeat procedure.

3. Sclerosis of the mastoid does not produce pain. Ask for the anti-neuralgia medications.

4. Osteomyelitis is severe bone infection. The changes will be easily picked up on an MRI + HRCT Temporal Bones.

5. There should be no bone pain 4 months after surgery. The bone itself does not have pain receptors, the lining (periosteum) of the bones has pain receptors.

6. The entire temporal bone can be removed, however this is only done for cancers and occasionally advanced osteomyelitis seen in immuno-compromised patients.

7. In your case the cortical mastoidectomy should suffice to drain the mastoid
bone and a review of antibiotics may help,

8. I would like to review any CT Temporal Bone images and other test results if you can upload them.

I hope that I have answered your query. If you have any further questions, I will be available to answer them.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Suffering from Chronic mastoiditis. CT scan shows fluid mastoid. Bone biopsy revealed some mild lymphocytes. Due to infection? 23 hours later
Hi

Some more questions:
1.My pain is from deep inside the ear to top of head. A very severe pain. As per my ENT my mastoid is inflammed. I have not done CT after 2nd surgery. What can be the cause of it?

2. Can this be vasculitis?

3. No pus was found in my mastoid. So no culture was done. How to get correct antibiotic in that case?

4. My bone scan shows increased uptake. Can this be related to my pain?

5. Do oral ciplox work in bone infection/inflammation ? I am take it without much benefit.

6. My aditus was closed when 2nd surgery was done. So my ENT has put a grommet this time. Will it help in opening the aditus?

7. Can this be migraine starting from ear?

8. What may be reason of bone inflammation?

9. Can I have another exhaustive elaborate surgery for a cure eliminating the whole mastoid? If so how long should I wait ? Last surgery was 4 months back.


Regards
XXXXX











 
 
Answered by Dr. Sumit Bhatti 16 hours later
Brief Answer:
As below:

Detailed Answer:
Hi,

Thank you for writing back.

1. I will need to review your CT images in a chronological order to suggest possible causes.

2. A vasculitis limited to one area is rare. There are may other symptoms and blood tests such as Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), Anemia (low Hb), increased (WBC) White Blood Cell count, eosinophilia, Anti-Neutrophil Cytoplasmic Antibody (ANCA) levels and test for blood in urine.

3. The trapped collection may now be sterile.

4. Increased uptake in one mastoid as compared to the normal side is suggestive of inflammation which may be causing the pain.

5. A grommet may not be of help in opening a blocked aditus.

6. Bone has poor blood supply, hence the antibiotic may not reach the site. In addition, there may not be an infection, only a trapped collection and inflammation due to lack of aeration of the mastoid through a blocked aditus.

7. It is unlikely to be migraine starting from ear. anti-migraine medication is different from regular painkillers. You may request a trial from your doctor to eliminate this possibility.

8. The reason for chronic bone inflammation may be inadequate ventilation of the middle ear and mastoid due to Eustachian Tube Dysfunction (ETD) and adhesions and a blocked mastoid aditus post surgery .

9. Since 4 months have passed, you may now scan the ear again. If it is possible to travel to Pune, a detailed ENT examination and a combined MRI+CT Temporal bones with a late diffusion scan post contrast will provide the maximum information possible.

I hope that I have answered your queries. If you have any further questions, I will be available to answer them.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Suffering from Chronic mastoiditis. CT scan shows fluid mastoid. Bone biopsy revealed some mild lymphocytes. Due to infection? 6 hours later
Hi

1. What is the permanent cure for a blocked aditus and getting an aireated mastoid

2. When I burp my ear drum gets inflated. Can this be a sign of blocked aditus? Can the aditus be opened without surgery again?

3. Can only inflammation without infection cause pain?

4. How long does sclerosis happen?

5. As you mentioned sclerosis does not cause any pain. So my pain suggests something more than only sclerosis.

6. How long does the aditus take to open after surgery?

7. My doctor did not get any pus or liquid in the mastoid. So no culture was done. In this case how to know the causative agent?

8. I am completely bed ridden suffering with pain. Kindly help me to get little better so that I can visit pune.

9. I have attached my recent surgery note.

10. Can this bone inflammation cause cancer later? My present bone biopsy does not reveal cancer. I have attached my biopsy report.

Regards,
XXXXX

 
 
Answered by Dr. Sumit Bhatti 49 minutes later
Brief Answer:
As below:

Detailed Answer:
Hi,

Thank you for writing back.

1. The permanent cure for a blocked aditus and getting an aerated mastoid is surgery. Use of a stent in the aditus may help.

2. If you can feel your ear drum move when you burp, it means that the Eustachian Tube is patent. This does not involve air flow through the aditus? It is unlikely that the aditus can be opened without surgery. It is interesting to note that before surgery, your mastoid probably had more air cells and now after two surgeries, it has almost been been converted into a single cavity. Hence the value of aeration is now not predictable. Rather, the opening of a blocked aditus (ad antrum) will enable drainage of the mastoid.

3. Inflammation without infection can cause pain.

4. Sclerosis is permanent.

5. Your pain suggests something more than only sclerosis.

6. Ideally, the aditus should remain open after surgery unless there is a lot of mucosal edema or till the commonly used gelfoam packing dissolves.

7. Culture should have been done. Without a culture, it is impossible now to know the causative agent. Assuming that it may have been a common pathogen, it must have responded to antibiotics by now.

8. It is unfortunate, that you are bedridden with the pain. For the pain, get a prescription of Tab. Tryptomer (amitriptyline) 5 mg once a day and Tab. Ultracet (tramadol + paracetamol) twice a day. If this does not work, ask for injectable painkillers for a few days. Take these only under strict medical supervision.

9. I have gone through your surgery notes. I assume they are of the second surgery. They are routine notes of a cortical mastoidectomy. The thick mucosa, fibrosis and calcification may be due to the reparative process after the previous surgery. The only significant findings are an aditus block and glue in the middle ear for which the grommet was placed in the ear drum.

10. It is unlikely that this bone inflammation may cause cancer later.

I hope that I have answered your queries. If you have any further questions, I will be available to answer them.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Suffering from Chronic mastoiditis. CT scan shows fluid mastoid. Bone biopsy revealed some mild lymphocytes. Due to infection? 1 hour later
Hi

1. My doctor told that since there was no fluid in the mastoid at the time of 2nd surgery no culture was done. He only got some lymphocytes in the bone biopsy. When I asked him he told there were no neutrophils so no active infection. Is it possible to do culture without fluid?

2. I have taken the following antibiotics over past 2 years:
- Ciftazodine(10 days), Pippercillin(3 weeks), Ciftrioxone(2 weeks), taxim(5 days), augmentin(1 month), AKT4(2 months), amikacin(5 days), Cipro(2 months), ofloxacin(3 weeks), gentamicin (5 days), Itraconazole (20 days)

I don't know now what I should take.

3. Is there any way to know if my aditus is closed? If so do I need to go for a 3rd mastoidectomy or any other simpler operation?

4. I have a hypoplastic transverse sinus on the same side. Can mastoid inflammation put pressure on that sinus and prevent normal blood flow of that sinus causing pain?

5. I have lupus anticoagulant positive. Can this suggest any thing?

6. The inflated ear drum during burping only happens in the affected ear.

7. Can the pain be due to nerve irritation in the ear during surgery?

8. My ear drum is white after grommet insertion. Is it normal?

9. If sclerosis is permanent my bone scan will always be positive?

10. My liver is in bad condition. Should I continue with antibiotics? I am taking liverolil forte for liver.

Regards,
XXXXX






 
 
Answered by Dr. Sumit Bhatti 2 hours later
Brief Answer:
As below:

Detailed Answer:
Hi,

Thank you for writing back.

1. It is always possible to take a swab from a cavity for culture.

2. After so may antibiotics and anti-fungal medication, you are likely to have a sterile collection or a resistant pathogen involved.

3. You need the MRI+HRCT Temporal with the special protocol to know if and why the aditus is closed and the requirement, if any, for further surgery.

4. Mastoid inflammation and infection may cause thrombosis of the sigmoid sinus and prevent normal blood flow of that sinus.

5. A positive Lupus Anticoagulant in the absence of increased Clotting Time (CT), raised PTTK or evidence of thrombosis does not require any active treatment.

6. The inflated ear drum happening during burping only in the affected ear may also be the sign of a hyper-mobile ear drum. Get a Tympanometry (Impedance Audiometry) done.

7. Any pain be due to nerve irritation in the ear during surgery should subside in a few months.

8. If your entire ear drum is white after grommet insertion it is not normal, unless there is a discharge from the middle ear or there has been fibrosis due to two surgeries.

9. Sclerosis does not cause a positive uptake on a bone scan.

10. If your liver is in bad condition, stop or reduce the dose of the antibiotics and get your liver function tests done, since most antibiotics are metabolized in the liver.

I hope that I have answered your queries. If you have any further questions, I will be available to answer them.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Suffering from Chronic mastoiditis. CT scan shows fluid mastoid. Bone biopsy revealed some mild lymphocytes. Due to infection? 20 hours later
Hi
Got CT done today. Attaching the report.

1. Can you get some clue regarding my pain?

2. Both the times I had surgery some air cells were left.It it normal? My doctor told that after cortical mastoidectomy I should not have any air cells but after surgery I can see that he has not done his work fully.

3. What I got from your previous replies is that my pain is due to mastoid bone inflammation. Is bone inflammation different from osteomyelitis?

4. Is it possible to clear all cells without removing them?

5. If I want to go for a 3rd surgery what should be the gap for it and what type of surgery can it be so that I can get rid of this mastoid bone completely?

6. Can you correlate my bone scan with my CT?

7. Please suggest what will be best for me now?

8. I felt a little better by taking ceftazodine IV for 10 days. But my liver is not well so had to leave it. Is there any equivalent oral medicine?

Regards,
XXXXX


 
 
Answered by Dr. Sumit Bhatti 4 hours later
Brief Answer:
As below:

Detailed Answer:
Hi,

Thank you for writing back.

1. I will need to view the images and not the printed report. For example, there is no mention about which exact cells remain and the state of the aditus.

2. Ideally all cells should be exenterated. It is common for some cells to be left behind. If all cells are removed, a dry mastoid cavity results. If some cells remain, the mastoid cavity continues to discharge.

3. Osteomyelitis is a severe inflammation and infection, The CT report mentions no sign of osteomyelitis.

4. It is possible to clear all cells without removing them, however complete exenteration must be achieved.

5. Repeat surgery may be performed after a gap of 4 to 8 weeks. Your scan images will help decide the type of surgery, if any.

6. Yes, you can you correlate my bone scan with my CT, but they should be done at the same time.

7. Take a trial of neurlagia medication. Share your CT images (entire sets including previous scans) through a file sharing site or on a CD sent to XXXXXXX

8. Your CT report mentions mild mastoiditis. You may stop your medication for now.

I hope that I have answered your queries. If you have any further questions, I will be available to answer them.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Suffering from Chronic mastoiditis. CT scan shows fluid mastoid. Bone biopsy revealed some mild lymphocytes. Due to infection? 45 hours later
Hi

I have attached my CT scans.

1. Tip cells and some cells in the top have not been removed. When I asked the doctor he told that those are very sensitive areas and can't be touched. What can be done for those areas?

2. I feel sometimes shortnesss of breath and fainting tendency. Can this be related to my mastoid problem?

3. What can be those opaque areas / cells - pus, blood, sclerotic bone growth, infection or something else.

4. I have continuous headache 24X7. Any relation to this mastoid problem?

5. Do you see any thinning of bone in the top portion of mastoid?

6. Can the operation site pain radiate to top of head?

7. Can there be bone inflammation like mine due to no reason?

8. I have attached my detailed case history from the beginning of infection around 2 years back.

9. Can this be chronic low graded osteomyelitis?

10. I had been taking neuralgic medicines but they are not of help. What do you suggest now?

Regards,
XXXXX
 
 
Answered by Dr. Sumit Bhatti 4 hours later
Brief Answer:
As below:

Detailed Answer:
Hi,

Thank you for writing back.

1. There are a lot of opacified cells remaining. An attempt to remove them should have been made in the second surgery.

2. Shortness of breath and fainting tendency may be investigated with soft tissue and brain window settings.

3. CT cannot differentiate the opaque areas / cells. An MRI Temporal bones will be necessary.

4. Continuous headache may be related to the mastoid problem if it is on the same side.

5. To define any thinning of bone in the top portion of mastoid, coronal and sagittal CT cuts are required.

6. The operation site pain may radiate to top of head due to common nerve supply (Referred Pain).

7. The bone inflammation has already presented as mastoiditis on moe than one occasion.

8. Your detailed case history is not attached / visible.

9. This is not osteomyelitis.

10. If neuralgic medicines are not of help, you need a re-evaluation in consultation with an ENT and a Neurologist,

I hope that I have answered your queries. If you have any further questions, I will be available to answer them.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Suffering from Chronic mastoiditis. CT scan shows fluid mastoid. Bone biopsy revealed some mild lymphocytes. Due to infection? 19 hours later
Hi
My case history.

I never had any ear problem or headache in my 32 years of life prior to this. I don't have blood sugar or BP problem.

29 XXXXXXX 2012 - Blisters appear on ear drum of left ear with severe pain at night. Back of ear drum got filled with bloody fluid. No discharge. Was diagnosed as "Viral haemorrhagic otitis media". Put on Acyclovir and Augmentin. Given ciplox and gentamycin ear drops for 7 days.

30 XXXXXXX 2012 - Pain subsided but hearing almost nil.

9 Feb 2012 - Pain again began shown local ENT. Put on Augmentin again for 10 days. This time pain just above the ear. Ear drum red as told by ENT. Some fungal debris seen in the ear canal.

17 Feb 2012 - Grommet insertion done under general anesthesia. Put on Augmentin again with Ofloxcin ear drop. Very severe pain at night. Ear lobe became red.

19 Feb 2012 - Pain started in the whole temple region of the affected ear. No deep ear pain.

Whole feb 2012 pain continued in the temple region of the affected ear. Was hospitalized for first time due to severe pain.

Done HRCT in Feb - Showed mastoiditis.

March 2012 - Put on cepodem xp antibiotic. No relief. Could feel swelling in the temple region and top of head pain started. Had a lumber puncture. It showed high protein in the CSF. ESR was 50.

April 2012 - Given IV Antibiotic Pipercillin for 1 day - felt little better. Then put on Cepodem xp again.
CT and MRI done again. Both showed mastoiditis.

Both top and temple region of head pain with a feeling of swelling continued throughout April and May. Grommet taken out in May due to fungal infection in it.

May 2012 - Pain in TMJ and Cheeks. Put on steroid for 10 days.
XXXXXXX - July 2012 - Bone scan done. Showed increased uptake in temporal bone area. Started on Pipercillin and Ofloxacin IV. Continued for 3 weeks Got little relief.

August 2012 - Mastoidectomy done. Found glue in mastoid. No growth in culture. Granulation tissues found. Temple pain and TMJ pain greatly reduced. but top and back portion of head still had pain.

Sept 2012 - Immediately after mastoidectomy was put on heparin due to severe headache. Suspected CVT. But found hypoplastic transverse sinus Stayed in hospital for 2 weeks.

Oct 2012 - Put on doxycycline and tegretol - No relief

Nov 2012 - Dec 2012 - Put on AKT 4 and Itraconazole - No relief
XXXXXXX 2013 - Started steroid for 15 days. Got some relief.

Feb, March, April 2013 - Top of head and back of head on affected side continued. Started getting neck pain in front of neck.

X XXXXXXX done in April 2013 showed mastoiditis.

May 2013 - Had second cortical mastoidectomy and grommet insertion.

Now my problems are -

1. A pain from ear region ( deep inside the ear) to throat. This becomes very severe at times.

2. Mild pain in the temple region mainly above and below the eye of the affected side. This eye pain is there since a year.

3. A pain at the top of head (near the vertex) and back of head on affected side only. A feeling that somebody has scratched that portion with sharp knife. There is also a feeling of swelling there.

4. Some pain in the back portion of neck on the affected side.

5. A feeling of mild constant pain on the whole affected side of the head.


I am sending you 2 images after 1st and 2nd surgery. Can you pls see if there is bone thinning after 2nd surgery.

Image 1. Done one year back after 1st surgery

Image 2. Done 5 days back.


Regards,
XXXXX
 
 
Answered by Dr. Sumit Bhatti 4 hours later
Brief Answer:
As below

Detailed Answer:
Hi,

Thank you for writing back.

1. The bullous myringitis may have been herpetic or mycobacterial.

2. The pain may be post herpetic neuralgia. The various pain sensations that you described are all seen in this condition.

3. the fungal debris might have been due to an otitis externa secondary to antibiotic use, due to the ear blisters rupturing or ear discharge through the grommet.

4. it is not clear why the ear grommet was put. Are there any clinical findings or ear Tympanometry reports on whic this procedure was based?

5. Mastoiditis and abnormal CSF are common findings in Herpes Zoster Oticus (Ramsay Hunt Syndrome Type II). PCR for mycobacteria should have been done on the CSF.

6. A hypoplastic transverse sinus on one side is a common finding.

There are no new images attached.

I hope that I have answered your query. If you have any further questions, I will be available to answer them.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Suffering from Chronic mastoiditis. CT scan shows fluid mastoid. Bone biopsy revealed some mild lymphocytes. Due to infection? 18 hours later
Hi

1. Mycobacterium Tuberculosis test was done on CSF which came to be negative. Is there any other mycobacterium test?

2. Normal painkillers help to relieve my pain. Can this be due to nerve irritation?

3. I reconfirmed with radiologist. There is no erosion of bone. But bone scan shows something. What can be the reason for it?

4. Does mastoid surgery give rise to sclerosis/any bone change in the remaining cells?

5. What is the medicine for mycobacterium?

6. My recent grommet has fallen inside my middle ear? What to do? Can it block mastoid aereation?

7. My first grommet was put to dry the middle ear. My middle ear was filled with blood during the first infection. Also there were bloody blisters on the ear drum. Does herpes stay inside the middle ear and cause bloody discharge there?

8. One side of my head feels blocked and heavy. Also there is a tiiiiii sound on that ear. What can be the reason for that? My ear drum is normal and the CT scan shows my middle ear has no fluid

9. I had a tympanometry - audiometry normal, impedence - on affected ear is "B" type. Can it give any hint whether there is any hole or grommet there?

Regards,
XXXXX
 
 
Answered by Dr. Sumit Bhatti 4 hours later
Brief Answer:
As below:

Detailed Answer:
Hi,

Thank you for writing back.

1. As mentioned before, PCR test may be done on the CSF.

2. Normal painkillers help to give some relief in most types of pain including nerve irritation or neuralgias.

3. It is good that you have confirmed that is no erosion of bone. The bone scan will indicate infammation or infection.

4. After cortical mastoid surgery, the remaining cells should drain in to the middle ear via the aditus.

5. The medicine for mycobacterium tuberculosis is AKT.

6. A grommet that has fallen inside the middle ear is of no consequence and requires no treatment.

7. Herpes infection is a reactivation of dormant chickenpox virus present in the body from childhood.

8. The abnormal sound is Tinnitus. t is due to the repeated mastoidtis and middle ear infections.

9. The "B" type tympanogram is seen in fluid collection behind an intact ear drum or in case where there is no airtight seal such as a perforation or grommet.

I hope that I have answered your query. If you have any further questions, I will be available to answer them.

Regards.
Above answer was peer-reviewed by
 
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