Intracranial infection complicating chronic ear disease.

An 18 year old Chinese girl was admitted with a one week history of fever, headache, constipation and pain in her left ear. She gave a history of re current ear problems during cruldhood. On examination temperature was 39.3 QC with a pulse rate of 1.00 per minute. Pus discharged through a perforation of her left tympanic membrane. The ESR was 100 mm in the first hour, haemoglobin 11.4 Gms/ 100 mls. white cell count 11.7 x 10 3 C.mm with 79 % polymorphonuclear leucocytes. Chest X-ra y_ urea a nd electrolytes and a Denco were all normal. Swabs from the thoat and left ear, and blood and urine <.:ultures were negative. X-rays of her skull showed a large bon y defect in the left mastoid, which was otherwise scJeroti<.: and poorly pneumatised. She was sLa rted on benzylpenicillin and continued on cotrimoxazole. Two hours a fter admission she su!fered a generalised convulsion which lasted 3 minutes. Immediat~ ly after this she \\'a5 delirious and had an axillary temperature of 42 °C. She was changed from intramuscular to intravenous benzylpenicillin. On the se~ond da y of admission hcr temperature was 38~C .. She was lethargic and had a slight degree of menmgIsm but there were no other neurological abnormalities. There was evidence of acute on chronic ear disease but there was no evidence of acute masto iditis. On the morning of the fourth day of admission she was apyrexial, lethargic and mentally dulled. She had early left sided papilloedema but there were no other neuro logical abnormalities. A CAT scan was arranged for the next day. That evening, however, ~hc became pyrcxiaJ and was found to have left Sided cerebellar signs, nystagmus. bi latera l extensor planta r and absent abdominal reflexes Emergency mastoidectomy revealed extensive cholesteatomatous di~ea~e invading the mastoid . The fl oor of the temporal fossa over the atric was removed and norma l dura found . The bony plate over the sigmoid sinus was removed and a large extradural co llection of pus was found . A modi fied radical (;aVily was formed . Streptococcus Group C wa ... cultured from the left mastoid cavity and Streptococcus pneumoniae from the extradural absces~ . Dexamethasone was started postoperatively. She slowly improved over the next week and tbe cerebellar signs gradually disappeared. The drowsiness. however. did not improve and on the fourlct:nth day of admission she agai n developed gross signs suggesling a left sided cerebeHar lesion. An emergency CAT scan showed a large left sided cerebellar abscess (Figure 1). An emergency occipital burr hole was made and the cerebellum needled. A large q uantity of fou l smelling pus was asp irated