otomastoiditis vs cholesteatoma radiology

37 years experience ENT and Head and Neck Surgery. 297-307. A comprehensive range of complications, such as petrous apicitis, dural sinus thrombosis, cholesteatoma, labyrinthine fistula, ossicular erosion and fixation are demonstrated. In our case, the extent of the tumor cannot be … Dural sinus thrombosis (post-contrast axial CT and axial 2D-TOF MRV) Case 4. cholesteatoma by multidetector computed tomography. Otoditis Media w/ Ossicular Erosion - 4 min. The middle ear and mastoid constitute an extension of the upper respiratory tract. The specific type of otitis media depends on various clinical findings and setting: 1. acute otitis media: acute infection of the middle ear 2. otitis media with effusion: middle ear fluid without signs or symptoms of acute infection 3. adhesive otitis media: retracted tympanic membrane with adhesions to medial wall of tympanic cavity, with or without perforation 4. chronic otitis media: tympanic membrane perforation in the setting of recurrent infection… Rarely Granulomatosis with polyangiitis, cholesteatoma, leukaemia and histiocytosis hence the need for tissue for histology at surgery (Kontorinis, 2012) 3. The temporal bones comprise the lateral skull base, forming portions of the middle and posterior fossae. Ask doctors free. P. Aeruginosa is common if recent recurrent AOM or recent antibiotic use Role of Radiology in Ear Discharge - Dr A Anbarasu. The nasopharynx, eustachian tube and otitis media. Cholesteatoma occurs when keratinising squamous epithelium (skin) is present in the middle ear as a result of tympanic membrane retraction. Albera R et al: Ossicular chain lesions in tympanic perforations and chronic otitis media without cholesteatoma. Repeated infections and/or a tear or pulling inward of the eardrum can allow skin into the middle ear. The attic floor (tympanic diaphragm), tympanic isthmus, and the aditus ad antrum play an important role in inflammatory processes of the middle ear cleft. 1 , 2 The focus of our topic is the radiology of referred otalgia. Otomastoiditis Summary - 8 min. Abstract . This chapter provides a detailed summary of middle ear cholesteatoma. Blom EF et al: Influence of ossicular chain damage on hearing after chronic otitis media and cholesteatoma surgery: a systematic review and meta-analysis. Thoracic a. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. If it was a canal ... Read More. Epidemiology . The mass is lined by epithelium (facing inwards) which continues to grow, thereby shedding additional cells into the mass. Mastoiditis may occur as a complication of acute otitis media (AOM) or COM. Apical petrositis 4. 7,21 Although the underlying pathophysiology remains controversial, congenital cholesteatomas are thought to arise … Normal pattern in with a thickness of … MATERIALS AND METHODS: We reviewed … 1. Case 7. Sade J. What is Chronic Otitis Media, Cholesteatoma and Mastoiditis? Chronic otitis media describes some long-term problems with the middle ear, such as a hole (perforation) in the eardrum that does not heal or a middle ear infection (otitis media) that doesn't improve or keeps returning. Department of Radiology, Södersjukhuset, Stockholm, Sweden. Depends: There are many different operations for cholesteatoma. SUMMARY: DWI is a useful technique for the evaluation of cholesteatomas. Age and sex were recorded for all patients and for otomastoiditis cases; location of the disease, symptoms of patients and TMJ findings were noted as well. It also depends on what type of cholesteatoma surgery you had. Mastoiditis with Abscess - 5 min. Furthermore, otomastoiditis reports and studies rarely analyzed TMJ CT scans. 1 doctor agrees. Departments of 1Radiology and Research Institute of Radiology, 2 ... the middle ear cavity rather than acquired cholesteatoma. Radiology of chronic otomastoiditis. The middle ear adenoma may present diagnostic dilemma because chronic otomastoiditis and cholesteatoma, which comprise the majority of middle ear diseases, may masquerade middle ear adenoma on high-resolution CT, the most commonly used imaging modality for middle ear diseases (3, 12). When cholesteatoma occurs in a patient (usually a child) with a normal tympanic membrane and no prior history of otorrhea, perforation, or prior surgery, the cholesteatoma is termed congenital. These findings were correlated with the findings of previous study (8). Inflammation of the middle ear cleft is a disease of great interest both from clinical and radiological points of view. The incidence in developed countries is 1.2-6.1 per 100,000. Chronic otomastoiditis (COM) should be considered a separate entity from acute otomastoiditis, and is thought to be primarily due to Eustachian tube dysfunction as demonstrated in this case secondary to enlarged nasopharyngeal adenoids. Stangerup, G. Havid. Acquired cholesteatomas occur in children and adults. Introduction to Imaging The Middle Ear - 4 min. 1 thank. Roof of the superior semicircular canal, was distinguished four different types, depending on their thickness. 78 … This change is only easily appreciated on thin section bone … The possibility of tumors such as adenoma or adenoid cystic carcinoma was very low from its bilaterality and from the findings of TBCT. RADIOLOGY OF'CHRONIC OTOMASTOIDITIS … Abstract. Cholesteatomas often develop as cysts or pouches that shed layers of old skin, which build up inside the middle ear. Gd-enhanced MRI may be useful in this context. Written directly to otolaryngologists, Imaging in Otolaryngology is a practical, superbly illustrated reference designed to enhance image reading skills at the point of care. Otomastoiditis ... Cholesteatoma. MATERIALS AND METHODS: We reviewed 19 cases of TOM, 30 cases of chronic otomastoiditis (COM), and 30 cases of COM with cholesteatoma … Mastoiditis & Cholesteatoma. Cholesteatoma. Top answers from doctors based on your search: Disclaimer. Case 6. Common disease processes resulting in primary otalgia include otomastoiditis, cholesteatoma, and foreign bodies lodged within the ear canal. Displacement of the ossicular chain can be seen in cholesteatoma, not in chronic otitis. Cholesteatoma can present with a non-dependent mass while chronic otitis shows thickened mucosal lining. However, in both diseases the middle ear cavity can be completely opacified, obscuring a cholesteatoma. AJNR Am J Neuroradiol. The temporal bone consists of five definable segments: squamous, petrous, tympanic, mastoid, and styloid (Fig. CrossRef View Record in Scopus Google Scholar. There is a rising incidence, however, which is connected to restrained antibiotic therapy of AOM, inadequate dosing, … Get Introduction to Imaging for free. Fig. Holotympanic absence of bony changes is suggestive of otitis media without cholesteatoma formation, whereas presence of bony erosions (along with clinical suspicion) indicates cholesteatoma . 2007; 28(3) : 493 -6 10. Computed tomography (CT) is the method of choice for evaluating otogenic intra- or extra-cranial complications. Chronic otomastoiditis is defined as persistent or recurrent inflammation of the middle ear (chronic otitis media) and mastoid, lasting usually for a minimum of 12 weeks, often resulting in permanent perforation of the tympanic membrane.It should be considered a separate entity from acute otomastoiditis. Without treatment cholesteatomas will progressively increase in size. The presence of bony erosions or expansion are strong support of cholesteatoma over chronic otomastoiditis. Discussion (Tuberculous otomastoiditis): Tuberculous otomastoiditis is an uncommon form of acute otomastoiditis secondary to tuberculosis infection It can present with wide range of presentations including painless chronic otorrhoea, purulent discharge, ossicular erosion and cervical nodes enlargement Otomastoiditis. RESULTS: Seven patients were diagnosed as acute otomastoiditis and one patient diagnosed as chronic active otitis media with cholesteatoma in the series of 2270 MR, which were representing a prevalence of 0.39%. This is an abnormal collection of skin cells inside the ear which may prevent the ear draining properly, leading to infection. BACKGROUND AND PURPOSE: Our purpose was to evaluate the differential findings of tuberculous otomastoiditis (TOM) and nontuberculous chronic otomastoiditis with or without middle ear cholesteatoma on high-resolution CT of the temporal bone. We describe and illustrate the radiological features of a variety of congenital and acquired conditions of the middle ear and mastoid, including ossicular anomalies, acute and chronic otomastoiditis. 1. The attic floor (tympanic diaphragm), tympanic isthmus, and the aditus ad antrum play an important role in … ct scan of temporal bone. Less frequently, acute otomastoiditis is seen secondary to chronic diseases of the middle ear, including cholesteatoma. Chronic otitis media describes some long-term problems with the middle ear, such as a hole (perforation) in the eardrum that does not heal or a middle ear infection (otitis media) that doesn't improve or keeps returning. Part of the Medical Radiology book series (MEDRAD) Abstract. Cholesteatoma and chronic otomastoiditis were assessed separately and were not considered mutually exclusive. Department of Radiology, Division of Neuroradiology, University of Utah School of Medicine, Salt Lake City, USA. Chronically discharging ear is a common cause of morbidity in developing countries, and it is also associated with intratemporal and intracranial complications. Background and purpose Cholesteatoma is an … Intracranial abscess (post-contrast axial CT and Cor T1 gad MR) Case 5. It often develops … Coalescent mastoiditis is simply the term given to acute otomastoiditis when mucoperiosteal disease extends to involve the bone. Key HRCT findings - otomastoiditis: [Figure [Figure1A 1A and andB B] Figure 1(A, B) HRCT axial and coronal images of the right temporal bone show soft tissue in … Chronic otitis media describes some long-term problems with the Cholesteatoma iii. For chronic otomastoiditis with cholesteatoma MR signal characteristics are nonspecific; ordinarily, ... Radiology, 170 (1989), pp. 2 ). Paul M. Bunch, Hillary R. Kelly, in Neuroradiology, 2019 Congenital Cholesteatoma. The computed tomographic (CT) appearances of chronic otomastoiditis, tympanosclerosis, cholesterol granuloma, attic retraction pocket, and acquired cholesteatoma are reviewed and illustrated. Right pars flaccida cholesteatoma. M. Tos, S.E. 14 Otomastoiditis and Cochlear Implantation Several types of middle ear and mastoid infections, as well as the presence of a previous canal wall down cavity, can hamper cochlear implantation. The ossicular erosion as seen on CT may be indistinguishable from that caused by cholesteatoma. The long process of the incus is most subject to erosion ( Fig. 111.4 ). In cholesteatoma, the soft tissue findings usually appear more localized and ossicular displacement may be seen. 502-507. 1-9, 2015. Antibiotic therapy is the mainstay of treatment for both acute and chronic mastoiditis.. Granulation tissue and … communicates with the nasopharynx via the eustachian tube and Neurilemoma diagnosed in left mastoid process in one patient. 95% of patients will require a second look procedure either to check for the presence of residual and/or recurrent cholesteatoma and also for the reconstruction of the ossicular chain. The discharge can be pus, blood, clear fluid or serous fluid; sometimes combinations can happen such as blood stained pus discharge. Case Discussion. In close to 50% of cases, however, the source of the pain does not reside within the ear but, rather, originates from sources distant from the ear—so called “referred otalgia” ( Fig 1 ). Soft tissue opacification of external ear with aggressive bone destruction was seen in the case of external otitis extema. The aim of HRCT is to ensure that there is no underlying cholesteatoma or other complications. Pulmonary infection and inflammation, including diseases of the airways, parenchyma, and pleura b. However, cholesteatoma in the “hidden areas” like anterior epitympanic recess and sinus tympani can be missed. It can be used to detect them when the physical examination is difficult and CT findings are equivocal, and it is especially useful in the evaluation of recurrent cholesteatoma. Coalescent Mastoiditis With Abscess, Thromboflabitis, Myositis, Cellulitis - 6 min. 6. Mastoid pneumatization: evidence of the environmental theory. Acute bacterial (suppurative) otomastoiditis responds to antibiotic treatment; radiologic study is required only when there is clinical suggestion of coalescent mastoiditis, intracranial complications, or an underlying chronic disease. A cholesteatoma cavity usually has a smooth margin. Dudau C, Draper A, Gkagkanasiou M, Charles-Edwards G, Pai I, Connor S. Cholesteatoma: multishot echo-planar vs non echo-planar diffusion-weighted MRI for the prediction of middle ear and mastoid cholesteatoma. Thus, many clinicians reserve the diagnosis for when … This paper presents a brief review of imaging methods possibilities in the diagnosis of primary cholesteatoma, as well as its postoperative recidivism. mumps, tumour. In most cases, it is acquired and occurs in the pars flaccida. CT is the imaging modality of choice for most of the pathologic conditions of the temporal bone, especially for those of the middle ear. This chapter deals with the preoperative management of the following diseases combined with cochlear implantation: • Chronic suppurative otitis media – Without cholesteatoma – With middle … MATERIALS AND METHODS: We reviewed 19 cases of TOM, 30 cases of chronic otomastoiditis (COM), and 30 cases of COM with cholesteatoma (CHOM), all of which had been confirmed by In acute otitis media, an inflammatory middle ear effusion is present that can freely move into the mastoid air cells. Case 3. Erosion of the antrum of the mastoid process can be visualized in the form of a translucent area within a sclerotic mastoid. Case 1. Otomastoiditis w/ Labrythitis - 6 min. Each temporal bone is compose… There are a limited number of structures and disease entities in the temporal bone with which one must be familiar in order to proficiently interpret a computed tomographic (CT) or magnetic resonance (MR) imaging study of the temporal bone. Cholesteatoma involves proliferation of keratinized stratified squamous epithelium, with pathological characteristics identical to those of epidermoid cyst. "i got my result temporal bone ct scan left otomastoiditis with cholesteatoma formation, unremarkable right temporal bone i need a surgery ?tnx" Answered by Dr. Zachary Veres: Otomastoiditis: very likely you will need surgery for this condition. Case 2. Mastoiditis in acute or chronic form is now quite rare. BJR Open 2019; 1: 20180015 . For chronic otomastoiditis with cholesteatoma MR signal characteristics are nonspecific; ordinarily, both T1 and T2 relaxation times are relatively long , , , , , , , , , , , , . Dr A Anbarasu Caran Diagnostic Imaging, Coimbatore _____ _____ Fluid Discharge from the ear is a common problem in both children and adults. Fig. 7. Cholesteatoma is an abnormal accumulation of squamous epithelium usually found in the middle ear cavity and mastoid process of the temporal bone. The mere presence of mastoid fluid on imaging, however, does not change the management of otherwise uncomplicated acute otitis media. An abnormal skin growth in the middle ear behind the eardrum is called cholesteatoma. Their cholesterol content (which is not always present) is responsible for their name, although 'keratoma' is probably a more apt term. Initial DWI techniques only detected larger cholesteatomas, >5 mm, due to limitations of section thickness and prominent skull base artifacts. The appearances on CT scans of chronic otomastoiditis, tympanosclerosis, cholesterol granuloma, attic retraction pocket, and acquired cholesteatoma are reviewed and illustrated. Acta Radiologica (Stockholm, Sweden : 1987), 01 Jan 2000, 41(1): 49-51 DOI: 10.1258/rsmacta.41.1.49 PMID: 10665870 . Complications include: Hearing loss, CN 7 palsy, venous sinus … Figure 1 shows image of cholesteatoma by high resolution computed tomography The role of X-rays in evaluation of a cholesteatoma is very less. On this axial CT scan a small, underdeveloped, poorly pneumatized mastoid is visible ( arrows) Opacification of mastoid air cells and sclerosis of mastoid are typical imaging findings (Fig. The role of magnetic resonance imaging (MRI) in the evaluation of chronic ear disease and cholesteatoma will be discussed. Results : Seven patients were diagnosed as acute otomastoiditis and one patient diagnosed as chronic active otitis media with cholesteatoma in the series of 2270 MR, which were representing a prevalence of 0.39%. Preoperative tomography evidence vs surgical findings; A reliable guidance for middle ear surgery? 1. Mastoiditis Treatments. The sequelae of otitis media can be considered in two broad categories: (1) direct destructive effects of the localized process, and (2) the effects of auditory deprivation during early childhood. Fluorescent otoscopy can highlight the presence of cholesteatoma with the potential to guide resection attempts in the future 49. The role of magnetic resonance imaging (MRI) in the evaluation of chronic ear disease and cholesteatoma will be … J Int Adv Otol. 3.1).1,2 The bulk of the external surface of temporal bone is comprised of the squamous portion, which has horizontal and vertical components separated by the zygoma. Computed tomography (CT) is the method of choice for evaluating otogenic intra- or extra-cranial complications. 0. Try before you buy. Cholesteatoma: Cholesteatomas can only be diagnosed radiologically when the disease process leads to bone erosion, because they are radiolucent. J Postgrad Med Inst 2016; 30(1): 133-40. The final diagnoses of all patients were made after medical consultation. Chronic otomastoiditis. Middle ear infections, such as acute otitis media and chronic suppurative otitis media, with or without American Journal of Neuroradiology, 01 Apr 2003, 24(4): 751-756 PMID: 12695217 PMCID: PMC8148678. Send thanks to the doctor. 11 (2):143-6, 2015. This article reviews the current understanding of the bony labyrinthine defect, including symptoms, etiology, surgical approach, as well as preoperative and postoperative imaging pearls. ABSTRACT Objective: To determine the CT patterns of temporal bone cholesteatoma in patients presenting with chronic discharge from ear. The history of surgery for middle ear cholesteatoma is of an evolution of techniques to meet the challenges of inaccessible disease and of post-operative cavity management. MATERIALS AND METHODS: We reviewed 19 cases of TOM, 30 cases of chronic otomastoiditis (COM), and 30 cases of COM with cholesteatoma … Free to read . Dr. David Astrachan answered. Become a Gold Supporter and see no ads. Superior semicircular canal dehiscence alters the normal fluid mechanics of the vestibulocochlear system and can be a debilitating condition. Otomastoiditis - 3 min. In such cases computed tomography is regarded to be the examination of choice, and imaging studies are performed to evaluate the reasons of conductive hearing loss—either ossicular chain fixation or erosion. Advertisements Search PubMed for Cholesteatoma for Mastoidectomy : Mastoidectomy ( Mastoid Surgery ): Before the advent of antibiotics, mastoid surgery used to be one of the most frequent surgeries performed. The Indian Journal of Radiology & Imaging, 01 Oct 2012, 22(4): 298-304 DOI ... Otomastoiditis . External otitis and acute otomastoiditis. The aim of this presentation is to demonstrate imaging findings of common diseases of the temporal bone. Cholesteatoma has been known for more than 300 years in the medical literature; still its precise detection with the use of cross-sectional imaging techniques remains challenging. Share this article Share with email Share with twitter Share with linkedin Share with facebook. Acute otomastoiditis is usually due to an acute pyogenic bacterial infection of the mastoid air cells and most often is seen as a complication of acute suppurative otitis media. Diagnosing mastoiditis. Radiology 148:465-472, 1983. AJNR. Rho MH, Kim DW, Kim SS, Sung YS, Kwon JS, Lee SW. Tuberculous otomastoiditis on high-resolution temporal bone CT: comparison with nontuberculous otomastoiditis with and without cholesteatoma. Radiology department of the University Medical Centre of Utrecht, the Netherlands. In such cases computed tomography is regarded to be the examination of choice, and imaging studies are performed to evaluate the reasons of conductive hearing loss—either ossicular chain fixation or erosion. Chronic otomastoiditis usually causes fixation or damage to the middle ear ossicles and tympanic membrane, resulting in conductive hearing loss. Patient with history of ear discharge demonstrates opacification of both middle ear cavities that extends into the both mastoids as well as opacified aditus adantrum. Left acute otomastoiditis. Acquired cholesteatoma is a complication of recurrent acute otitis media (AOM), chronic eustachian tube dysfunction, chronic suppurative otitis media (CSOM), and chronic otitis media with effusions (COME). These conditions may be manifest by recurrent pyogenic middle ear infections, negative middle ear pressure, and tympanic membrane perforation. The computed tomographic (CT) appearances of chronic otomastoiditis, tympanosclerosis, cholesterol granuloma, attic retraction pocket, and acquired cholesteatoma are reviewed and illustrated. Anatomy of the Middle Ear on CT - 9 min. ; Kwon, J.S. Right coalescent otomastoiditis. Methodology: This was a cross-sectional study conducted at Department of Radiology, Rehman Medical Institute Peshawar from January 2013 to June 2014. 14 Otomastoiditis and Cochlear Implantation Several types of middle ear and mastoid infections, as well as the presence of a previous canal wall down cavity, can hamper cochlear implantation. J Laryngol Otol. Acquired cholesteatoma c.Tumor/tumor-like i.Exostoses ii.Osteoma iii.Squamous cell carcinoma iv.Basal cell carcinoma v.Melanoma vi.Ceruminomas vii.Parotid malignancy (local invasion) 3.Middle ear and mastoid a.Congenital i.Ossicular malformations ii.Congenital cholesteatoma iii. Otomastoiditis and its Complications. otomastoiditis (TOM) and nontuberculous chronic otomastoiditis with or without middle ear cholestea-toma on high-resolution CT of the temporal bone. 0 comment. 1994; 108(2) : 95 -100 The most common indication is to remove a cholesteatoma or a skin … Rho, M.H. Pyogenes, Staph. In chronic otomastoiditis, repeated inflammation of the mucous membranes of the middle ear and mastoids leads to reactive bone formation and appearance of underpneumatized mastoid air cells.12 In contrast to acute otomastoiditis, which is associated with fluid in the middle ear and mastoids, chronic otomastoiditis presents with web-like linear soft-tissue density. Mafee M, Kumar A, Yannias D, et al: Computed tomography of the middle ear in the evaluation of cholesteatoma and other soft tissue masses: Comparison with pleuri-direction tomography. Recommended Emergency Radiology Curriculum for Residents iv. Arch Otolaryngol, 10 (1984), pp. Share this article Share with email Share with twitter Share with linkedin Share with facebook. Additionally, an anti-confocal microscopy system has been proposed that may highlight inflammation of the middle ear, though this has yet to be tested in vivo 50. CrossRef View Record in Scopus Google Scholar. Via the aditus ad antrum the mastoid antrum, which is the largest mastoid cell, communicates with the epitympanic portion of the middle ear cavity. Age and sex were recorded for all patients and for otomastoiditis cases; location of the disease, symptoms of patients and TMJ findings were noted as well. Inflammation of the middle ear cleft is a disease of great interest both from clinical and radiological points of view. Pneumoniae, Strep. … The bacterial species implicated most often are Strep. CT in a patient with coalescent mastoiditis on the right side obviously shows coalescence of the mastoid cells and resorption of the lateral mastoid wall ( arrows) ( a, c ). It would be reasonable to expect a residual cholesteatoma rate of between 5%-15% at second look surgery. BACKGROUND AND PURPOSE: Our purpose was to evaluate the differential findings of tuberculous otomastoiditis (TOM) and nontuberculous chronic otomastoiditis with or without middle ear cholesteatoma on high-resolution CT of the temporal bone. Most common presenting symptoms include ear discharge, hearing loss, ear pain and vertigo. Acute otomastoiditis is a typical complication of acute otitis media but few cases of acute otomastoiditis complicated with TMJ arthritis have been reported in the international literature. Consequently, some authors comment that a mild mastoiditis is technically present in nearly all cases of acute otitis media 6. The pertinent anatomy is described, and the role of the tympanic diaphragm and isthmus in determining the degree to which middle ear disease may progress is stressed. 2007-03-01 00:00:00 BACKGROUND AND PURPOSE: Our purpose was to evaluate the differential findings of tuberculous otomastoiditis (TOM) and nontuberculous chronic otomastoiditis with or without middle ear cholesteatoma on high-resolution CT of the temporal bone. CT scans can show stages of disease progression when infection … A cholesteatoma is an abnormal, noncancerous skin growth that can develop in the middle section of your ear, behind the eardrum. The prognosis however at second look is extremely good. otomastoiditis cases; location of the disease, symptoms of patients and TMJ findings were noted as well. ; Lee, S.W. Selcuk Kuzu1, Erdogan Okur2, ... CT could determine cholesteatoma in mastoid and middle ear space with 74% sensitivity, 64% specificity, 85% positive predictive value (PPV) and 24% negative predictive value (NPV), respectively. After including 80 positive cases (160 ears), 80 normal cases (160 ears) were added retrospectively as statistical controls. As before, the diagnosis of a cholesteatoma at first presentation is mainly based on clinical suspicion. Seven patients were diagnosed as acute otomastoiditis and one patient diagnosed as chronic active otitis media with cholesteatoma in the series of 2270 MR, which were representing a prevalence of 0.39%. Clinical and imaging differences between acquired and congenital forms are highlighted, and potential differential diagnoses are explored. It is helpful to examine the region in an organized and systematic fashion, going through the same checklist of key structures each time. This chapter deals with the preoperative management of the following diseases combined with cochlear implantation: • Chronic suppurative otitis media – Without cholesteatoma – With middle … Acute … A GP will examine the inside of your ear with an otoscope (a device with a light and magnifying glass). JAMA Otolaryngol Head Neck Surg. Acute bacterial (suppurative) otomastoiditis responds to antibiotic treatment; radiologic study is required only when there is clinical suggestion of coalescent mastoiditis, intracranial complications, or an underlying chronic disease.

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