Cerebral complications of ear disease.

Dear Editor: A useful case report I published in EAR, NOSE & THROAT JOURNALillustrates the reductio ad absurdissimum of the widespread belief that all cerebral complications of ear disease are secondary to the ear infection . Otitis media (OM) can be described as a temporary collectio n of fluid in the middle ear, with or without infection, with local inflammation and possible labyrinthine symptoms such as dizziness not necessarily indicating spread of infec tion . A high index of suspicion is needed to identify signs or symptoms of extrat ympan ic involvement, which might indicate serious brain disease. By my count there were at least 23 such red flags in this case (a record ?), including lifelong otorrhea , profuse watery discharge , glucose and protein in ear fluid, drowsiness, headache, fever, disorientation, seizures, Kernig's sign, papilledema, meningitis, abscesses (mastoid, cerebellar, and Bezold 's), sigmo id sinus thrombosis, otitic hydrocephalus, cholesteatoma, and fistulas (via the sinus plate, dura, round and oval window s, and horizontal and superior semicircular canals). The overriding question that the otogenic theory totally fails to ask, let alone answer, is Why are these fe atures unilateral ? What possible local cause is there for such a serious, multiface ted infective proces s? If it is systemic, then why on earth is the other ear not attacked? Bhat and Manjun ath I mention only two mechanisms for CSF otorrhea in CSOM : ( I) erosive action of the disease on bone or (2) previous surgica l trauma. There was clearly "extensive disease and destruction," yet the bone damage was very variable, with areas of total loss, intact areas (e.g., tegmen ), and circum scribed holes (fistulas). An osteogenic process must surely be presumed to be globa l, wherea s fistulou s tracts are only large enough to accommodate the flow of fluid forced through them. According to Mosnier et aI, in only I of 14 patients with prior mastoid surgery and brain herniation through a tegmen defect was this fistula iatrogenic.' Incidentally, they located 145 cases of brain herniation associa ted with OM repor ted in the previo us 20 years. These patients typically presented with CSF otorrhea, so there are many more cases of OM with CSF leak than the 19 Bhat and Manjunath ' found . Hippocrates had no problem at all with such cases'; they were simply due to decompression of CSF from the brain into the ear-from minor trauma, for example, or in this case , latent (congenital? postinfective?) hydrocephalus, with seco ndary ear infections. Since pressure release