The Journal of Laryngology and Otology
May 1986. Vol. 100. pp. 595-597

Clinical Records
Nominal aphasia following a radical
mastoidectomy
by
B. A. GIRGIS and J. SIEGLER (Wirral)

Introduction
This case is being reported because it is a rare complication to a routine radical mastoid
operation. Its purpose is to advise otologists of such a possibility and guide them in management and prognosis should they come across such a complication.
Intra-cranial complications of chronic otitis media are well documented in the standard
text books of otology. Intra-cranial complications following a radical mastoid operation are
rare, bearing in mind the large number of mastoid operations which are still being performed
by otologists practising in heavy industrialized areas with large populations who are living
under adverse hygienic conditions.
The recent increase of litigation alleging negligence during operations is an additional
reason for bringing this unusual complication to the notice of otologists. There have been
only two previous case reports on this complication (Windle-Taylor, 1980).
History
P.M., aged 13, was seen in the outpatients department at Arrowe Park Hospital on 12 November
1983 complaining of pain in his left ear. It had
begun three months previously and had recurred
twice during this period. There had been a history
of the patient inserting a foreign body into his left
ear during childhood.
His left ear showed an attic perforation through
which cholesteatoma was being discharged. The
right ear showed a normal drum and canal. His
audiogram showed a conductive loss in both ears
but was more severe on the left.
The initial treatment was a course of aural toilet
in the outpatients but the ear continued to discharge. In December 1983 his left ear was examined under anaesthetic and an attempt was made to
evacuate all the cholesteatoma through the attic
perforation. The disease was found to be inaccessible and a mastoid operation was therefore advised.
The mastoidectomy was performed on 16 May
1984 via an incision behind the ear. The mastoid
was found to be partially pneumatised and the cells
contained infected mucous membrane and granulation tissue. The middle ear was opened and cholesteatoma was found to occupy the attic and

mesotympanum. The incus showed necrosis of its
long process. During the operation the dura of the
middle cranial fossa was exposed and recorded as
being healthy. There was a small area of bleeding
which was treated by the use of a diamond burr and
diathermy.
The diseased air cells and cholesteatoma were
removed together with the remains of the incus and
the head of the malleus. A BIPP pack was inserted
into the cavity as a routine procedure.
Post-operatively the patient was well until the
third day after operation when he complained of a
severe headache. Next day he behaved in a very
strange manner and he was found to be suffering
with nominal aphasia. An attempt was made to get
him to name various common objects but he was
unable to do so.
The patient was then referred to the Regional
Neurological Centre where he was examined by
Mr. John Miles, consultant neurosurgeon. A CAT
scan was performed but there was no evidence of a
brain abscess or a shift of the mid-line structures to
one side. The region of the left temporo-parietal
region of the brain showed evidence of low density
(Fig. 1), which was consistent of a diagnosis of
595

B. A. GIRGIS AND J. SIEGLER

FIG. 1.
CAT scan with arrow pointing to zone of reduced density, with arrow pointing to area of low density in brain.

cortical thrombophlebitis. During his investigation
in the Regional Neurological Centre he had one fit
of Jacksonian epilepsy which lasted for two minutes. It was treated by Erythromycin 250 mgs. four
times a day, Epilim 200 mgs. three times a day, and
he was referred to a speech therapist in Arrowe
Park.
His aphasia lasted for about a week and he then
responded to speech therapy. During the initial
phase of his illness he failed to respond to all forms
of testing. He was unable to understand complex
written or spoken instructions. He was unable to
repeat sentences, produce serial speech or name
common objects. He was unable to perform simple
oral calculations. All of these symptoms have subsided and he now has no difficulty in answering
simple questions. He is being supervised in the
Neurosurgical Unit and is continuing with his Epilim for another 6 months.

thrombophlebitis can occur after any operation
which involves manipulation of the dura and it must
be assumed that in this case thrombosis occurred in
some of the vessels involving the dura and spread to
the veins overlying the temporo-parietal region of
his brain. There was no possible way to prevent this
happening and its must be assumed that such a
complication, rare as it is, cannot be due to negligence on the part of the surgeon.
Summary
(1) A rare complication of a radical mastoid operation is described.
(2) Possible reasons for such a complication are
mentioned.
(3) All clinical manifestations subsided
spontaneously.
Acknowledgements

Discussion
This is a rare complication of an uncomplicated
mastoid operation. Neurosurgeons recognize that

The authors wish to thank Mr. John Miles, consultant neurosurgeon, and Miss Susan Stevenson,
speech therapist, for their assistance in managing
this patient.

CLINICAL RECORDS

597

Reference
WINDLF.-TAYLOR, P. C. (1980) Superficial cerebral thrombosis following mastoid surgery. Journal of Laryngology
and Otology, 94: 317-320.
Address for correspondence:
Mr. J. Siegler.
31 Rodney Street.
Liverpool LI 9EH.