Extradural Hematoma Complicating Middle-Ear Infection Report of a Case VIRGILIO NOVAES, M . D . AND CARLOS GORBITZ !V[., M . D . * Department of Neurosurgery,~ Hospital Estadual Souza Aguiar, Guanabara, Brazil Case Report M.C.S., a 96-year-old white man, was admitted on September 8, 1963. He was very drowsy and the family gave a history of left middle-ear suppuration. For days he had complained of severe headache and vomited several times. The secretion from his ear "became darker." One day before admission the patient had a convulsion beginning on the right side and then becoming generalized. After the seizure he was drowsy and apathetic. Examination revealed a right hemiparesis and anisocoria with left midriasis, reaction to light being preserved. The fundus was normal. The patient was afebrile. X-rays of the skull and blood and urine analysis were normal. With a presumptive diagnosis of otitic temporal abscess, left carotid angiography was performed on the day of admission. There was a deviation of the anterior cerebral artery toward the right side, elevation of the Sylvian group and depression of the posterior cerebral artery, probably by a temporal lobe herniation (Fig. 1). Operation. A subtemporal burr hole revealed the presence of an extradural hematoma. At craniotomy a huge hematoma, weighing 80 gm., mainly basal, was exposed and drained (see Fig. ~). There was diffuse Received for publication June ~ , 1964. * Present address: University of Trujillo, Trujillo, Peru. Surgeon in chief: J. G. Silva Neves, M.D. meningeal bleeding. The undamaged middle meningeal artery was occluded in the orifice of entry. Damage to the upper face of the petrous bone was found with a corresponding zone of pachymeningitis and venous bleeding. After hemostasis and fixation of the dura mater had been accomplished, the wound was closed in the usual manner. Postoperative course was uneventful and the patient was discharged after 15 days. He is now working full time and is normal neurologically. Discussion E x t r a d u r a l b l e e d i n g as a c o m p l i c a t i o n of midd l e - e a r i n f e c t i o n is v e r y rare. T h e l i t e r a t u r e cont a i n s o n l y one report, b y Schneider a n d H e g a r t y , 5 of a p a t i e n t w i t h r e c u r r i n g s u p p u r a t i v e infection of t h e m i d d l e e a r w i t h signs of a h o m o l a t e r a l ext r a d u r a l mass. A diagnosis of otitic abscess of t h e t e m p o r a l lobe was m a d e a n d t h e p a t i e n t died sudd e n l y b e f o r e o p e r a t i o n could b e p e r f o r m e d . A t n e c r o p s y a h u g e h e m a t o m a was f o u n d p r o b a b l y c a u s e d b y r u p t u r e of t h e middle m e n i n g e a l a r t e r y r e s u l t i n g f r o m a necrotizing process e x t e n d i n g t o the foramen spinosum. I n t h e case we are r e p o r t i n g d e v e l o p m e n t of t h e h e m a t o m a was p r e s u m a b l y s e c o n d a r y t o recurr e n t b l e e d i n g f r o m progressive d e t a c h m e n t of t h e d u r a m a t e r , a c o m m o n occurrence in t r a u m a t i c FIG. 1. Left auteroposterior (left) and lateral (right) angiogram showing the shift of the anterior cerebral artery toward the right side and medial displacement of the Sylvian arteries. Note in the lateral view the depression of the posterior cerebral artery indicating transtentorlal herniation. 85~ Middle-Ear Infection with Extradural Hematoma 353 venous h e m a t o m a . T h e rarity of this complication in s u p p u r a t i v e infection of the middle ear is p r o b a b l y a t t r i b u t a b l e to the usual formation of a zone of pachymeningitis and bony-dural adhesions, w i t h a consequent restraint of hemorrhagic oozing. T h e p r e s u m p t i v e diagnosis of otitic abscess of the t e m p o r a l lobe, could be modified only after surgical exposition of t h e h e m a t o m a . T h e same was t r u e of the case reported previously. 5'G I n our case, we decided to operate at once because angiographic findings indicated a tentorial pressure cone and the clinical signs (anisocoria) confirmed the existence of pressure. Summary A case of extradural h e m o r r h a g e following a middle-ear infection, a p p a r e n t l y only the second in neurosurgical literature, is described. A review of t h e classical textbooks of surgical diseases has failed to reveal any references to this rare entity.1-4 I n t h e ease of Schneider and H e g a r t y 5 the course was acute and the bleeding proved to be arterial; the slow course in the present ease is p r o b a b l y explained b y the venous origin of the oozing. I n b o t h eases an incorrect initial diagnosis of otitie abscess of the t e m p o r a l lobe was made. References 1. BRUNNER, H. Intraeranial complications of ear, nose and throat infections. Chicago: Year Book Publishers, Inc., 1946, xii, 444 p p 2. COURVrLLE, C. B., and ROSENVOLD, L. K. Intracranial complications of infections of nasal cavities FIG. r Operative exposure of the extradural hematoma. and accessory sinuses. A survey of lesions observed in a series of fifteen thousand autopsies. Arch. Otolaryng., Chicago, 1938, 27:69~-781. $. JACKSON,C., and JACKSON, C. L. [Ed.] Diseases of the nose, throat, and ear. Including bronchoscopy and esophagoscopy. Philadelphia: W. B. Saunders Co., 1945, xiv, 844 pp. 4. MORRISON,W . W . Diseases of ear, nose and throat. New York: Appleton-Century-Crofts, Inc., 1948, xviii, 77~ pp. 5. SCHNEIDER, R. C., and HEGARTY, W. q-~. Extradural hemorrhage as a complication of otological and rhinological infections. Ann. otol., etc., St. Louis, 1951, 60:197-~06. 6. SCHNEIDER, R. C., and TYTUS, J. S. Extradural hemorrhage: factors responsible for the high mortality rate. Ann. Surg., 1955, 142:938-948.