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Imaging of Complications of Acute Mastoiditis in Children¹

¹ From the Departments of Pediatric Radiology (E.V., A.C., J.P., S.M., S.C., J.C.C., J.L.), Pediatric Otorhinolaryngology (F.P.), and Pediatric Infectious Diseases (C.F.), Hospital Universitario Vall d’Hebron, Area Materno-infantil, Psg Vall d’Hebron 119–129, E-08035 Barcelona, Spain. Presented as an education exhibit at the 2001 RSNA scientific assembly. Received April 8, 2002; revision requested July 23 and received November 13; accepted November 18. Address correspondence to E.V. (e-mail: evazquez@cs.vhebron.es).

View larger version (71K): [in a new window]   Figure 1.  Complications in acute mastoiditis. Extension of the infectious process beyond the mastoid system leads to intracranial and extracranial suppurative complications, including subperiosteal abscess (A), epidural abscess (B), subdural empyema (C), brain abscess (D), meningitis (E), lateral sinus thrombosis (F), carotid artery involvement (G), and apical petrositis (H).

View larger version (185K): [in a new window]   Figure 2a.  Acute incipient mastoiditis in a 3-year-old girl with suspected right acute mastoiditis. (a, b) Axial CT scans of the temporal bone (a obtained inferior to b) show increased attenuation of the entire right middle ear with no osseous defects. Note the normal aeration of the tympanum and mastoid cells on the left side. (c) Axial contrast material-enhanced CT scan shows no complications.

View larger version (184K): [in a new window]   Figure 2b.  Acute incipient mastoiditis in a 3-year-old girl with suspected right acute mastoiditis. (a, b) Axial CT scans of the temporal bone (a obtained inferior to b) show increased attenuation of the entire right middle ear with no osseous defects. Note the normal aeration of the tympanum and mastoid cells on the left side. (c) Axial contrast material-enhanced CT scan shows no complications.

View larger version (105K): [in a new window]   Figure 2c.  Acute incipient mastoiditis in a 3-year-old girl with suspected right acute mastoiditis. (a, b) Axial CT scans of the temporal bone (a obtained inferior to b) show increased attenuation of the entire right middle ear with no osseous defects. Note the normal aeration of the tympanum and mastoid cells on the left side. (c) Axial contrast material-enhanced CT scan shows no complications.

View larger version (166K): [in a new window]   Figure 3a.  Acute coalescent mastoiditis with a subperiosteal abscess in a 2-year-old girl with right acute otomastoiditis. (a, b) Axial CT scans of the temporal bone (a obtained inferior to b) show abnormal soft-tissue attenuation in the right mastoid air cells with erosion of the external cortex and sigmoid plate (arrows). Abnormal attenuation was also seen on the left side, which was probably due to serous otitis. (c) Axial contrast-enhanced cranial CT scan shows a subperiosteal abscess (arrow). No intracranial complications were identified.

View larger version (159K): [in a new window]   Figure 3b.  Acute coalescent mastoiditis with a subperiosteal abscess in a 2-year-old girl with right acute otomastoiditis. (a, b) Axial CT scans of the temporal bone (a obtained inferior to b) show abnormal soft-tissue attenuation in the right mastoid air cells with erosion of the external cortex and sigmoid plate (arrows). Abnormal attenuation was also seen on the left side, which was probably due to serous otitis. (c) Axial contrast-enhanced cranial CT scan shows a subperiosteal abscess (arrow). No intracranial complications were identified.

View larger version (135K): [in a new window]   Figure 3c.  Acute coalescent mastoiditis with a subperiosteal abscess in a 2-year-old girl with right acute otomastoiditis. (a, b) Axial CT scans of the temporal bone (a obtained inferior to b) show abnormal soft-tissue attenuation in the right mastoid air cells with erosion of the external cortex and sigmoid plate (arrows). Abnormal attenuation was also seen on the left side, which was probably due to serous otitis. (c) Axial contrast-enhanced cranial CT scan shows a subperiosteal abscess (arrow). No intracranial complications were identified.

View larger version (148K): [in a new window]   Figure 4a.  Perisinus abscess in an 18-month-old girl with left acute mastoiditis. (a, b) Axial CT scans of the temporal bone show increased attenuation of the left mastoid air cells with subtle erosion of the mastoid cortex (arrow in a) and superior sigmoid plate (arrow in b). (c, d) Axial unenhanced (c) and contrast-enhanced (d) cranial CT scans show an unsuspected small epidural abscess (arrow). The ipsilateral sigmoid sinus (S) demonstrated normal enhancement on CT scans and normal flow void on T2-weighted MR images. (e) Posterior coronal MR venogram shows slightly diminished venous flow with decreased size of the left sigmoid sinus.

View larger version (141K): [in a new window]   Figure 4b.  Perisinus abscess in an 18-month-old girl with left acute mastoiditis. (a, b) Axial CT scans of the temporal bone show increased attenuation of the left mastoid air cells with subtle erosion of the mastoid cortex (arrow in a) and superior sigmoid plate (arrow in b). (c, d) Axial unenhanced (c) and contrast-enhanced (d) cranial CT scans show an unsuspected small epidural abscess (arrow). The ipsilateral sigmoid sinus (S) demonstrated normal enhancement on CT scans and normal flow void on T2-weighted MR images. (e) Posterior coronal MR venogram shows slightly diminished venous flow with decreased size of the left sigmoid sinus.

View larger version (149K): [in a new window]   Figure 4c.  Perisinus abscess in an 18-month-old girl with left acute mastoiditis. (a, b) Axial CT scans of the temporal bone show increased attenuation of the left mastoid air cells with subtle erosion of the mastoid cortex (arrow in a) and superior sigmoid plate (arrow in b). (c, d) Axial unenhanced (c) and contrast-enhanced (d) cranial CT scans show an unsuspected small epidural abscess (arrow). The ipsilateral sigmoid sinus (S) demonstrated normal enhancement on CT scans and normal flow void on T2-weighted MR images. (e) Posterior coronal MR venogram shows slightly diminished venous flow with decreased size of the left sigmoid sinus.

View larger version (157K): [in a new window]   Figure 4d.  Perisinus abscess in an 18-month-old girl with left acute mastoiditis. (a, b) Axial CT scans of the temporal bone show increased attenuation of the left mastoid air cells with subtle erosion of the mastoid cortex (arrow in a) and superior sigmoid plate (arrow in b). (c, d) Axial unenhanced (c) and contrast-enhanced (d) cranial CT scans show an unsuspected small epidural abscess (arrow). The ipsilateral sigmoid sinus (S) demonstrated normal enhancement on CT scans and normal flow void on T2-weighted MR images. (e) Posterior coronal MR venogram shows slightly diminished venous flow with decreased size of the left sigmoid sinus.

View larger version (165K): [in a new window]   Figure 4e.  Perisinus abscess in an 18-month-old girl with left acute mastoiditis. (a, b) Axial CT scans of the temporal bone show increased attenuation of the left mastoid air cells with subtle erosion of the mastoid cortex (arrow in a) and superior sigmoid plate (arrow in b). (c, d) Axial unenhanced (c) and contrast-enhanced (d) cranial CT scans show an unsuspected small epidural abscess (arrow). The ipsilateral sigmoid sinus (S) demonstrated normal enhancement on CT scans and normal flow void on T2-weighted MR images. (e) Posterior coronal MR venogram shows slightly diminished venous flow with decreased size of the left sigmoid sinus.

View larger version (160K): [in a new window]   Figure 5a.  Petrous apicitis in a 7-year-old girl with fever, right-sided facial pain, and diplopia. (a) Axial CT scan of the temporal bone shows increased attenuation of the mastoid air cells and erosion of the right petrous apex (arrow) with a well-pneumatized left petrous apex. (b) Axial contrast-enhanced CT scan obtained with the soft-tissue algorithm shows a hypoattenuating area (arrow) without a significant enhancing soft-tissue mass. (c, d) Axial T1-weighted (c) and T2-weighted (d) MR images show a lesion (arrow) with low (c) and high (d) signal intensity. The patient was treated with mastoid drainage and intravenous antibiotics. (e) Follow-up axial CT scan shows postmastoidectomy changes and progressive reossification of the right petrous apex.

View larger version (127K): [in a new window]   Figure 5b.  Petrous apicitis in a 7-year-old girl with fever, right-sided facial pain, and diplopia. (a) Axial CT scan of the temporal bone shows increased attenuation of the mastoid air cells and erosion of the right petrous apex (arrow) with a well-pneumatized left petrous apex. (b) Axial contrast-enhanced CT scan obtained with the soft-tissue algorithm shows a hypoattenuating area (arrow) without a significant enhancing soft-tissue mass. (c, d) Axial T1-weighted (c) and T2-weighted (d) MR images show a lesion (arrow) with low (c) and high (d) signal intensity. The patient was treated with mastoid drainage and intravenous antibiotics. (e) Follow-up axial CT scan shows postmastoidectomy changes and progressive reossification of the right petrous apex.

View larger version (143K): [in a new window]   Figure 5c.  Petrous apicitis in a 7-year-old girl with fever, right-sided facial pain, and diplopia. (a) Axial CT scan of the temporal bone shows increased attenuation of the mastoid air cells and erosion of the right petrous apex (arrow) with a well-pneumatized left petrous apex. (b) Axial contrast-enhanced CT scan obtained with the soft-tissue algorithm shows a hypoattenuating area (arrow) without a significant enhancing soft-tissue mass. (c, d) Axial T1-weighted (c) and T2-weighted (d) MR images show a lesion (arrow) with low (c) and high (d) signal intensity. The patient was treated with mastoid drainage and intravenous antibiotics. (e) Follow-up axial CT scan shows postmastoidectomy changes and progressive reossification of the right petrous apex.

View larger version (157K): [in a new window]   Figure 5d.  Petrous apicitis in a 7-year-old girl with fever, right-sided facial pain, and diplopia. (a) Axial CT scan of the temporal bone shows increased attenuation of the mastoid air cells and erosion of the right petrous apex (arrow) with a well-pneumatized left petrous apex. (b) Axial contrast-enhanced CT scan obtained with the soft-tissue algorithm shows a hypoattenuating area (arrow) without a significant enhancing soft-tissue mass. (c, d) Axial T1-weighted (c) and T2-weighted (d) MR images show a lesion (arrow) with low (c) and high (d) signal intensity. The patient was treated with mastoid drainage and intravenous antibiotics. (e) Follow-up axial CT scan shows postmastoidectomy changes and progressive reossification of the right petrous apex.

View larger version (118K): [in a new window]   Figure 5e.  Petrous apicitis in a 7-year-old girl with fever, right-sided facial pain, and diplopia. (a) Axial CT scan of the temporal bone shows increased attenuation of the mastoid air cells and erosion of the right petrous apex (arrow) with a well-pneumatized left petrous apex. (b) Axial contrast-enhanced CT scan obtained with the soft-tissue algorithm shows a hypoattenuating area (arrow) without a significant enhancing soft-tissue mass. (c, d) Axial T1-weighted (c) and T2-weighted (d) MR images show a lesion (arrow) with low (c) and high (d) signal intensity. The patient was treated with mastoid drainage and intravenous antibiotics. (e) Follow-up axial CT scan shows postmastoidectomy changes and progressive reossification of the right petrous apex.

View larger version (158K): [in a new window]   Figure 6a.  Epidural abscess with sigmoid sinus phlebothrombosis in a 3-year-old girl with acute right mastoiditis but no neurologic symptoms. (a) Axial CT scan of the temporal bone shows increased attenuation of the right middle ear with a large osseous defect over the sigmoid sinus plate (arrow). (b) Axial contrast-enhanced CT scan shows a large epidural fluid collection (arrow) with some septa. Mastoidectomy with surgical drainage was performed, and intravenous antibiotic therapy was started. MR imaging was subsequently performed. (c-e) Axial T1-weighted (c) and T2-weighted (d) MR images and coronal MR venogram (e) show absence of flow (arrow) in the right sigmoid sinus.

View larger version (139K): [in a new window]   Figure 6b.  Epidural abscess with sigmoid sinus phlebothrombosis in a 3-year-old girl with acute right mastoiditis but no neurologic symptoms. (a) Axial CT scan of the temporal bone shows increased attenuation of the right middle ear with a large osseous defect over the sigmoid sinus plate (arrow). (b) Axial contrast-enhanced CT scan shows a large epidural fluid collection (arrow) with some septa. Mastoidectomy with surgical drainage was performed, and intravenous antibiotic therapy was started. MR imaging was subsequently performed. (c-e) Axial T1-weighted (c) and T2-weighted (d) MR images and coronal MR venogram (e) show absence of flow (arrow) in the right sigmoid sinus.

View larger version (155K): [in a new window]   Figure 6c.  Epidural abscess with sigmoid sinus phlebothrombosis in a 3-year-old girl with acute right mastoiditis but no neurologic symptoms. (a) Axial CT scan of the temporal bone shows increased attenuation of the right middle ear with a large osseous defect over the sigmoid sinus plate (arrow). (b) Axial contrast-enhanced CT scan shows a large epidural fluid collection (arrow) with some septa. Mastoidectomy with surgical drainage was performed, and intravenous antibiotic therapy was started. MR imaging was subsequently performed. (c-e) Axial T1-weighted (c) and T2-weighted (d) MR images and coronal MR venogram (e) show absence of flow (arrow) in the right sigmoid sinus.

View larger version (148K): [in a new window]   Figure 6d.  Epidural abscess with sigmoid sinus phlebothrombosis in a 3-year-old girl with acute right mastoiditis but no neurologic symptoms. (a) Axial CT scan of the temporal bone shows increased attenuation of the right middle ear with a large osseous defect over the sigmoid sinus plate (arrow). (b) Axial contrast-enhanced CT scan shows a large epidural fluid collection (arrow) with some septa. Mastoidectomy with surgical drainage was performed, and intravenous antibiotic therapy was started. MR imaging was subsequently performed. (c-e) Axial T1-weighted (c) and T2-weighted (d) MR images and coronal MR venogram (e) show absence of flow (arrow) in the right sigmoid sinus.

View larger version (132K): [in a new window]   Figure 6e.  Epidural abscess with sigmoid sinus phlebothrombosis in a 3-year-old girl with acute right mastoiditis but no neurologic symptoms. (a) Axial CT scan of the temporal bone shows increased attenuation of the right middle ear with a large osseous defect over the sigmoid sinus plate (arrow). (b) Axial contrast-enhanced CT scan shows a large epidural fluid collection (arrow) with some septa. Mastoidectomy with surgical drainage was performed, and intravenous antibiotic therapy was started. MR imaging was subsequently performed. (c-e) Axial T1-weighted (c) and T2-weighted (d) MR images and coronal MR venogram (e) show absence of flow (arrow) in the right sigmoid sinus.

View larger version (142K): [in a new window]   Figure 7a.  Dural venous phlebothrombosis in a 4-year-old girl with left acute mastoiditis. (a, b) Axial CT scans of the temporal bone (a obtained inferior to b) show increased attenuation of the left mastoid air cells with a clear defect in the posterior and lateral mastoid cortex (arrow). (c) Axial contrast-enhanced cranial CT scan shows asymmetric enhancement of the sigmoid sinus (arrow). (d) Axial T2-weighted MR image shows hyperintense material in the left mastoid cells with a hyperintense thrombus at the level of the sigmoid sinus (arrow). (e) Axial MR venogram shows absence of normal venous flow with occlusion at the level of the mid transverse sinus on the left side and some evidence of adjacent collateralization (arrow).

View larger version (142K): [in a new window]   Figure 7b.  Dural venous phlebothrombosis in a 4-year-old girl with left acute mastoiditis. (a, b) Axial CT scans of the temporal bone (a obtained inferior to b) show increased attenuation of the left mastoid air cells with a clear defect in the posterior and lateral mastoid cortex (arrow). (c) Axial contrast-enhanced cranial CT scan shows asymmetric enhancement of the sigmoid sinus (arrow). (d) Axial T2-weighted MR image shows hyperintense material in the left mastoid cells with a hyperintense thrombus at the level of the sigmoid sinus (arrow). (e) Axial MR venogram shows absence of normal venous flow with occlusion at the level of the mid transverse sinus on the left side and some evidence of adjacent collateralization (arrow).

View larger version (144K): [in a new window]   Figure 7c.  Dural venous phlebothrombosis in a 4-year-old girl with left acute mastoiditis. (a, b) Axial CT scans of the temporal bone (a obtained inferior to b) show increased attenuation of the left mastoid air cells with a clear defect in the posterior and lateral mastoid cortex (arrow). (c) Axial contrast-enhanced cranial CT scan shows asymmetric enhancement of the sigmoid sinus (arrow). (d) Axial T2-weighted MR image shows hyperintense material in the left mastoid cells with a hyperintense thrombus at the level of the sigmoid sinus (arrow). (e) Axial MR venogram shows absence of normal venous flow with occlusion at the level of the mid transverse sinus on the left side and some evidence of adjacent collateralization (arrow).

View larger version (155K): [in a new window]   Figure 7d.  Dural venous phlebothrombosis in a 4-year-old girl with left acute mastoiditis. (a, b) Axial CT scans of the temporal bone (a obtained inferior to b) show increased attenuation of the left mastoid air cells with a clear defect in the posterior and lateral mastoid cortex (arrow). (c) Axial contrast-enhanced cranial CT scan shows asymmetric enhancement of the sigmoid sinus (arrow). (d) Axial T2-weighted MR image shows hyperintense material in the left mastoid cells with a hyperintense thrombus at the level of the sigmoid sinus (arrow). (e) Axial MR venogram shows absence of normal venous flow with occlusion at the level of the mid transverse sinus on the left side and some evidence of adjacent collateralization (arrow).

View larger version (117K): [in a new window]   Figure 7e.  Dural venous phlebothrombosis in a 4-year-old girl with left acute mastoiditis. (a, b) Axial CT scans of the temporal bone (a obtained inferior to b) show increased attenuation of the left mastoid air cells with a clear defect in the posterior and lateral mastoid cortex (arrow). (c) Axial contrast-enhanced cranial CT scan shows asymmetric enhancement of the sigmoid sinus (arrow). (d) Axial T2-weighted MR image shows hyperintense material in the left mastoid cells with a hyperintense thrombus at the level of the sigmoid sinus (arrow). (e) Axial MR venogram shows absence of normal venous flow with occlusion at the level of the mid transverse sinus on the left side and some evidence of adjacent collateralization (arrow).

View larger version (166K): [in a new window]   Figure 8a.  Subdural empyema in a 3-year-old girl with left acute otomastoiditis who developed lethargy, stiff neck, and headache. (a, b) Axial high-resolution CT scans (a obtained inferior to b) show bilateral middle ear disease with no evidence of osseous erosion. (c, d) Axial contrast-enhanced cranial CT scans show fluid collections (arrow) extending along the left tentorium cerebelli (c) and posterior interhemispheric fissure (d). (e) Direct coronal contrast-enhanced CT scan shows continuity of both fluid collections as well as subperiosteal inflammatory soft tissue on the left side.

View larger version (165K): [in a new window]   Figure 8b.  Subdural empyema in a 3-year-old girl with left acute otomastoiditis who developed lethargy, stiff neck, and headache. (a, b) Axial high-resolution CT scans (a obtained inferior to b) show bilateral middle ear disease with no evidence of osseous erosion. (c, d) Axial contrast-enhanced cranial CT scans show fluid collections (arrow) extending along the left tentorium cerebelli (c) and posterior interhemispheric fissure (d). (e) Direct coronal contrast-enhanced CT scan shows continuity of both fluid collections as well as subperiosteal inflammatory soft tissue on the left side.

View larger version (152K): [in a new window]   Figure 8c.  Subdural empyema in a 3-year-old girl with left acute otomastoiditis who developed lethargy, stiff neck, and headache. (a, b) Axial high-resolution CT scans (a obtained inferior to b) show bilateral middle ear disease with no evidence of osseous erosion. (c, d) Axial contrast-enhanced cranial CT scans show fluid collections (arrow) extending along the left tentorium cerebelli (c) and posterior interhemispheric fissure (d). (e) Direct coronal contrast-enhanced CT scan shows continuity of both fluid collections as well as subperiosteal inflammatory soft tissue on the left side.

View larger version (155K): [in a new window]   Figure 8d.  Subdural empyema in a 3-year-old girl with left acute otomastoiditis who developed lethargy, stiff neck, and headache. (a, b) Axial high-resolution CT scans (a obtained inferior to b) show bilateral middle ear disease with no evidence of osseous erosion. (c, d) Axial contrast-enhanced cranial CT scans show fluid collections (arrow) extending along the left tentorium cerebelli (c) and posterior interhemispheric fissure (d). (e) Direct coronal contrast-enhanced CT scan shows continuity of both fluid collections as well as subperiosteal inflammatory soft tissue on the left side.

View larger version (165K): [in a new window]   Figure 8e.  Subdural empyema in a 3-year-old girl with left acute otomastoiditis who developed lethargy, stiff neck, and headache. (a, b) Axial high-resolution CT scans (a obtained inferior to b) show bilateral middle ear disease with no evidence of osseous erosion. (c, d) Axial contrast-enhanced cranial CT scans show fluid collections (arrow) extending along the left tentorium cerebelli (c) and posterior interhemispheric fissure (d). (e) Direct coronal contrast-enhanced CT scan shows continuity of both fluid collections as well as subperiosteal inflammatory soft tissue on the left side.

View larger version (142K): [in a new window]   Figure 9a.  Carotid artery involvement in an 18-month-old boy with acute left otomastoiditis but no neurologic symptoms. (a) Axial CT scan of the temporal bone obtained at admission shows mastoid disease without evidence of complications. Cranial CT also showed no evidence of complications. Owing to persistent fever and otorrhea, a second CT examination was performed 3 days later. (b) Axial CT scan shows abnormal enhancement of the left sigmoid sinus (arrow). MR imaging was performed the same day. (c) Axial MR venogram shows thrombosis of the left lateral and sigmoid sinuses. (d) Coronal gadolinium-enhanced T1-weighted MR image shows associated pachymeningeal enhancement. (e, f) Axial gadolinium-enhanced T1-weighted MR image (e) and coronal MR angiogram (f) show unsuspected markedly decreased flow in the left internal carotid artery. The patient was quickly treated with surgical mastoid drainage and broad-spectrum antibiotics. (g, h) Follow-up coronal MR images obtained 1 week (g) and 2 weeks (h) later show slow recovery of normal flow in the left carotid artery.

View larger version (122K): [in a new window]   Figure 9b.  Carotid artery involvement in an 18-month-old boy with acute left otomastoiditis but no neurologic symptoms. (a) Axial CT scan of the temporal bone obtained at admission shows mastoid disease without evidence of complications. Cranial CT also showed no evidence of complications. Owing to persistent fever and otorrhea, a second CT examination was performed 3 days later. (b) Axial CT scan shows abnormal enhancement of the left sigmoid sinus (arrow). MR imaging was performed the same day. (c) Axial MR venogram shows thrombosis of the left lateral and sigmoid sinuses. (d) Coronal gadolinium-enhanced T1-weighted MR image shows associated pachymeningeal enhancement. (e, f) Axial gadolinium-enhanced T1-weighted MR image (e) and coronal MR angiogram (f) show unsuspected markedly decreased flow in the left internal carotid artery. The patient was quickly treated with surgical mastoid drainage and broad-spectrum antibiotics. (g, h) Follow-up coronal MR images obtained 1 week (g) and 2 weeks (h) later show slow recovery of normal flow in the left carotid artery.

View larger version (144K): [in a new window]   Figure 9c.  Carotid artery involvement in an 18-month-old boy with acute left otomastoiditis but no neurologic symptoms. (a) Axial CT scan of the temporal bone obtained at admission shows mastoid disease without evidence of complications. Cranial CT also showed no evidence of complications. Owing to persistent fever and otorrhea, a second CT examination was performed 3 days later. (b) Axial CT scan shows abnormal enhancement of the left sigmoid sinus (arrow). MR imaging was performed the same day. (c) Axial MR venogram shows thrombosis of the left lateral and sigmoid sinuses. (d) Coronal gadolinium-enhanced T1-weighted MR image shows associated pachymeningeal enhancement. (e, f) Axial gadolinium-enhanced T1-weighted MR image (e) and coronal MR angiogram (f) show unsuspected markedly decreased flow in the left internal carotid artery. The patient was quickly treated with surgical mastoid drainage and broad-spectrum antibiotics. (g, h) Follow-up coronal MR images obtained 1 week (g) and 2 weeks (h) later show slow recovery of normal flow in the left carotid artery.

View larger version (154K): [in a new window]   Figure 9d.  Carotid artery involvement in an 18-month-old boy with acute left otomastoiditis but no neurologic symptoms. (a) Axial CT scan of the temporal bone obtained at admission shows mastoid disease without evidence of complications. Cranial CT also showed no evidence of complications. Owing to persistent fever and otorrhea, a second CT examination was performed 3 days later. (b) Axial CT scan shows abnormal enhancement of the left sigmoid sinus (arrow). MR imaging was performed the same day. (c) Axial MR venogram shows thrombosis of the left lateral and sigmoid sinuses. (d) Coronal gadolinium-enhanced T1-weighted MR image shows associated pachymeningeal enhancement. (e, f) Axial gadolinium-enhanced T1-weighted MR image (e) and coronal MR angiogram (f) show unsuspected markedly decreased flow in the left internal carotid artery. The patient was quickly treated with surgical mastoid drainage and broad-spectrum antibiotics. (g, h) Follow-up coronal MR images obtained 1 week (g) and 2 weeks (h) later show slow recovery of normal flow in the left carotid artery.

View larger version (151K): [in a new window]   Figure 9e.  Carotid artery involvement in an 18-month-old boy with acute left otomastoiditis but no neurologic symptoms. (a) Axial CT scan of the temporal bone obtained at admission shows mastoid disease without evidence of complications. Cranial CT also showed no evidence of complications. Owing to persistent fever and otorrhea, a second CT examination was performed 3 days later. (b) Axial CT scan shows abnormal enhancement of the left sigmoid sinus (arrow). MR imaging was performed the same day. (c) Axial MR venogram shows thrombosis of the left lateral and sigmoid sinuses. (d) Coronal gadolinium-enhanced T1-weighted MR image shows associated pachymeningeal enhancement. (e, f) Axial gadolinium-enhanced T1-weighted MR image (e) and coronal MR angiogram (f) show unsuspected markedly decreased flow in the left internal carotid artery. The patient was quickly treated with surgical mastoid drainage and broad-spectrum antibiotics. (g, h) Follow-up coronal MR images obtained 1 week (g) and 2 weeks (h) later show slow recovery of normal flow in the left carotid artery.

View larger version (129K): [in a new window]   Figure 9f.  Carotid artery involvement in an 18-month-old boy with acute left otomastoiditis but no neurologic symptoms. (a) Axial CT scan of the temporal bone obtained at admission shows mastoid disease without evidence of complications. Cranial CT also showed no evidence of complications. Owing to persistent fever and otorrhea, a second CT examination was performed 3 days later. (b) Axial CT scan shows abnormal enhancement of the left sigmoid sinus (arrow). MR imaging was performed the same day. (c) Axial MR venogram shows thrombosis of the left lateral and sigmoid sinuses. (d) Coronal gadolinium-enhanced T1-weighted MR image shows associated pachymeningeal enhancement. (e, f) Axial gadolinium-enhanced T1-weighted MR image (e) and coronal MR angiogram (f) show unsuspected markedly decreased flow in the left internal carotid artery. The patient was quickly treated with surgical mastoid drainage and broad-spectrum antibiotics. (g, h) Follow-up coronal MR images obtained 1 week (g) and 2 weeks (h) later show slow recovery of normal flow in the left carotid artery.

View larger version (72K): [in a new window]   Figure 9g.  Carotid artery involvement in an 18-month-old boy with acute left otomastoiditis but no neurologic symptoms. (a) Axial CT scan of the temporal bone obtained at admission shows mastoid disease without evidence of complications. Cranial CT also showed no evidence of complications. Owing to persistent fever and otorrhea, a second CT examination was performed 3 days later. (b) Axial CT scan shows abnormal enhancement of the left sigmoid sinus (arrow). MR imaging was performed the same day. (c) Axial MR venogram shows thrombosis of the left lateral and sigmoid sinuses. (d) Coronal gadolinium-enhanced T1-weighted MR image shows associated pachymeningeal enhancement. (e, f) Axial gadolinium-enhanced T1-weighted MR image (e) and coronal MR angiogram (f) show unsuspected markedly decreased flow in the left internal carotid artery. The patient was quickly treated with surgical mastoid drainage and broad-spectrum antibiotics. (g, h) Follow-up coronal MR images obtained 1 week (g) and 2 weeks (h) later show slow recovery of normal flow in the left carotid artery.

View larger version (76K): [in a new window]   Figure 9h.  Carotid artery involvement in an 18-month-old boy with acute left otomastoiditis but no neurologic symptoms. (a) Axial CT scan of the temporal bone obtained at admission shows mastoid disease without evidence of complications. Cranial CT also showed no evidence of complications. Owing to persistent fever and otorrhea, a second CT examination was performed 3 days later. (b) Axial CT scan shows abnormal enhancement of the left sigmoid sinus (arrow). MR imaging was performed the same day. (c) Axial MR venogram shows thrombosis of the left lateral and sigmoid sinuses. (d) Coronal gadolinium-enhanced T1-weighted MR image shows associated pachymeningeal enhancement. (e, f) Axial gadolinium-enhanced T1-weighted MR image (e) and coronal MR angiogram (f) show unsuspected markedly decreased flow in the left internal carotid artery. The patient was quickly treated with surgical mastoid drainage and broad-spectrum antibiotics. (g, h) Follow-up coronal MR images obtained 1 week (g) and 2 weeks (h) later show slow recovery of normal flow in the left carotid artery.