Silent otitis media with multiple intracranial complications

A man in his early 40s, with no comorbidities, presented with a swelling in the right postauricular region for 5 days, which had progressively increased in size. He also gave a history of ear pain 2 months back. He denied history of ear discharge, difficulty hearing, giddiness or tinnitus. There was no history of fever, headache or seizures. On examination, the right pinna and external auditory canal were normal. The tympanic membrane was greyish white and intact. A swelling of size 4×3 cm was noted over the right mastoid region. High-resolution CT of the temporal bone showed right otomastoiditis with suspected mastoid cortical breach. Contrast-enhanced MRI was performed and revealed a bony defect in the mastoid cortex with adjacent pachymeningitis, subdural empyema, cerebellar and temporal lobe abscess. The patient was started on empirical intravenous antibiotics. Neurosurgical evaluation was performed and he underwent surgical evacuation of the abscess. 3 weeks later, he underwent a cortical mastoidectomy. He has been on regular follow-up for 6 months with no further complaints.