https://doi.org/10.53453/ms.2026.4.10
Chronic otitis media complicated by mastoiditis and cerebral
venous sinus thrombosis in a pediatric patient: a case report
Goda Ivaškevičiūtė
1
, Vaiva Mickevičienė
2
1
Vilnius University, Faculty of Medicine, Vilnius, Lithuania
2
Vilnius University Hospital Santaros Klinikos, Clinic of Ear, Nose, Throat and Eye Diseases, Institute of Clinical
Medicine, Vilnius, Lithuania
Abstract
Introduction. Chronic otitis media with cholesteatoma is associated with recurrent purulent discharge and
progressive bone destruction and may lead to rare yet serious complications, including mastoiditis, cerebral
venous sinus thrombosis and intracranial abscesses. We present a case of chronic otitis media with cholesteatoma
diagnosed at an advanced stage and complicated by mastoiditis and intracranial spread.
Case report. A 5-year-old boy was admitted to the hospital with left-sided postauricular pain and mild swelling,
purulent ear discharge and episodic headaches. The patient had been treated for otitis externa during the three
months prior to hospitalization. Ear examination revealed a thickened, erythematous eardrum covered with
purulent discharge. Urgent contrast-enhanced Magnetic resonance imaging demonstrated mastoiditis complicated
by the left retroauricular abscess, cerebellar abscess and an extensive thrombosis of the superior sagittal, left
sigmoid and transverse sinuses. Emergency tympanostomy, retroauricular abscess incision and drainage were
performed. Broad-spectrum antibiotics and anticoagulation were initiated. Following the treatment, purulent
discharge persisted daily from the postauricular incision and the middle ear. Two weeks after the initial surgery,
a left-sided atticoantromastoidectomy was performed, cholesteatoma and two ossicular bones were removed. One
month later, the patient was discharged.
Discussion and conclusions. Post-COVID studies have reported a higher proportion of severe otogenic
intracranial complications, including cerebral venous sinus thrombosis, raising discussion about possible
associations with hypercoagulability, immune dysregulation and delayed diagnosis. Treatment of cerebral venous
sinus thrombosis includes broad-spectrum antibiotic therapy, anticoagulation and surgical intervention in cases
associated with mastoiditis, bone destruction, subperiosteal abscess or cholesteatoma.
Keywords: atticoantral otitis; Chronic otitis media; Cerebral venous sinus thrombosis; Mastoiditis.
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Medical Sciences 2026 Vol. 14 (2), p. 97-103, https://doi.org/10.53453/ms.2026.4.10
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1. Introduction
Chronic otitis media is a common condition
encountered in both children and adults. Based on
the type of ear discharge, it is classified into
suppurative and non-suppurative (also referred to as
serous or mucous otitis media) [1]. The atticoantral
type of chronic suppurative otitis media is
considered the most aggressive one due to its
tendency to cause tympanic membrane perforation
and destruction of the surrounding bone [2]. This
type of otitis media is most associated with
cholesteatoma, defined as an abnormal growth of
keratinizing stratified squamous epithelium [3].
Cholesteatoma is most frequently located in the
middle ear but may also involve the petrous part of
the temporal bone or extend intradurally [4].
Chronic otitis with cholesteatoma is considered a
relatively rare condition in Europe, with
epidemiological studies reporting an overall
prevalence of approximately 2.32 cases per 1000
inhabitants [5]. Although cholesteatoma is
considered a benign lesion, it is associated with
serious health consequences. In children,
cholesteatoma tends to follow a more aggressive
course compared to adults and is associated with a
higher risk of complications [4]. Some authors
explain these differences by anatomical factors, such
as greater mastoid pneumatization and a higher
occurrence of Eustachian tube dysfunction and otitis
media in children, which may contribute to disease
progression [6]. In addition, molecular studies have
shown that pediatric cholesteatoma is associated
with increased inflammatory activity and epithelial
proliferation, which may contribute to a more
aggressive disease course [7]. Complications of
cholesteatoma include hearing loss, mastoiditis and
potentially life-threatening conditions, such as
cerebral venous sinus thrombosis, meningitis and
intracranial abscesses [8].
2. Case report
A 5-year-old patient was admitted to the tertiary
university clinic complaining of pain and minor
swelling in the left postauricular region, purulent
discharge from the left ear and episodic but quite
intense frontal headaches. A detailed anamnesis
revealed a prolonged and worsening condition of ear
infection and general symptoms. During the three
months prior to hospitalization, the patient had been
treated for otitis externa, which had been incorrectly
diagnosed. One week before the current admission,
mild fever, nausea and vomiting developed in
addition to a recurrent ear discharge, leading to a
hospitalization in a secondary care hospital. There,
the patient was administered intravenous fluids and
antibacterial therapy and discharged five days later.
Ear examination revealed a thickened, hyperemic
tympanic membrane with purulent discharge in the
left external auditory canal. The left postauricular
region was mildly swollen, with normal overlying
skin. Laboratory tests demonstrated leukocytosis
and elevated C-reactive protein levels. Ultrasound
examination of the soft tissues in the left
postauricular region revealed a 20.5 × 9.1 mm
cavitary lesion associated with focal sequestration of
the bony plate. Given the suspicion of intracranial
extension, urgent contrast-enhanced magnetic
resonance imaging (MRI) was performed. Imaging
revealed left-sided mastoiditis complicated by a left
retroauricular abscess, cerebellar abscess and
extensive thrombosis of the superior sagittal, left
sigmoid and left transverse sinuses.
The patient underwent emergency surgical
intervention: left-sided tympanostomy was
performed and an incision was made in the left
retroauricular region. A large amount of purulent
discharge was drained and a rubber drain was
placed. No bony destruction was identified
intraoperatively at the time. Broad-spectrum
antibiotic therapy and anticoagulation with low-
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molecular-weight heparin (fraxiparine) were
initiated immediately. The patient was admitted to
the neurosurgical department. Middle ear culture
later grew Escherichia coli. Despite treatment, the
patient’s clinical condition showed only minimal
improvement, as headaches persisted and purulent
discharge was present daily from both the
postauricular incision and the ear canal.
During the second week after the initial surgery,
because of the persistent purulent discharge,
atticoantromastoidectomy was scheduled.
Fraxiparine was discontinued 24 hours prior to the
surgery. A postauricular incision was made and
mastoid air cells filled with purulent material and
granulation tissue were cleared. After widening the
opening toward the antrum, atticotomy was
performed and a large cholesteatoma extensively
involving the tympanic cavity was removed. The
incus, head of the malleus and stapes superstructure
were removed and the facial nerve was carefully
exposed and cleaned. The tympanic membrane
defect was reconstructed using auricular cartilage.
The wound margins were cauterized to ensure better
hemostasis before anticoagulation was restarted and
the incision was closed.
Following the second surgery, the patient received
conservative treatment in the pediatric
otorhinolaryngology ward, including continued
anticoagulation, intravenous antibiotic therapy and
postoperative wound care. Three weeks later,
follow-up contrast-enhanced MRI demonstrated
marked radiological improvement with clear
retroauricular region and left middle ear, as well as
partial regression of the cerebral venous sinus
thrombosis. After completion of antibiotic therapy
and sustained clinical improvement, the patient was
discharged six weeks after the admission to the
hospital. Anticoagulation therapy was continued
with rivaroxaban and was terminated 6 months later.
The patient is periodically observed by an
otorhinolaryngologist, a neurosurgeon and a
hematologist.
3. Discussion
This case illustrates a clinically complicated course
of chronic otitis media. Initially misdiagnosed as
otitis externa, the patient was later hospitalized and
operated on for acute suppurative otitis media
complicated by mastoiditis, retroauricular
subperiosteal abscess, cerebellar abscess and
cerebral venous sinus thrombosis. Ultimately the
patient was treated surgically the second time and
the final diagnosis of chronic otitis media with
cholesteatoma was made. The patient underwent a
very long path to reach complete recovery. This case
report highlights that rare complications of chronic
otitis media may occur even in patients without prior
illness or immunosuppression.
There are two types of cholesteatoma: congenital
and acquired. Congenital cholesteatoma represents
up to 5% of all cholesteatoma cases and is believed
to originate from embryonic epidermal cell nests
[4,9]. It may remain asymptomatic for a long time
and is often detected incidentally during otoscopic
examination as a white mass behind an intact
tympanic membrane [10]. In contrast, acquired
cholesteatoma is associated with local infection,
chronic Eustachian tube dysfunction and tympanic
membrane perforation [9]. Otorrhea is often the first
major symptom that leads to the diagnosis of
acquired cholesteatoma [10]. If left untreated,
cholesteatoma expands and compresses surrounding
tissues, while chronic inflammation promotes the
production of proteolytic enzymes such as
collagenase, acid phosphatase and acidic proteases.
These mediators stimulate osteoclast activation,
resulting in erosion and destruction of adjacent bony
structures [11].
Chronic otitis media with cholesteatoma may be
difficult to diagnose, as symptoms can initially be
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subtle and otoscopic findings may require
examination by an experienced examiner. In chronic
suppurative otitis media with cholesteatoma,
otoscopic examination may reveal tympanic
membrane perforation, purulent otorrhea and visible
keratin flakes [1]. To assess the extent of
cholesteatoma further radiological evaluation is
necessary. Computed tomography (CT) is preferred
for the initial evaluation, demonstrating a soft tissue
density mass within the middle ear or adjacent
structures. CT allows to assess the disease extension,
ossicular involvement and potential complications
[1]. Magnetic resonance imaging, however, is
essential when intracranial complications are
suspected or when further characterization of soft
tissue is required [4].
Surgery with complete removal of cholesteatoma is
the only effective treatment. In uncomplicated cases,
an elective surgery is usually planned. Traditionally,
surgery is performed under microscopic guidance
using a postauricular approach and may include
canal wall up mastoidectomy, canaloplasty and
posterior tympanotomy to access the tympanic
cavity and mastoid region. Although minimally
invasive endoscopic cholesteatoma surgery has
advanced significantly in recent years, microscopic
surgery remains the most reliable and widely used
approach in cases where cholesteatoma extends
through the aditus ad antrum into the mastoid [9]. In
pediatric patients, cartilage grafts are more
commonly recommended for tympanic membrane
reconstruction, whereas temporalis fascia is more
frequently used in adults [4]. In the reported case,
the initial surgical management consisted of
retroauricular abscess drainage and tympanostomy,
as complicated acute suppurative otitis media was
suspected. However, slow clinical improvement
suggested the possibility of previously undiagnosed
chronic middle ear disease. Therefore, an
atticoantromastoidectomy was performed, which
resulted in favorable outcomes and noticeable
clinical improvement.
Cholesteatoma-related complications are classified
as intracranial and extracranial, with extracranial
complications further divided into intratemporal and
extratemporal. The most common intratemporal
complication is conductive hearing loss, which
results from the accumulation of cholesteatoma
mass, ossicular chain destruction and tympanic
membrane retraction, all of which impair sound
transmission through the middle ear. As the disease
progresses further destruction of the cochlea can
lead to permanent sensorineural hearing loss, which
is sometimes complicated by tinnitus [12]. Hearing
loss is particularly unfavorable in children because
of its impact on speech development, social skills
and cognitive development [8].
Unlike conductive hearing loss, which is typically a
chronic manifestation of cholesteatoma, mastoiditis
is an acute intratemporal complication that develops
when chronic otitis media is exacerbated by an acute
infection spreading to the mastoid. It is the second
most frequent intratemporal complication [13].
Extension of acute infection into the mastoid
typically presents with retroauricular pain. While
uncomplicated cases may be managed
conservatively or with tympanostomy, complicated
mastoiditis often requires intravenous antibiotics
and surgical intervention, including mastoidectomy
or, in selected cases, craniotomy [14].
In patients with chronic otitis media with
cholesteatoma, untreated acute mastoiditis may
promote further spread of infection beyond the
temporal bone, increasing the risk of both
intracranial and extracranial complications.
Extratemporal complications occur when infection
extends from the mastoid into the surrounding soft
tissues. These complications, such as subperiosteal
abscess and, more rarely, Bezold’s abscess, require
surgical drainage with appropriate antibiotic
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treatment [1,4]. Less common extracranial
complications include facial nerve paralysis and
vertigo [1,13]. Due to slow growth of
cholesteatoma, complications often present late.
Acute exacerbation may occur with superimposed
infection or involvement of critical anatomical
structures [8]. In the reported case, the initial
presentation mimicked otitis externa, but
exacerbation with systemic symptoms (febrile fever,
nausea and vomiting, headache) and postauricular
swelling raised suspicion of an advanced infectious
process. Acute otitis media complicated by acute
mastoiditis was the primary diagnosis, however
delayed clinical improvement suggested
cholesteatoma and necessitated a second surgery.
Intracranial complications of chronic
cholesteatomatous otitis media include brain
abscess, meningitis, cerebral venous sinus
thrombosis, subdural abscess or empyema and otitic
hydrocephalus [4]. Although acute and chronic ear
infections remain common in the pediatric
population, intracranial complications have become
rare due to a widespread antibiotic use [15].
However, following the COVID-19 pandemic an
increased incidence of otogenic and sinogenic
intracranial complications has been reported.
Systematic review by Patel et al. reported a rise in
cases complicated by cerebral venous sinus
thrombosis, parenchymal abscess and meningitis
[16]. Some authors have associated this trend with
possible post-COVID hypercoagulability, immune
dysregulation, and mucosal barrier dysfunction, but
the exact mechanism is unclear [17,18]. This
increase could also be explained by significant
delays in access to routine healthcare during the
pandemic and changes in healthcare seeking
behavior [16,19].
An association between the patient’s age and the
type of intracranial complications has been
described. A retrospective study by Lee et al. found
that cerebral venous sinus thrombosis, intracranial
abscesses and facial nerve paralysis occur more
frequently in adolescents and young adults
compared to younger children [13]. A retrospective
study by Van der Poel et al. suggests that in pediatric
patients, symptoms of otogenic intracranial
complications more often present with nausea,
vomiting, headaches, diplopia – symptoms that
mimic meningitis. Whereas adult presentations
resemble a stroke – more commonly symptoms
include altered mental status, hemiparesis and focal
neurological signs [15].
Otogenic cerebral venous sinus thrombosis, on the
other hand, is the most common intracranial
complication of otomastoiditis in children [14]. It is
thought to develop either through direct erosion of
the sigmoid sinus bone wall or indirectly through the
spread of thrombophlebitis [20]. Magnetic
resonance venography is considered the most
accurate diagnostic method, although contrast-
enhanced computed tomography may also be used
[21]. Treatment for cerebral venous sinus
thrombosis includes broad-spectrum antibiotic
therapy and anticoagulation, whereas surgical
intervention should be reserved for selected cases
involving mastoiditis, bone destruction,
subperiosteal abscess or cholesteatoma [21].
Anticoagulation with low-molecular-weight heparin
is recommended during the acute phase and is
typically continued for a median duration of 3
months [22]. In clinically stable pediatric patients,
maintenance anticoagulant therapy can be changed
from low-molecular-weight heparin to rivaroxaban
[22,23].
Brain abscess may also be the complication of
otomastoiditis and is most commonly located in the
ipsilateral temporal lobe or cerebellum and if left
untreated, may progress to encephalitis [8]. Typical
symptoms include fever, headache, altered state of
consciousness and signs of increased intracranial
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pressure. In cases of cerebellar abscess, additional
neurological signs such as tremor and dysmetria
may be observed [8]. Treatment consists of broad-
spectrum antibiotics, corticosteroids and
anticonvulsants when indicated, as well as surgical
drainage of both the abscess and the mastoid [4,8].
4. Conclusions
The reported clinical case highlights the importance
of early diagnosis and appropriate management in
complicated forms of otitis media. The patient
received comprehensive treatment in accordance
with current literature recommendations, including
prompt surgical drainage of the infectious site,
broad-spectrum antibiotic therapy and
anticoagulation. Definitive surgical management
with atticoantromastoidectomy allowed complete
removal of the cholesteatoma and infected tissue,
eliminating the primary source of infection.
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