 The vast majority of cases of middle-ear inflammation do not require imaging. This is usually a diagnosis that's made at pediatrician's office usually associated with just a uncomfortable ear and There may be several bouts of this otitis media middle-ear inflammation that occurs during one's childhood However, when it fails to Clear You may again see that Entity known as chronic otitis media or COM and one of the complications Potentially of chronic otitis media is a caestia toma, which we'll talk about shortly When the middle-ear inflammation Extends to the mastoid air cells. It's termed otomastoid itis if the mastoid air cells start to have Irregularity and destruction of the septi between the various mastoid air cells We call that coalescent mastoid itis and we treat it as if it is a form of osteomyelitis and therefore often requiring Aggressive antibiotic use sometimes even intravenous antibiotics Now unfortunately when you have mastoid itis you may have some of the complications of mastoid itis which include thrombophrobitis of The sigmoid sinus or transverse sinus or you can have adjacent Inflammation of the meninges and the patient presenting with a meningitis So here we have a CT scan Through the middle-ear cavity and mastoid air cells and as you can see there is a pacification on the left side of the middle-ear cavity as well as the mastoid air cells and in point of fact you can even see An air fluid level identifying this as acute otitis media Here however is a patient who has a little bit different Appearance and that is that we have lost these septations within the mastoid air cells Bilaterally, there's still is a pacification of the middle-ear cavity But with this loss of the normal septations of the mastoid air cells we would call this coalescent Mastoid itis or coalescent otomastoid it is because there's information in both locations similarly here we have a patient who has Otitis media with opacification around the middle-ear ossicles But in addition there has been erosion and expansion of that anterior epitome panic space so again some coalescent expansion that Would lead to the diagnosis of coalescent otomastoid itis Here we have a patient Who has a flare stand showing high signal intensity in the mastoid air cells now two points to make here The first point is that it is very unusual for the fluid that it occurs in the mastoid air cells to be The same signal intensity as that of CSF so whatever it is that is within the mastoid air cells It's not just pure fluid it is usually inflammatory disease And that's why you see it as bright in signal intensity on the flare scan now This applies also to patients who have nasogastric tubes or have been irradiated where you see fluid in the Mastoid air cells even though it's not likely to be infected in other words It's just an obstructive phenomenon when you have nasogastric tubes or it's a weeping With radiation therapy it still does not show CSF signal on the Flare scan so it's going to be bright and signal intensity allows you to see Mastoid effusions very easily so even though we might call it a mastoid effusion We know that it's not the same fluid as CSF The second main point to make is that this is a patient who is an adult and in an adult that has mastoid Fluid or chronic otitis media or recurrent bouts of otitis media. You better look at the nasopharynx so otomastoiditis in an adult is due to nasopharyngeal carcinoma until proven otherwise and for those of you who had good eyes You may have noticed that there was this mass in the nasopharynx Which is obliterating the normal fat space between the tensor and belly palatine muscles And instead we have this soft tissue that would be obstructing the eustachian tube Here's the tourist barriers and eustachian tube orifice, and you see that it's narrowed and Probably displaced by this mass, which also it looks like is Infiltrating the longest coli muscle on the right side So when you see a patient presenting with chronic otitis media or episodes of otitis media or otomastoiditis We have to always be cognizant of the potential for a nasopharyngeal carcinoma That is obstructing the eustachian tube Here is one of the complications of otomastoiditis and that is an abscess in this case We see a peripheral enhancing mass which is in the cerebellum You see the displacement of the fourth ventricle from right to left and we're also seeing the superficial enhancement of the meninges Suggesting that this is meningitis with a cerebellar abscess and we can see the enhancing soft tissue in the mastoid air cells representing the inflammatory process the next thing to look for is the Venus sinuses the transverse and sigmoin sinus and jugular vein to ensure that there is not Thrombophobitis I Spoke about the entity of Malin otitis external when we were talking about the external auditory canal because by and large That's where it's thought that the infection resides remember that this is a pseudomonas infection which typically occurs in an elderly diabetic patient and and There is inflammation which extends to the skull base and gets there via the fissures of Santorini which are the fissures that occur between the cartilaginous and bony portion of the External auditory canal However, it's not unusual for that Malin otitis externa to extend into the middle ear cavity As well as the skull base and you may see the cortical bone erosion of the Clivus a soft tissue mass at the skull base usually extending into the paraphernalia space and then either osteoleus or increased bone Thickening at the clivus. So here for example is our case that I showed on the talk on the extra auditory canal where we have soft tissue in the external Auditory canal cartilaginous portion Thickening along the wall of the bony portion of the external auditory canal with erosion Infiltration into the middle ear cavity, which you can see also on the MRI scan and then the MRI scan nicely demonstrates on this post Gatellin and fats at scan the inflammation around the carotid artery the enhancement of the clivus Here's the normal fat suppressed clivus. This is abnormally enhancing clivus from the Osteomyelitis associated with the malinotitis externa. You have enhancement of the longest muscle Here's the contralateral normal longest muscle and then the paraphernalia space inflammation adjacent to the nasopharynx So this is going from the extra auditory canal into the middle ear cavity and from the middle ear cavity into the Vascular space the mastoid air cells as well as the skull base