News Letter
Recurrent pyogenic meningitis
- ENT case study


A 53 year old male presented to our clinic with history of at least 7 episodes of meningitis occurring over a period of 11 years. Of late, the frequency of attacks had increased - 3 attacks of meningitis in the last 6 months.

Patient also complained of watery discharge from both nostrils, that was seen only during the infective episodes. He also had occasional headache and nasal block.

He was referred to us with a diagnosis of CSF leak from the anterior skull base. CT PNS taken showed bilateral cribriform plate dehiscence but, no contrast study was done to demonstrate the leak. He was hence advised to undergo contrast study of the paranasal sinuses and temporal bones.

Left temporal bone showed a 4 mm dehiscence of the tegmen antri (roof of mastoid antrum) and a bony defect in the superior wall of superior semicircular canal. There was evidence of a soft tissue mass lying in the mastoid. Surgical exploration of the mastoid showed a soft irregular bluish white mass filling the medial part of mastoid antrum eroding the lateral semi circular canal . The mass was found to be highly vascular, with a bag of worms feel. After removing most of the diseased tissue, a watertight seal was established with bone pate and temporalis fascia. Biopsy of the lesion showed only granulation tissue. Although in the differential diagnosis of eosinophilic granuloma, glomus tumor haemangioma, congenital cholesteatoma and encephalocele were entertained , the recurring meningitis has subsided following treatment.
Photo Quiz Answers
1.Subglottic fibroma found in a 24 year old male with stridor.
2.Arterio - Venous mal formation in the parotid region.
3.Keratosis pharyngis - an asymptomatic condition that requires only reassurance and no medications.
4.Branchial fistula.
Allergic rhinitis vs chronic rhinosinusitis
- similarities & differences
Allergic and non-allergic rhinitis are the most common nasal problems presenting to the ENT surgeon. Clinically chronic rhinosinusitis is found to be an extension of allergic rhinitis. Management of these two conditions is markedly different. A patient with allergic rhinitis is advised long term medical treatment, unless it is refractory and associated with structural abnormalities like deviated nasal septum, concha bullosa (bullous middle turbinate) and medialised uncinate process. In such cases surgical intervention to correct these anomalies is followed by conservative management over a period of months to years. Allergic rhinitis usually presents as continuous or intermittent bouts of sneezing, running nose, nasal block, itching of eyes, lacrimation. The mucosa of the nose appears bluish pale especially the anterior ends of the inferior and middle turbinates. In case of chronic rhinosinusitis the symptoms are more severe with a history of recurrent headaches, heaviness over the cheek, and nasal obstruction being a prominent complain.

Long-term insult to the nasal mucosa in chronic rhinosinusitis leads to a wide spectrum of presentations ranging from polypoid changes to frank polyposis. These polyps arise from the ethmoids, maxillary and sphenoid sinuses. Patients who are hypersensitive to fungal elements develop severe polyposis mixed with inspissated secretions and semisolid allergic fungal debris. All these pathologic variables in chronic rhinosinusitis require surgical removal using a nasal endoscope. We rely on serum Ig E levels, allergy skin prick tests and CT PNS for differentiating the two. Both these variants can be managed by topical medications, even though chronic rhinosinusitis requires surgery for recurrent polyposis. Two types of topical preparations are available- sprays and drops. We prefer to instill drops by maintaining a specific position as this helps to directly reach the osteomeatal complex ( the site in the middle meatus where the initial changes occur). whereas if sprays are used they cannot reach OMC especially if there is a grossly deviated septum.