Case of the Week 152: Courtesy of Olivier Class, DC, Küssnacht am Rigi, Switzerland

1. Case of the Week 152: Courtesy of Olivier Class, DC, Küssnacht am Rigi, Switzerland 13 year old male presented to Dr. Class’ practice with 10 days of acute torticollis. He had no trauma or preceding infection. The mother reported that he has recently been seen by an ear, nose and throat specialist due to ear ache but had negative findings. After 3 treatments the boy stated that he felt better, however, the antalgic posture persisted and he was very tender in the suboccipital region. After discussion with his MD, the boy was sent for MRI. The cervical spine MRI was normal. However, the child was then getting worse so he was sent to the Children’s hospital for further work-up.

2. Here are the Chiropractor’s radiographs, which are normal other than the obvious marked rotation of the head and posterior ponticle at C1.

3. Axial MRI slices of the skull base and 1 coronal slice through the relevant anatomy. Which side did the boy compain of earache?

4. ANSWERS Which side did the boy complain of earache? Left. Not the asymmetry in signal intensity between the two sides in the region of the mastoid processes and petrous portions of the temporal bones. High signal intensity (fluid) is noted on the left side.

5. Coronal and axial CT scans were then done. Note the sclerosis of the left mastoid process and petrous portion of the temporal bone. This is the bone’s reaction to infection after the acute phase. Bone Window

6. Final Diagnosis Mastoiditis and spread of infection to the petrous portion of the temporal bone. The boy was very ill and a shunt was considered. However, he responded to high doses of antibiotics.