Complications Of Chronic Otitis Media Research Articles

Pseudoaneurysm of the Petrous Section Internal Carotid: A Co-incidence or a Complication of Chronic Otitis Media: A Case Report

Although rare, a Petrous Internal Carotid Artery (ICA) pseudoaneurysm is a possible complication following chronic otitis media. A 57-year-old woman was brought to the Emergency Department with multiple painless episodes of right ear bleeding and epistaxis over the last two months. Upon evaluation, bony dehiscence was observed over the petrous carotid’s first (proximal) genu, along with a pseudoaneurysm detected in the Magnetic Resonance Angiography (MR angiogram). The Balloon Occlusion Test (BTO) showed no cross-flow from the opposite side. Consequently, the patient was considered for high-flow bypass surgery between the external carotid artery and the M2 segment of the Middle Cerebral Artery (MCA), utilising a radial artery graft in the neurosurgery specialty. The present rare case report emphasises the significance of maintaining a high index of suspicion and implementing prompt intervention through a multidisciplinary approach. It also raises an open-ended question about whether the petrous carotid pseudoaneurysm is a complication of chronic otitis media or merely a co-incidence.

Localized Pachymeningitis - An Uncommon Complication of Chronic Otitis Media and Mastoiditis

We describe the case history of a 55-year-old male presenting with gradual onset of bilateral facial nerve paralysis. A radiological test of CT temporal bone revealed soft tissue thickening in bilateral mastoid air cells and middle ear cavities. Tl weighted contrast-enhanced MRI revealed thickening and early enhancement of the adjacent dura, indicating active pachymeningitis. The past middle ear infection appears to cause the above inflammatory findings in the meninges and worsening on the untreated side. Currently, he is on steroids with some improvement in facial nerve paralysis.

A Rare Complication of Chronic Otitis Media: Septic Thrombosis of the Transverse Sinus and Meningoencephalitis due to a Parameningeal Infection. A Case Report

BACKGROUND: Septic cerebral venous sinus thrombosis or septic cavernous thrombosis is an extremely rare disorder, with 2 to 13 cases per million per year, following the introduction of antibiotics and advances in diagnostic imaging. It is a complex pathology, difficult to diagnose and life threatening. It has a high risk of otoneurologic sequelae, and it requires follow-up by various specialties, as treatment is medical and surgical, including neurology, internal medicine, intensive care, otorhinolaryngology, and infectiology, among others. Due to the low occurrence of septic cavernous thrombosis, the diagnosis may be erroneous or delayed, increasing complications and mortality. It is essential to perform a complete physical examination with emphasis on the ophthalmological, otological, rhinosinusal and neurological examinations, which is why this case is described. THE CASE: We describe a 77-year-old male patient, with history of high blood pressure, nasopharyngeal carcinoma in remission, bilateral hearing loss, prostatic hyperplasia, otitis media, and chronic mastoiditis. He was admitted due sudden onset of difficulty standing, gait instability, mutism, unquantified fever spikes, headache, and vertigo. The initial laboratory tests only revealed a complete blood count with leukocytosis. A simple brain computed tomography (CT) scan did not show relevant findings; therefore, a lumbar puncture (LP) was carried out due to suspicion of bacterial meningoencephalitis. Analysis of cerebrospinal fluid (CSF) showed pleocytosis with a predominance of polymorphonuclear cells, hypoglycorrhachia and hyperproteinorrachia. Empirical antibiotic therapy was started with Vancomycin and Cefepime. At day five since onset of symptoms, he did not have improvements of his symptoms, so a new LP was carried out and antibiotic therapy was escalated. In the CSF it was found an increased cellularity with greater hypoglycorrhachia, persistent hyperproteinorrachia, and cellular shift to lymphocyte predominance. A contrast-enhanced magnetic resonance imaging (MRI) of the brain was requested, showing pyogenic ventriculitis and decreased flow at the left transverse sinus, suggesting possible thrombosis, which was later confirmed with a contrast-enhanced brain angio-MRI. Furthermore, due to the otological involvement, a CT scan of the ears was performed, which showed severe bilateral otomastoiditis with bilateral mastoid cholesteatomas, bilateral otitis externa, and osteomyelitis of the left petrous apex. A diagnosis of a septic thrombosis of the left transverse sinus, in the context of meningoencephalitis secondary to a parameningeal focus, was made. Treatment with Meropenem 1 gr intravenously every 8 hours and Vancomycin 1 gr every 8 hours was continued up to 28 days. During the hospitalization, otorhinolaryngology did a mastoidectomy and continued outpatient antibiotic management with Ciprofloxacin for seven more days. The patient did not require anticoagulation, and at follow-up he was notably recovered, and in control studies the recanalization of the thrombosis was confirmed. CONCLUSION: Septic cerebral venous sinus thrombosis is a rare pathology, but with a high associated morbidity and mortality, which requires multidisciplinary management. It is vital to know its pathophysiology and predisposing factors to include it in differential diagnoses when managing a patient with meningeal symptoms.

Decision Making in Complicated Chronic Otitis Media- Squamous Active Disease on Surgical Approach: How it Influenced the Outcome?

Chronic Otitis Media (COM) with complications is a common clinical entity in Otorhinolaryngology, but advances in antibiotics and surgical techniques have reduced complication rates and mortality. Management warrants surgical disease clearance, the choice of surgical approach of which may vary. Endaural approach is a less commonly performed approach in view of its complexity and surgical expertise. This case report presents a 13-year-old female with COM-squamous active type with cerebellar abscess, managed with Lempert's endaural mastoidectomy. The patient presented with long-standing left sided purulent ear discharge, ear pain, headache, and vomiting. Diagnosis included bilateral COM-squamous active type with left cerebellar abscess, status post suboccipital craniotomy. Endaural mastoidectomy was performed to circumvent the pseudomeningocoele and achieve disease clearance. Postoperative follow-up showed well-healed scars and no evidence of disease recurrence. Chronic Otitis Media with complications requires surgical management to prevent disease progression and related complications. Surgical approaches for disease clearance include post aural and endaural techniques. Lempert's endaural approach provided a superior view of the middle ear and mastoid, facilitating disease clearance and simplifying postoperative care with enhanced cosmesis. Although endaural approach demands surgical expertise, it can be a viable option for complicated cases. In this case, Lempert's endaural canal wall down mastoidectomy effectively managed COM-squamous active type with cerebellar abscess, offering a clear view of the disease epicenter with limited bone removal. The endaural approach, in the hands of an experienced surgeon, can be a feasible alternative for surgical clearance in complicated COM cases, providing favorable outcomes with superior visibility and cosmesis.

Automastoidectomy — a case report

BackgroundAutomastoidectomy denotes extensive destruction of the middle ear cavity and the mastoid air cells, mimicking the appearance of a reminiscent image of the post-mastoidectomy cavity. This condition, although rare, might occur as a unique complication of chronic otitis media with cholesteatoma with subsequent destruction of the posterior wall of the external auditory canal and spontaneous partial or complete evacuation of the cholesteatoma through the canal.Case presentationSeventy-year-old gentleman, a retired soldier, presented to us in the ENT OPD with right ear pain for more than a year, right ear discharge for 9 months, and a decrease in the hearing of the right ear for 6 months. The condition started 18 months ago with intermittent right otalgia; Dull aching in nature. Ten months later, the patient started to experience right-sided otorrhoea which was profuse, offensive, mucopurulent, and yellowish in color. Later on, he noticed a gradually deteriorating hearing.On examination of the right ear, there is a fleshy mass obstructing the EAC, no auricular deformity tenderness, no preauricular swelling, sinus, or deformity, and there is thinning of the skin in the right postauricular region with mild tenderness but no swelling or sinus and preserved sulcus. Otoscopic examination shows a mass obstructing the EAC found to be an everted skin tag from the posteroinferior wall of the canal. There was a widening of the canal with the destruction of the walls and the absence of the TM, the annulus tympanicum, and the ossicles with polypoidal mucosa all over the middle ear cavity.InvestigationHRCT scan of the temporal bone shows destruction of the air cells of the right mastoid cavity with the absence of the ossicles and destruction of the posterior EAC walls.ConclusionAlthough uncommon it is considered to be a known complication of Cholesteatomatous otitis media and sometime keratosis obturates with the main feature of osteogenic destruction of the posterior wall of the EAC.

Sigmoid and Transverse Sinus Thrombosis in a Child with Chronic Otitis Media: a Case Report.

Sigmoid sinus and transverse sinus thrombosis may occur as intracranial complications of chronic otitis media. Central venous sinus thrombosis typically presents with picket fence fever along with otalgia, otorrhea, and altered mental status. CT and MRI are investigations of choice for diagnosis. Once diagnosed, one should be started on empiric antibiotics. The use of anticoagulants has been debatable. From a surgical point of view, the current trend is to perform a mastoidectomy with the removal of inflammatory tissue from the sinus walls.

Correlative Study of High-Resolution Computed Tomography Temporal Bone with Intraoperative Findings in Tympanomastoid Surgery

Abstract Introduction: The global incidence of chronic otitis media (COM) is approximately 4.76 per thousand, with 31 million cases causing various complications. Most of these patients require one of the various forms of mastoid surgeries. High-resolution computed tomography (HRCT) has greatly improved the ability to assess both bony architecture and soft-tissue status. Aim: The aim is to assess the correlation of HRCT temporal bone with intraoperative findings in tympanomastoid surgery and to evaluate the sensitivity, specificity, positive predictive value, and negative predictive value of HRCT temporal bone. Materials and Methods: This prospective study was conducted in the Department of Otorhinolaryngology, SDM College of Medical Sciences and Hospital, Dharwad from November 2012–April 2014. Fifty patients of COM were taken up for study who underwent preoperative HRCT temporal bone followed by appropriate tympanomastoid surgery. Results: HRCT temporal bone showed increased sensitivity and specificity in detecting ossicular chain erosion and soft tissue abnormality within the middle ear and mastoid air cells. Facial nerve canal erosion was correctly detected in 62.50%, and overall agreement between surgical findings and the scan was high (90%). It also showed a very high specificity of 95.24%. For semicircular canal erosion and dural plate erosion, sensitivity was 50% each, specificity was 100% and had a very good correlation with surgical findings. Two cases of erosion of the posterior bony wall of the external auditory canal were correctly detected by the HRCT scan. Conclusion: HRCT temporal bone was found to have a high overall correlation with surgical findings and can be a useful method for early diagnosis of complications of COM and preoperative assessment.

Intracranial Complications of Otitis Media - The Menace of Discharging Ears in Children.

Background: In developing nations, otitis media is widespread among people of low socioeconomic backgrounds. Chronic otitis media is a potentially fatal condition due to its consequences. Gradualbone erosion in chronic otitis media leads to serious intracranial complication.Objective: The objective of this study was to determine the frequency of intracranial complications of otitis media in children.Material and Methods: This was a prospective, descriptive & cross-sectional study conducted at the Department of ENT -----from 1st October 2018 to 30th September 2019 on 120 patients to determine the frequency of intracranial complications of otitis media in children. Children with ages ranging from 1 to 14 years were included in the study. Patients with suspicion of intracranial complications were admitted to ward for management and investigated. The types of complications occurring were noted to determine their frequencies.Results: A total of 120 children were included in the study. The male to female ratio was 3:2. Patients with age range of 3 and 5 years was the commonest group presenting with intracranial complications constituting 30.8% of all. Brain abscess was the commonest complication observed in 13(10.8%) of patients. Conclusion: Intracranial complication of chronic otitis media is common clinical problem faced by ENT surgeon affecting children of 3 to 5 years age, predominantly brain abscess.Keywords: Frequency, Intracranial Complications, Otitis Media, Children, Brain Abscess.

Outcomes of Complications of Chronic Otitis Media in Tertiary Care Facilty in Western Uttar Pradeh

Objectives: This study aims to investigate the frequency and management of complications of chronic suppurative otitis media(CSOM).Patients and Methods: Out of 376 patients with CSOM, 44 patients (25 males, 19 females; mean age 48.5±3.5 years; range 21to 76 years) meeting study criteria were enrolled in this descriptive cross sectional study which was conducted at the Department of Ear Nose and Throat, Head and Neck Surgery. All newly diagnosed patients having CSOM with complications were enrolled. The complications were treated first. Intracranial abscesseswere evacuated by neurosurgeons. Radical and modified radical mastoidectomy were performed.Results: Majority of the patients presented in the second and third decade of life (21-30 years: 27.27%, 31-40 years: 18.18%).Most of the patients (59.1%) had lower socioeconomic status. Canal wall down mastoidectomy was the most common (79.5%) procedure performed. Cholesteatoma was the most common operative finding (100%). Among extracranial complications, subperiosteal abscess was the most common finding (38.63%), while extradural abscess outnumbered (22.72%) in intracranial complications.Conclusion: Complications of CSOM commonly affect younger people with low socioeconomic status. Collaborating withneurosurgeons may assist in the successful management of this infection.

Lateral semicircular labyrintine fistula

Labyrinthine fistula (LF) is a well-known complication of chronic otitis media with cholesteatoma. The most common location of the LF is in the area of the lateral semicircular canal, but it can also affects other semicircular canals and in rare cases the cochlea. The treatment of LF has been discussed in the literature by various authors and is still debatable. Hearing preservation is an important goal of labyrinthine fistula treatment. The appropriate management of LF depends on factors like hearing condition of both ears, the extent of the disease and the intraoperative size of the fistula. Sometimes the disease induced changes can’t be detected radiologically or diagnosed clinically preoperatively. Such cases surprise the surgeon during intraoperative period and can be very challenging.

Incidence of Complications of Unsafe Chronic Suppurative Otitis Media Presenting in a Tertiary Care Hospital at Assam, IndiaA Retrospective Study

Introduction: Chronic otitis media is inflammation of the middle ear cleft presenting with recurrent ear discharge through a tympanic membrane perforation. The disease spectrum ranges from mild to severe forms of complications. Complications of chronic otitis media can be extracranial or intracranial. Aim: To evaluate the demographic profile of patients with chronic otitis media and to estimate the incidence of complications in upper Assam province during a period of 5 year. Materials and Methods: This retrospective study was carried out on a total of 260 patients of chronic otitis media admitted in Ear, Nose and Throat Department, Assam Medical College and Hospital, Dibrugarh, Assam, India, during a period of 5 years from August 2016 to July 2021. The data collected were tabulated in Microsoft Excel Worksheet. The categorical variables were summarised as proportions and percentages. Results: From the records, majority (31.2%) of the cases were found in the age group of 11-20 years with a male to female ratio of 1.13. The disease was more common during the winter season (56.5%). A 13.5% cases showed complications of chronic otitis media. Mastoiditis was the most common extracranial complication (31.4%) , followed by periosteal abscesses (22.9%), facial nerve paralysis (11.4%) and labyrinthitis (5.7%). Conclusion: The early identification of symptoms by rural healthcare personnels and immediate management of unsafe chronic otitis media, to avoid complications.

The Role of Biofilms in Chronic Otitis Media-Active Squamosal Disease: An Evaluative Study.

To study the presence of biofilms in patients of chronic otitis media (COM)-active squamosal disease and to evaluate the microflora and clinical impact of biofilms. A total of 35 patients suffering from COM - active squamosal disease was studied. Cholesteatoma sample was collected at the time of mastoid surgery and the same was used to image for biofilms by scanning electron microscope. The said sample was also analyzed microbiologically. Biofilms were present in 25 (72%) patients including 6 cases of fungal biofilms (24%). Biofilms were detected irrespective of the micro-organism growth. No statistically significant relationship was observed between biofilms and discharging ear and complications of COM. Though univariate analysis of our data found some correlation between duration of disease, the extent of cholesteatoma and ossicular necrosis but multivariate analysis revealed no such associations, thereby implying a doubtful association between these factors and biofilm. Biofilms are an integral part of cholesteatoma ear disease and sometimes harbors fungal isolates.

English

Petrositis is a rare complication of chronic otitis media. It is known to cause variety of intratemporal and intracranial complications, if not managed timely. Traditionally, surgery was advocated, but with better antibiotics availability, focus is now more on conservative treatment. We hereby present a rare case of petrositis, without full triad of Gradenigo’s syndrome and being managed by intravenous antibiotic only. This highlights importance of early diagnosis and treatment. A 19-year-old male presented with discharge from left ear and left sided headache, (becoming holocranial) for 2 years, with increased severity since a month. Discharge was scanty and yellowish; blood tinged occasionally and was often foul smelling. The headache was insidious, gradually worsening, aggravated by cold food intake and exposure to cold weather. He also gave history of mild hearing loss from left ear. There was history of some improvement with oral antibiotics, prescribed by local practitioners, but the relief was incomplete and lasted shortly. He had no complain of trauma to head or ear, double vision, vomiting, fever or facial weakness. Physical examination was normal especially with respect to extra ocular muscles (Fig.1) and muscles of facial expression.

A case study of post-auricular persistent mastoid cutaneous fistula closure by anteriorly based temporalis muscle flap and tempero-mastoid fascio-cutaneous-periosteal flap

<p class="abstract">Post-auricular cutaneous mastoid fistula (PAMCF) is a rare complication of chronic otitis media (COM), following complicate mastoid surgery and very rarely following congenital cholesteatoma. The failure rate with simple closure is high due to necrotic skin edges. Therefore several techniques for the closure of this fistula have been described. Post aural fistula after canal wall down (CWD) mastoidectomy can be successfully treated by fistula tract excision and obliterating the mastoid cavity. A 45 year old woman presented with discharging PAMCF, 10 years following radical mastoidectomy surgery. It was due to non-compliance of the patient, as she had not gone for follow up for 10 year following radical mastoidectomy. The temporo-mastoid fascio-cutaneous-periosteal advancement flap is effective for proper closure of the fistula and obliteration of the cavity by conchal cartilage along with anteriorly based vascularised pedicled temporalis muscle flap to ensure the viability of the flap and preventing the necrosis of the skin edges, henceforth the recurrence of the fistula.</p>

Intracranial and extracranial complications of chronic otitis media and their management at a tertiary care center: a descriptive study

<p><strong>Background: </strong>In the pre-antibiotic era complications from otitis media occurred abundantly, accompanied by high morbidity and mortality. With availability of higher antibiotics, morbidity and mortality due to chronic otitis media (COM) has reduced, but still complications due to COM remain a significant problem in developing countries. The aim is to study clinical presentation, management and outcomes of intracranial and extracranial complications of COM. Study design is retrospective case series study.</p><p><strong>Methods:</strong> Patients admitted in department of otorhinolaryngology and head and neck surgery, S. Nijalingappa medical college and H.S.K hospital and research center, Bagalkot from May 2018 to April 2020 with COM associated with intracranial or extracranial complications were included in the study. Data of clinical presentation, associated complications, management, and follow-up were analyzed.</p><p><strong>Results:</strong> A total of 20 patients were reviewed during study period. Of these seventeen patients had extracranial (EC) complications, while one had intracranial (IC) complications and two had both. Otalgia, otorrhea and fever were the main presenting symptoms. The encountered IC complication were lateral sinus thrombophlebitis, cerebellar abscess. Among the EC complications most common were post-auricular subperiosteal abscess, lateral semicircular canal fistula and facial paralysis. Most commonly isolated organism was staphylococcus. Surgery was main modality of treatment.</p><p><strong>Conclusions:</strong> COM is still a significant problem in developing countries in spite of availability of antibiotics and early diagnosis is crucial in the management of complications associated. This study emphasizes the importance of early diagnosis and prompt treatment to limit the morbidity.</p>

Trends of Complications of Chronic Otitis Media in Tertiary Care Facilty in Western Uttar Pradesh

Objectives: This study aims to investigate the frequency and management of complications of chronicsuppurative otitis media(CSOM).Patients and Methods: Out of 376 patients with CSOM, 44 patients (25 males, 19 females; mean age48.5±3.5 years; range 21to 76 years) meeting study criteria were enrolled in this descriptive cross sectionalstudy which was conducted at the Department of Ear Nose and Throat, Head and Neck Surgery. All newlydiagnosed patients having CSOM with complications were enrolled. The complications were treated first.Intracranial abscesses were evacuated by neurosurgeons. Radical and modified radical mastoidectomy wereperformed.Results: Majority of the patients presented in the second and third decade of life (21-30 years: 27.27%,31-40 years: 18.18%).Most of the patients (59.1%) had lower socioeconomic status. Canal wall downmastoidectomy was the most common (79.5%) procedure performed. Cholesteatoma was the most commonoperative finding (100%). Among extracranial complications, subperiosteal abscess was the most commonfinding (38.63%), while extradural abscess outnumbered (22.72%) in intracranial complications.Conclusion: Complications of CSOM commonly affect younger people with low socioeconomic status.Collaborating with neurosurgeons may assist in the successful management of this infection.

Lemierre's syndrome: A rare complication of otitis media

Lemierre's syndrome, also known as septic internal jugular vein thrombophlebitis, is an extremely rare complication of chronic otitis media, which can be fatal if not managed on time. A 28-year-old female presented to us with left sided otorrhea lasting from 1 month, headache, fever with chills and rigors since 10 days. This was accompanied by torticollis and tenderness along the course of the left internal jugular vein. Otological examination revealed features of chronic suppurative otitis media squamosal type. Computerized tomography revealed features of an occluding thrombophlebitis of the left internal jugular vein up to the left brachiocephalic vein. We performed a canal wall down mastoidectomy for the left ear. The internal jugular vein was not ligated. Patient recovered well after the surgery.

Mastoid surgery during coronavirus disease 2019 pandemic: Focusing on mitigation measures

Mastoid surgery is an aerosol-generating procedure and is considered as high-risk procedure during this pandemic of coronavirus disease. It should, however, be performed in certain life-threatening conditions. Otorhinolaryngologists should be well versed with the measures to protect ourselves from acquiring the coronavirus. We, therefore, report a case of mastoidectomy performed during this pandemic for an intracranial complication of chronic otitis media, focusing on the mitigation measures.

Study on temporalis fascia graft versus temporalis fascia with cartilage graft

Background: The aim of this analytical study is to compare the hearing improvement in type I Tympanoplasty between Temporalis Fascia used alone and temporalis Fascia with cartilage as graft material. Material and Methods: The study was done in ENT department at PSGIMSR, from October 2016 to July 2018. A total of 21,453 cases attended the ENT Outpatient department during the study period. Out of these, 75 cases with dry perforation of the tympanic membrane were chosen for the study. Patients were selected in random, excluding ear discharge, Attico-antral disease, and complications of chronic otitis media. Results: In the study population, disease afflicting the nose and throat were also ruled out. Detailed evaluation of each case was done comprising of history taking, clinical examination, investigations including pure tone audiometry. Patients were divided into 2 groups. Group A consist of 50 patients underwent type I Tympanoplasty with temporalis fascia alone. Group B consist of 25 patients underwent type I Tympanoplasty with combined Temporalis Fascia & Conchal Cartilage. Post-operative hearing improvement measured by Audiometry is compared among the two groups and found that small perforations had best improvement with Temporalis Fascia graft, large and subtotal perforation had good improvement in postoperative hearing with combined Temporalis Fascia and Conchal Cartilage graft. Conclusion: Mean hearing improvement in Group A with temporalis graft was 12.98 dB (better) than Group B, with Temporalis Fascia & Cochal Cartilage graft mean hearing improvement was 8.96 dB.

Pneumocephalus as a complication of multidrug-resistant Klebsiella Pneumoniae bacteremia in patient with acute myeloid leukemia

Pneumocephalus indicates air in the cranial cavity and commonly results from craniofacial trauma and neurosurgical procedures. Infections can rarely cause pneumocephalus through formation of brain abscess, or as complication of chronic otitis media, or meningitis. Patients might present with headache, fever, change in mental status and diagnosis is confirmed by Brain CT scan. A 51 years old male diagnosed with acute myeloid leukemia (AML) and admitted for fourth cycle of consolidation chemotherapy. He developed prolonged febrile neutropenia and septic shock and multi-organ failure due to Klebsiella Pneumoniae MDR bacteremia. Patient had persistent bacteremia despite being on Meropenem, Colisten, Levofloxacin, Caspofungin, Tigecycline. Due to profound thrombocytopenia, he had severe pulmonary hemorrhage and bilateral diffuse subarachnoid hemorrhage. Repeated CT brain angiography later showed extensive pneumocephalus with finding suggestive of brain death. Ethical approval for case report obtained. Meningitis associated with pneumocephalus is rare and has been reported in gas-forming organisms such as E. coli, Klebsiella Pneumoniae, Bacteroides, mixed aerobic and anaerobic species and streptococcus infection. Treating the underlying meningitis might results in resolution of pneumocephalus, although fatal outcomes were reported. Pneumocephalus secondary to Klebsiella Pneumoniae meningitis is uncommon and one case reported successful treatment using meropenem and amikacin for MDR Klebsiella Pneumoniae meningitis associated with pneumocephalous resulting from chronic otitis media. Pneumocephalus associated with MDR K. pneumonia bacteremia is very rare and had high mortality rate especially in setting of febrile neutropenia with multi-organ failure. Intracerebral hemorrhage in setting of persistent bacteremia might increase the risk of pneumocephalus.