Timeline of Notable Events

EVENT - CT SINUS

I had deviated septum repair in 2009 which I felt did not work as left side still very congested, all assumed was sinus related.

NOTES/FINDINGS

No evidence of acute or chronic sinusitis. Left Septal deviation, septal spur and rhinitis. Jugular bulbs dominant, large and high bilaterally.

EVENT - ACCIDENT

Ambulance to SCGH, accident. Fell off bicycle, left side of head injury.

NOTES/FINDINGS

Imaging was taken, I have no records I can find. Fractured left jaw, which then fractured right jaw. Fractured left cheek bone. Significant concussion. Dislocated left shoulder. Was wearing helmet although left ear was bloodied.

EVENT - CT SINUS

Left sinuses and left ear blocked, all assumed was chronic sinusitis.

NOTES/FINDINGS

Mild leftward deviation left. Paranasal sinuses and nasal clear. Advised it may be allergies or a defect in the left nostril not allowing air flow.

EVENT - CT SINUS

Left sinuses and left ear blocked, all assumed was chronic sinusitis.

NOTES/FINDINGS

Paranasal sinuses are clear.

No mucosal thickening or fluid levels.

Both ostiomeatal complexes are patent.

Sphenoethmoidal and frontoethmoidal recesses are patent.

Bony walls are intact.

The nasal septum is midline.

Nasal passages are patent.

Postnasal space is normal.

Both orbits and soft tissues are normal.

No abnormality detected.

EVENT - CT TEMPORAL BONES

Had visited Dr Fiona Whelan (Western ENT) in approx. 2019 with fully blocked ear and sinuses left side. She advised it was allergies and glue ear and there was nothing she could do. After nearly drowning at the beach from a dizzy spell I returned to request a grommet. Dr Whelan sent me for a temporal scan as Dr Jafri Kuthubutheen had made recent findings of CSF in ear.

NOTES/FINDINGS

Right temporal bone is thinned with dehiscence notable 5x3mm dehiscence. High riding jugular bulb. Left temporal bone is thinned, there was no obvious dehiscence although subsequent surgery in Dec 2020 proved the bone was almost disintegrated. Imaging did not pick up. High riding jugular bulb.

EVENT - MRI BRAIN

Follow up on the CT scan on the 29/5/2020 to investigate the tegmen bone dehiscence.

NOTES/FINDINGS

There is T2 hyperintense and T1 mildly hyperintense mildly proteinaceous secretion with mucosal thickening partially opacifying the left otomastoid cavity. The small focus of opacity in the anterior aspect of the middle ear cavity corresponds to T2 hyperintense, T1 mildly hyperintense peripheral enhancing mucosal thickening. No enhancing mass lesion and no evidence of glomus tumour.

EVENT - VESTIBULAR ASSESSMENT

Balance Assessment due to left ear fullness, dizzy spells.

NOTES/FINDINGS

Mild conductive loss to left ear. Reduced tracking at high frequency. Caloric response 15% UW left ear.

EVENT - GROMMET INSERTION & FLUID ASPIRATION

NOTES/FINDINGS

After failed aspiration of ear to determine if the fluid was CSF, Dr Jafri inserted a grommet and obtained fluid under GA. BTP positive 21.6

EVENT - NEUROSURGEON CONSULT

Referred to Dr Arul Bala for opinion to perform Craniotomy Middle Fossa Repair after CSF leak finding - BTP 21.6

NOTES/FINDINGS

Dr Bala agreed Craniotomy Middle Fossa Repair should go ahead and booked in.

EVENT - SLEEP STUDY

Following positive CSF leak diagnosis, Dr Jafri referred me to Dr Smith to explore sleep apnoea as the cause.

NOTES/FINDINGS

Participated in overnight sleep study. No sleep apnoea.

EVENT

Brain Surgery - Craniotomy Middle Fossa Repair

NOTES/FINDINGS

Tegmen repair left side. Found bone was extremely thin and worse than appeared on MRI/CT.

EVENT - CT SINUS & HEAD

Went to GP as skull depressed on left side post Craniotomy. Notable indent temporal and parietal bones. Note, this is still depressed and a pain point.

NOTES/FINDINGS

No abnormality detected.

EVENT - MRI BRIAN

Referred back from GP to Dr Jafri post left middle fossa surgery for CSF leak. Persistent left facial puffiness, post nasal drip and congestion. Left scalp nerve pain occipital area. Depressed skull left side.

NOTES/FINDINGS

Noted temporal craniotomy. There is moderate fluid in the underlying left petrous bone air cells, including fluid in the anterior-inferior middle ear cleft. Recommended CT for ongoing CSF leak. In the brain, there is a chronic focus of haemorrhage in the deep left parietal white matter with an adjacent venous anomaly, probably a cavernous malformation.

EVENT

Referred back to Dr Bala (neurosurgeon craniotomy) as skull depressed since surgery, notable. Sharp pain along left side of scalp.

NOTES/FINDINGS

Dr Bala advised the depressed skull could be from the clamp used to hold the skull in place. Advised pain sounded like Occipital Neuralgia which could go away or stay forever. NB: the depression is skull is notable and has not improved, Occipital Neuralgia currently still daily pain.

EVENT

Repeat yeast infections from grommet, fluid in ear, blocked sinuses.

NOTES/FINDINGS

Repeat yeast infections from grommet. Dr Jafri booked me in for grommet removal and ballonoplasty surgery under a trial to see if Eustachian tube was causing the fluid to back up. Repair appeared solid and fluid was not tested for CSF.

EVENT

Remove grommet and eustachian tube balloonoplasty

NOTES/FINDINGS

Repeat yeast infections in ear. Blocked left ear and sinuses. Dr Jafri removed grommet and inserted a balloon as part of a trial into Eustachian tube. This did not work. Ear infections stopped but ear fluid and sinus congestion did not.

EVENT - CT SINUS

Chronic pain left side of head and also pressure over frontal and maxillary sinuses.

NOTES/FINDINGS

Sinuses clear.

EVENT - CT CERVICAL SPINE

Neck spasm and pain left side of head. ? nerve root impingement.

NOTES/FINDINGS

C3/4 shallow posterior central disc bulge. Mild right side C7/T1 facet arthropathy. No significant foraminal or canal stenosis.

EVENT - CONSULT

Ear full of fluid, feeling of ground giving way, unbalanced, severe hearing loss

NOTES/FINDINGS

Referred for balance assessment, MRI and CT.

EVENT - MRI BRAIN

Episodic fullness, hearing loss, imbalance, tinnitus.

NOTES/FINDINGS

Moderate volume left otomastoid effusion. No evidence for a vestibular schwannoma, neural or labyrinthine abnormality. There is equivocal evidence for mild right cochlear and vestibular hydrops. Left parietal developmental venous anomaly with associated cavernoma.

EVENT - MRI + CT TEMPORAL BONES AND ANGIOGRAM

Post left middle cranial fossa repair and myringoplasty. Left pulsatile tinnitus.

NOTES/FINDINGS

No obvious dehiscence of the tegmen identified at the repair margin, persistent moderate otomastoid effusion. Large bilateral jugular bulbs, with superiorly projecting diverticula. The bony covering at the hypotympanum is thin bilaterally, with suspected micro dehiscence’s on the left. There is focal dehiscence at the abutment of the jugular bulb and the non-enlarged vestibular aqueduct on both sides, also dehiscence at its contact with the left descending facial nerve canal. Bilateral punctate dehiscence of bone intervening between the tympanic facial nerve canal and the lateral semi-circular canal. No arterial cause for pulsatile tinnitus identified, no cervical arterial dissection, stenosis and there is no evidence for aberrant skull base arterial vascularity or Dural fistula.

EVENT - VESTIBULAR ASSESSMENT

Assessment due to balance issues, tinnitus, severe hearing loss, pain.

NOTES/FINDINGS

Weakness in left ear. Fistula positive on Valsalva with left beating nystagmus of 9 degrees/second.

NB: severe increase in pain following testing.

EVENT - CONSULT

Follow up post testing. Advised Dr Jafri development of involuntary swaying at all times unless lying down.

NOTES/FINDINGS

Dr Jafri would like to consult with group he meets with once a month to determine best course of action.

EVENT

Perilymph fistula repair.

NOTES/FINDINGS

Found fluid leaking through oval or round window. Repaired. Fluid was not tested.

NB: Involuntary swaying stopped post surgery.

EVENT - CONSULT

Follow up for perilymph repair was brought forward due to escalating pain and ear full of fluid again.

NOTES/FINDINGS

Dr Jafri aspirated ear and BTP 21, referred to NIISwa (The Neurological Intervention & Imaging Service of Western Australia) to explore reason for persistent CSF leak.

EVENT - EMERGENCY HOSPITILISATION

Presented to ED at SCGH with increased pain left side. Nerve pain, ear pain, bone aches, left jaw pain, neck pain.

NOTES/FINDINGS

Admitted. Started on pain management plan. Repeat MRI showed no findings varied from previous MRI. Advised to wait NIISwa appointment.

EVENT - LUMBAR PUNCTURE & VENOUS SINUS MANOMETRY

Lumbar Puncture & Venous Sinus Manometry

NOTES/FINDINGS

Opening CSF pressure 9.5. Consistent with chronic leak. High riding jugular bulbs. No venous stenosis.

NB: Severe pain experienced during angiogram on left side. Felt like scratching, raw pain in left ear.

EVENT - CONSULT

Follow up post NIISwa.

NOTES/FINDINGS

Advised Dr Jafri of escalating pain levels. Nerve pain, ear pain, bone and neck pain. Current pain management plan no longer working. Dr Jafri advised to admit to SCGH and he will 'rally the troops'.

Emergency hospitalisation. Admitted as per Dr Jafri advice

EVENT - CT HEAD TEMPORAL BONES

Complex otological history with multiple surgeries and CSF leak. Progressive pain.

NOTES/FINDINGS

Subtotal opacification of the left mastoid air cells and middle ear cleft, is non-specific, although similar to prior MRI. Status post left tegmen repair with a cancellous bone graft. No residual bony dehiscence identified.

EVENT

Nerve Block.

NOTES/FINDINGS

Occipital Neuralgia diagnosis confirmed. Nerve Block performed. Lasted 6 weeks.

EVENT - MRI HEAD

Complex history of multiple ear surgeries for CSF leak. Ongoing postauricular pain with neuropathic surrounding component. Presented with severe progression of pain.

NOTES/FINDINGS

Almost complete opacification of left mastoid air cells, stable with no obvious cause identified. Subcutaneous soft tissue oedema at the left occipital region. Left parietal developmental venous anomaly with associated cavernoma.

EVENT - LUMBAR PUNCTURE/CONE BEAM CT

Lumbar Puncture/Cone Beam CT

NOTES/FINDINGS

Contrast into CSF, post procedure CT noted well consolidated extensive left tegmen repair, left subtotal otomastoid effusion. Small volume of contrast within sulci at the middle cranial fossa although large volume of contrast within subarachnoid space not shown. no evidence for contrast opacification of left otomastoid effusion.

NB: Blinding pain through left side of head/ear area specific and left sinuses when the dye hit the area.

EVENT

Hospital Discharge.

NOTES/FINDINGS

Discharged with new pain management plan and follow up with Dr Jafri post lumbar puncture contract CSF CT.

EVENT - CONSULT

Follow up post hospital admission in December 2023.

NOTES/FINDINGS

Dr Jafri offered a grommet or closing the ear. Declined. Referred to Dr Stephen Rodrigues for second opinion. Dr Jafri is at a loss as to the next steps and where the leak is coming from as the tegmen repair appears consolidated. Cannot find reason for escalating and constant pain.

EVENT - CT OCCIPITAL

CT Cranial bones - occipital. Otorrhoea post left perilymph fistula, grommet removal and myringoplasty, as well as craniotomy middle fossa repair. Exclude Occipital Condyle Fracture.

NOTES/FINDINGS

Left Temporal Bone: Stable Appearance with respect to the extensive radiopaque well consolidated tegmen repair, with no evident marginal dehiscence. The subtotal otomastoid effusion has however increased in volume since August 2023. Minor skin thickening along roof of EAC noted. No Occipital bone or condylar fracture. High riding jugular bulb and diverticulum.