Is it safe to discharge a 39-year-old male patient with a history of pulmonary tuberculosis (PTB) relapse, multiple electrolyte imbalances, cerebral atrophy, chronic suppurative otitis media, cholesteatoma, disease-related malnutrition, and oral candidiasis, who presents with facial asymmetry and bilateral hearing loss, pending the results of a contrast-enhanced cranial CT scan?

Neurology Clearance for Discharge in Cholesteatoma with Intracranial Extension and Facial Asymmetry

Direct Recommendation

This patient should NOT be discharged until the contrast-enhanced cranial CT results are reviewed and intracranial complications are definitively excluded, given the high-risk features of bilateral cholesteatoma with documented intracranial extension, facial nerve palsy, and active tuberculosis. 1

Risk Stratification and Clinical Context

This 39-year-old male presents with multiple concerning features that mandate careful neurological evaluation before discharge:

High-Risk Features Present

• Facial asymmetry (right nasolabial flattening) indicating facial nerve involvement, which occurs more frequently with tuberculous otitis and cholesteatoma with extensive temporal bone destruction 2
• Documented intracranial extension of cholesteatoma on plain CT, creating risk for epidural abscess, subdural abscess, brain abscess, venous thrombosis, or meningitis 3
• Cerebral atrophy undue for age suggesting chronic or progressive intracranial pathology 1
• Active pulmonary tuberculosis with associated middle ear tuberculosis, which demonstrates more aggressive temporal bone destruction and higher rates of facial palsy and sensorineural hearing loss compared to non-tuberculous cholesteatoma 2, 4

Critical Pending Information

The contrast-enhanced CT is essential and must be reviewed before discharge. 3, 5 While non-contrast CT identified the cholesteatoma and intracranial extension, contrast enhancement is specifically indicated when the non-contrast scan shows abnormalities, as it can reveal:

• Extent of intracranial suppurative complications (epidural/subdural collections, brain abscess) 3
• Meningeal enhancement suggesting meningitis 5
• Venous sinus thrombosis 3
• Precise delineation of cholesteatoma margins and inflammatory tissue 6

In patients with abnormal non-contrast CT findings (as in this case), contrast-enhanced studies provide diagnostic information that directly impacts acute management in 34% of cases. 5

Neurological Stability Assessment

Currently Stable Features

• GCS 15, alert and oriented to three spheres 1
• No motor or sensory deficits in extremities 1
• Intact cranial nerves except CN VII (facial) and CN VIII (hearing) 1
• Hemodynamically stable (BP 100/60, adequate for cerebral perfusion) 1

Concerning Features Requiring Explanation

• Facial nerve palsy (right nasolabial flattening) is an otogenic complication that occurs more frequently with tuberculous otitis than cholesteatoma alone, suggesting more aggressive disease 2
• Bilateral hearing loss in the context of bilateral cholesteatoma with intracranial extension 2
• Documented intracranial extension on imaging creates ongoing risk for life-threatening complications 3

Discharge Safety Criteria NOT Yet Met

The patient does NOT meet criteria for safe discharge because:

1. Intracranial pathology is documented but not fully characterized - The plain CT shows "probable extradural extension," but the contrast study is needed to exclude epidural abscess, subdural empyema, or other suppurative complications that would require urgent neurosurgical intervention 3, 5

2. New focal neurological deficit (facial palsy) is present - This represents an active otogenic complication that may indicate progressive disease requiring surgical intervention 2

3. Active infection with intracranial involvement - The combination of PTB, cholesteatoma, and intracranial extension creates high risk for meningitis, brain abscess, or other CNS complications 3, 2

Recommended Management Algorithm

Immediate Actions (Before Discharge Decision)

1. Review contrast-enhanced cranial CT immediately when available 5, 6

   • Specifically assess for epidural/subdural collections
   • Evaluate for meningeal enhancement
   • Assess venous sinus patency
   • Delineate extent of cholesteatoma and bone destruction

2. If contrast CT shows ANY intracranial suppurative complication:

   • Immediate neurosurgery consultation 3
   • Admission for IV antibiotics (vancomycin for comprehensive coverage including MRSA) 3
   • Serial neurological examinations 1
   • Consider MRI for better soft tissue characterization if diagnosis remains unclear 7

3. If contrast CT shows only cholesteatoma without active suppurative complications:

   • Urgent ENT follow-up (within 1-2 weeks, not routine OPD) for surgical planning 2
   • Continue anti-TB therapy and otic drops 4
   • Provide detailed written discharge instructions 1, 8

Discharge Instructions (If Deemed Safe After Contrast CT Review)

Written and verbal instructions must include immediate return precautions: 1, 8

• Worsening headache or new severe headache
• Increased confusion, altered mental status, or difficulty staying awake
• New or worsening facial weakness
• New weakness or numbness in arms/legs
• Seizure activity
• Fever >38.5°C
• Neck stiffness
• Vision changes
• Worsening balance or coordination

Follow-Up Requirements

• ENT follow-up within 1-2 weeks (not routine OPD timing) for cholesteatoma surgical planning 2, 4
• Neurology follow-up in 2-4 weeks to reassess facial nerve function and monitor for delayed complications 2
• Continue anti-TB therapy with infectious disease follow-up 4
• Repeat imaging in 4-6 weeks if not proceeding to surgery, to assess for progression 2

Critical Pitfalls to Avoid

1. Do not discharge based on normal neurological examination alone when imaging shows intracranial extension - complications can develop rapidly even with initially stable exam 3, 2

2. Do not assume facial palsy is simply from cholesteatoma - in the context of TB and intracranial extension, this may represent more serious pathology requiring urgent intervention 2

3. Do not delay contrast CT review - this is the critical piece of information needed for safe discharge decision-making 5, 6

4. Do not provide routine discharge instructions - this patient requires specific, detailed return precautions given the high-risk features 1, 8

Summary of Recommendation

Discharge is NOT appropriate until the contrast-enhanced CT is reviewed and shows no intracranial suppurative complications. 3, 5 The combination of facial nerve palsy, documented intracranial extension, and active tuberculosis creates substantial risk for life-threatening complications including meningitis, brain abscess, and epidural empyema. 3, 2 If the contrast study excludes these complications, discharge with urgent (not routine) ENT follow-up and detailed return precautions is reasonable. 1, 8