Should I discharge the patient based on the contrast‑enhanced computed tomography (CT) showing cerebral atrophy with ex‑vacuo ventricular dilatation (undue for age), extensive sinonasal disease with possible fungal components, a left antrochoanal polyp with ostiomeatal complex obstruction, and bilateral cholesteatoma with intracranial extradural extension?

Do NOT Discharge This Patient

This patient requires immediate neurosurgical and ENT consultation and hospital admission—discharge is contraindicated given bilateral cholesteatoma with documented intracranial extradural extension, extensive sinonasal disease with possible invasive fungal components, and cerebral atrophy undue for age. 1

Critical High-Risk Features Requiring Immediate Action

Bilateral Cholesteatoma with Intracranial Extension

• Patients with cholesteatoma and intracranial extension should not be discharged until intracranial complications are definitively excluded, given the documented intracranial extension creates risk for epidural abscess, subdural abscess, brain abscess, venous thrombosis, or meningitis 1
• The contrast-enhanced CT is essential and must be reviewed immediately to exclude epidural abscess, subdural empyema, or other suppurative complications that would require urgent neurosurgical intervention 1
• Cholesteatoma with intracranial complications has been associated with serious morbidity including meningitis, brain abscess, and facial nerve paralysis requiring surgical intervention 2

Possible Invasive Fungal Sinusitis

• Invasive fungal sinusitis with intracranial extension carries 50-80% mortality and requires immediate aggressive management 3
• The CT findings of extensive polysinus disease with possible fungal components warrant urgent evaluation, as invasive fungal sinusitis can progress rapidly with intracranial and intraorbital extension, cavernous sinus thrombosis, or carotid invasion 3
• Both CT and MRI may be necessary to better define soft-tissue structures, orbital contents, and brain to guide appropriate treatment 3

Cerebral Atrophy Undue for Age

• Cerebral atrophy undue for age suggests chronic or progressive intracranial pathology requiring neurological evaluation 1
• This finding, combined with the other high-risk features, necessitates comprehensive neurological assessment including GCS, motor and sensory deficits, and cranial nerve examination 1

Immediate Management Algorithm

Step 1: Urgent Consultation (Within Hours)

• Neurosurgery consultation for bilateral cholesteatoma with intracranial extradural extension 1
• ENT consultation for surgical planning and assessment of cholesteatoma extent 1
• Infectious disease consultation if invasive fungal sinusitis is confirmed 3

Step 2: Additional Imaging Required

• MRI with contrast is superior to CT for evaluating intracranial complications (97% accuracy vs 87-91% for CT) and should be obtained to better characterize soft tissue, assess for epidural/subdural collections, meningeal enhancement, and venous sinus patency 4, 1
• MRI provides excellent soft-tissue differentiation between tumor, retained fluid, and fungal disease, with T2-weighted sequences showing extremely hypointense signals characteristic of fungal masses 3, 5

Step 3: Admission and Monitoring

• Hospital admission for IV antibiotics, serial neurological examinations, and monitoring for complications 1
• Documented serial neurological examinations are essential, as patients admitted for observation often do not receive adequate monitoring (only 50% had documented serial exams in one study) 3

Step 4: Definitive Surgical Planning

• Surgical debridement with establishment of sinus drainage is the most reliable method to diagnose and treat complications of cholesteatoma 2
• Temporal bone CT scan plays an important role in surgical planning for cholesteatoma complications 2

Critical Pitfalls to Avoid

Do Not Rely on Contrast CT Alone

• The contrast-enhanced CT you have is insufficient for complete evaluation—MRI with contrast provides superior soft-tissue characterization and is the preferred modality for assessing intracranial extension 4, 3
• Non-contrast CT is adequate for uncomplicated sinusitis, but contrast is mandatory when evaluating orbital or intracranial complications 4

Do Not Discharge Based on Normal Neurological Exam Alone

• Even with a normal neurological examination, the documented intracranial extension and possible invasive fungal components create unacceptable risk for rapid deterioration 1, 3
• Patients can deteriorate within 24 hours, with 57% of deteriorations occurring in the first day 3

Do Not Delay Treatment for Invasive Fungal Sinusitis

• If invasive fungal sinusitis is confirmed, the mortality rate is 50-80% without aggressive early intervention 3
• Immunocompromised patients, those with poorly controlled diabetes, or patients on high-dose steroids require particularly high suspicion 3

Required Follow-Up After Hospitalization

When eventually appropriate for discharge (after definitive treatment):

• ENT follow-up within 1-2 weeks for cholesteatoma surgical planning 1
• Neurology follow-up in 2-4 weeks to monitor for delayed complications 1
• Written discharge instructions must include immediate return precautions: worsening headache, increased confusion, new facial weakness, seizure activity, fever, neck stiffness, vision changes, or worsening balance 1