Abstract Intracranial complications of otitis media are associated with high mortality. Persistent otalgia or otorrhea while on oral antibiotics with associated neurological symptoms are ominous signs suggestive of a complication. A high index of suspicion and early diagnosis with radio- imaging are essential for better outcome in these patients. We report a neglected case of chronic otitis media and discuss the magnetic resonance imaging findings. Introduction In spite of significant decrease after antibiotic advent, intracranial complications of otitis media still represent a jeopardizing situation associated with high mortality. 1,2 A high index of suspicion and early diagnosis are essential for better outcome in these patients. 2,3 Extension of the infectious process beyond the mastoid system can lead to a variety of intracranial and extracranial complications, including meningitis; epidural, subdural and intraparenchymal abscesses; vascular thrombosis; osteomyelitis and abscesses deep within the neck. A neglected case of chronic otitis media is presented and the magnetic resonance imaging (MRI) findings are discussed. Case Report A 21-years old female patient presented with intermittent right ear pain and discharge of 8 years duration. Presently, the ear discharge was persistent for last two months, with no response to medication. She developed headache with multiple episodes of vomiting during last 24 hours and gradually lapsed into altered sensorium. On examination, she had neck rigidity. She was responding to deep pain and was moving all four limbs. Rest of the examination was unremarkable. Blood investigations were normal. A previous pus culture from ear discharge showed Pseudomonas aeroginosa resistant to all antibiotics except Ceftriaxone and Amikacin. She underwent MRI of brain and it showed mastoiditis, extradural abscess, subdural empyema, cerebritis and transverse sinus thrombosis (Figures 1-2). She was started on Inj. Cefriaxone, Gentamicin and Metronidazole, anti-epileptics and anti- oedema measures. While she was awaiting for emergency surgery, she deteriorated in her neurological status and succumbed to it. Discussion A variety of intra and extracranial complications can occur due to extension of the infectious process beyond the mastoid system. 1,3 The most common early symptoms are 785 J Pak Med Assoc Case Report Imaging findings in a neglected case of chronic otitis media Amit Agrawal, 1 Akshay Pratap, 2 Awadhesh Tiwari 3 Department of Surgery, 1,2 Department of Radiology, 3 B.P. Koirala Institute of Health Sciences, Dharan, Nepal. Figure-1: MRI brain T1 image (A) showing multiple hypointense lesions in the right middle ear, enhancing irregularly with contrast and evidence of thrombus in right sigmoid sinus (B), also note the extensive subdural collection along the right tentorium cerebelli and falx cerebri (C and D). Figure-2: MR venogram shows absence of normal venous ?ow with occlusion in the right transverse sinus and evidence of adjacent collateralization.