COMPLICATION OF CHRONIC SUPPURATIVE OTITIS MEDIAAmalina Aminuddin0820121000 67

• Factors • Spread of infection• Classification• Sequelae• Complications:

• Intratemporal complication• Intracranial complication

Content

Factors

Age Poor socioeconomic group Virulence of organism Immune-compromised host Preformed pathways Cholesteatoma

Pathways spread of infection Direct bone erosion Venous thrombophlebitis Preformed pathways

Congenital dehiscences Patent sutures Previous skull fractures Surgical defects Oval and round windows Infection from labyrinth

Sequelae of otitis mediaPerforation of tympanic membrane

Ossicular erosion

Atelectasis and

adhesive otitis media

Tympanosclerosis

Cholesteatoma

formation

Conductive hearing loss

Sensorineural hearing loss

*Speech impairment

*Learning disabilities

Classifications

Mastoiditis Petrositis Facial paralysis Labyrinthitis

Extradural abscess Subdural abscess Meningitis Brain abscess Lateral sinus

thrombophlebitis Otitic hydrocephalus

INTRATEMPORAL INTRACRANIAL

Intratemporal

Complication

A. [i] ACUTE MASTOIDITIS Inflammation

of mucosal lining of antrum and mastoid air cell system

mucosa bony walls

Accompanies / follow ASOM1. Virulence of

organism 2. Lowered resistance 3. Children

1. Production of pus under tension Production > drainage

2. Hyperaemic decalcification and osteoclastic resorption of bony wall

Destruction, coalescence of mastoid air cell [empyema of mastoid] subperiosteal abscess fistula

Aetiology PATHOLOGY

Clinical Features

Pain behind the ear Fever Ear discharge

Mastoid tenderness Light house effect

( pulsatile purulent discharge)

Sagging of posterosuperior meatal wall

Perforation of tympanic membrane

Swelling over the mastoid Hearing loss

SYMPTOMS SIGNS

Blood counts (Polymorphonuclaer leucocytosis)

ESR

X-ray mastoid Ear swab

INVESTIGATION

Differential diagnosis Suppuration of

mastoid lymph nodes

Furunculosis of meatus

Infected sebaceous cyst

Treatment Hospitalization Antibiotics Myringotomy Cortical

mastoidectomy[Subperiosteal abscess, positive resevoir sign, no change despite medical treatment for 48hours]

Complications Subperiosteal

abscess Labyrinthitis Facial paralysis Petrositis Extradural

abscess

Subdural abscess Meningitis Brain abscess Lateral sinus

thrombophlebitis Otitic

hydrocephalous

Abscesses in relation to mastoid infection

Postauricular abscess Zygomatic abscess Bezold abscess

Meatal abscess (Luc abscess)

Behind the mastoid (Citelli’s abscess)

Para/retropharyngeal abscess

A. (ii) MASKED (LATENT) MASTOIDITIS

Slow destruction of mastoid air cells with no sign and symptoms

Destruction of air cells + dark gelatinous material + Eroded tegmen tympani and sinus plate + extradural or perisinus abscess

Aetiology : Inadequate dose/ duration/ frequency of

antibiotic

Mild pain behind ear + Persistent hearing loss

Thick , opaque tympanic membrane

Tenderness over mastoid Audiometry- conductive

hearing loss X-ray mastoid- clouding

of air cells with loss of cell outline

Cortical mastoidectomy

Antibiotics

CLINICAL FEATURES

TREATMENT

B.PETROSITIS Spread from middle

ear and mastoid to petrous part of temporal bone

Associated with acute coalescent /latent mastoiditis or chronic middle ear infection

Pathology Spread thorugh:

1. Posterosuperior tract- mastoid runs behind/ above labyrinth petrous apex

2. Anteroinferior tract- hypotympanum near Eustachian tube cochlea petrous apex

Clinical Symptoms Gradenigo syndrome

External rectus palsy Deep-seated ear /retro-

orbital pain Persistent ear discharge

Fever, headache, vomiting, neck rigidity

Facial paralysis, recurrent vertigo

Diagnosis- CT scan and MRI

Treatment Cortical, modified radical /radical

mastoidectomy Find fistulous tract, curette and

enlarge free drainage IV antibiotic + surgical intervention Only antibiotics: Initial 4-5 days of

high dose systemic antibiotics

C. FACIAL PARALYSIS Result from cholesteatoma /penetrating

granulation tissue Cholesteatoma destroys bony canal + edema

pressure on nerve Insidious but slowly progressive Treatment:

Exploration of middle ear and mastoid Uncapped cholesteatoma Remove granulation tissue if not involving nerve

sheath Resection of nerve and grafting after infection

controlled and fibrosis matured

D. LABYRINTHITIS Circumscrib

ed labyrinthiti

s

Diffuse suppurative labyrithitis

Diffuse serous

labyrinthitis

Circumscribed labyrinthitis Thinning/erosion of bony

capsule of labyrinth Aetiology:

Chronic suppurative otitis media

Neoplasm of middle ear Surgical or accidental

trauma Clinical Features

Transient vertigo by pressure on tragus/ Vasalva manoeuvre

Diagnosis: Fistula test Pressure on tragus Siegel’s speculum

Treatment Mastoid exploration

and systemic antibiotic therapy

Diffuse labyrinthitisSEROUS SUPPURATIVE • Diffuse intralabyrinthine inflammation • Diffuse pyogenic infection

• Reversible sensorineural hearing loss

• Permanent loss of vestibular and cochlear function

• Pre-existing circumscribed labyrinthitis • Acute infection of middle ear cleft, • follow stapedectomy /fenestration

operation

• follows serous labyrinthitis

• Mild vertigo, nausea, vomiting • Severe vertigo, nausea and vomiting• Appears more toxic

• Quick component of nystagmus toward affected side

• Quick component of nystagmus toward healthy side

Treatment Patient is put to bed, head immobilised with affected ear above Antibacterial therapy Labyrinthine sedatives (prochlorperazine ) Myringotomy Cortical /modified radical mastoidectomy

Intracranial Complication

s

A. EXTRADURAL ABSCESS Collection of pus

between the bone and dura

Pathology: Destroyed by

cholesteatomapus contact directly with dura

Venous thrombophlebitis dura is intact

Dura covered by granulations / appear unhealthy and discoloured

Asymptomatic Persistent headache on

the side of otitis media Severe pain in ear General malaise with

low grade fever Pulsatile purulent ear

discharge Disappearance of

headache with free flow of pus from the ear

Cortical / modified radical /radical mastoidectomy

Antibiotic X 5 days Diagnosis:

contrast enhanced CT or MRI

CLINICAL FEATURE TREATMENT

B. SUBDURAL ABSCESS Pus between dura

and archnoid Pathology

Spreads by erosion of bone and dura /thrombophlebitic process subdural space and comes to lie against the convex surface of cerebral hemisphere

Clinical features Meningeal irritation

[ headache, fever, neck rigidity, Kernig’s sign]

Cortical venous thrombophlebitis [ aphasia, hemiplegia]

Raised ICP [ papilledema, ptosis, dilated pupil ]

Treatment: burr holes /craniotomy for

drainage +IV antibiotics

C. MENINGITIS Inflammation of pia

and arachnoid Most common

intracranial complication

Mode of infection Blood-borne Chronic ear disease

Fever with chills and rigors Headache Neck rigidity Photophobia and mental

irritability Nausea and vomiting Drowsiness, delirium or

coma Cranial nerve palsies and

hemiplegia

CLINICAL FEATURES

Contrast CT or MRI, Lumbar puncture CSF examination

Antibiotics + corticosteroids

AOM :Myringotomy or cortical mastoidectomy

Cholesteoma :Radical or modified radical mastoidectomy

DIAGNOSIS TREATMENT:

D. OTOGENIC BRAIN ABSCESS Adult ( 50%) : CSOM with

cholesteatoma Child ( 25%) : acute otitis media

Route of infection: Cerebral : direct extension through

tegmen /retrograde thrombophlebitis Cerebellar : direct extension through

Trautmann’s triangle / retrograde thrombophlebitis

Bacteriology: aerobic [ SP, PM, EC,] Anaerobic [ BF, HI]

Pathology Stage of invasion (initial

encephalitis) Headache, low grade

fever, malaise, drowsiness Stage of localization

(latent abscess) Stage of enlargement

(manifest abscess) Edema raised ICP

Stage of termination (rupture of abscess)

Clinical features 1.Symptoms and

signs of raised ICP Headache Nausea and

vomiting

Level of consciousness

Papilloedema Slow pulse and

subnormal temperature

2.Localizing features

Nominal aphasia Homonymous

hemianopia Contralateral motor

paralysis Epileptic fits Pupillary changes and

oculomotor palsy

Headache Spontaneous

nystagmus Ipsilateral hypotonia Ipsilateral ataxia Past-pointing and

intention tremor Dysdiadokinesia

Temporal lobe abscess Cerebellar abscess

Skull x-ray CT scan X-ray mastoids or

CT scan Lumbar puncture

Antibiotics IV Dexamethasone or

mannitol Suction clearance and

topical drops Repeated aspiration

through a burr hole Excision of abscess Open incision of the

abscess and evacuation of pus

Radical mastoidectomy

INVESTIGATION TREATMENT

E.LATERAL SINUS THROMBOPHLEBITIS

Inflammation of inner wall of lateral venous sinus with formation of intrasinus thrombus

Occur due to acute coalescent mastoiditis, masked mastoiditis, chronic suppuration of middle ear and cholesteatoma

Pathology:Formation of

perisinus abscess

Endophlebitis and mural

thrombus formation

Obliteration of sinus lumen and intrasinus abscess

Extension of

thrombus

Acute- haemolytic streptococcus, pneumococcus or staphylococcus

Chronic- + cholesteatoma, Bacillus proteus, Pseudomonas pyocyaneus, E. coli and staphylococci

Hectic Picket-fence type of fever with rigors

Headache Progressive anaemia

and emaciation Griesinger’s sign Papilloedema Tobey-Ayer test,

Crowe-Beck test Tenderness along

jugular vein

BACTERIOLOGY CLINICAL FEATURES:

Blood smear Blood culture CSF examination X-ray mastoid Imaging studies Culture and

sensitivity

Septicaemia and pyaemic abscess in lungs, bones, joints or subcuteaneous tissue

Meningitis and subdural abscess

Cerebellar abscess Thrombosis of jugular

bulb and jugular vein Cavernous sinus

thormbosis Otitic hydrocephalus

INVESTIGATION COMPLICATION

Treatment Intravenous antibacterial drugs C/ MR mastoidectomy and exposure of sinus Ligation of internal jugular vein

Failed antibiotic and surgical treatment Spreading tenderness along jugular vein

Anticoagulant therapy Supportive treatment

F.OTITIC HYDROCEPHALUS Raised ICP with normal CSF findings In children with acute/ chronic middle ear

infection Lateral sinus thrombosis obstruction +

extension to superior sagittal sinus decreased absorption

Clinical featuresSymptoms:• Severe

headache• Diplopia • Blurring of

vision

Signs:• Papilloedema•Nystagmus

Treatment:

Reduce CSF pressure to prevent optic atrophy and blindness

Acetazolamide and corticosteroids

Repeated lumbar puncture / placement of lumbar drain, lumboperitoneal shunt

Antibiotic therapy and mastoid exploration