Intracranial complication of chronic suppurative otitis media

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  • 1. INTRACRANIAL COMPL.- CSOM• EXTRADURAL ABSCESS• SUBDURAL ABSCESS• MENINGITIS• OTOGENIC BRAIN ABSCESS• LATERAL SINUS THROMBOPHLEBITIS• OTITIC HYDROCEPHALUS
  • 2. EXTRADURAL ABSCESSPATHOLOGY• Coll. of pus b/w bone & dura-middle or post. Cranial fossa• Affected dura- covered i granulation & discoloured.• a/c- bone over dura-destroyed by hyperaemic decalcification.• c/c-destroyed by cholesteatoma• Spread – destruc. Of bone – venous thrombophlebitis- bone over dura remains intact
  • 3. • C/F mostly asymp.- discovered CM or MRM presence suspected when persistent headache on side of otitis media severe ear ache pulsatile purulent ear d/s disapp. Of headache- i flow of pus from ear general malaise i low grade fever• DIAGNOSIS Contrast enhanced CT or MRI
  • 4. • Rx abscesss- evacuated by removing overlying bone till healthy dura are reached. Causative d/s- CM broad spectrum antibiotics
  • 5. SUBDURAL ABSCESS• PATHOLOGY Spread- erosion of bone & dura or thrombophlebitic process- bone intact. pus lie against surface of cerebral hemisphere causing pr. Symp and pus get loculated.•
  • 6. C/FMENINGEAL fever(102F or more)IRRITATION Headache malaise, drowsiness neck rigidity +ve kernig’s signTHROMBOPHLEBITIS- aphasia, hemianopia, hemiplegCORTICAL VEINS OF iaCEREBRUM jacksonian type of epileptic fitsRAISED ICT III nerve- Papilloedema, ptosis, dilated pupil
  • 7. • DIAGNOSIS CT scan or MRI• Rx Series of burr hole OR Craniotomy BSA once infection subsides- CM LP- cause herniation of cerebellar tonsils.
  • 8. MENINGITIS• Inflm. Of Leptomeninges.(piamater and arachnoid )+ bact. Invasion of CSF in subarachnoid space.• Most common intracranial complication• 2nd most compl. Of OM.• Infants & children- a/c- blood borne adults-c/c - bone erosion or thrombophlebitis- asso Extradural abs. or granulation tissue
  • 9. C/f Infection Raised ICT meningeal or cerebral irritation.• Fever 102-104F+ chills & rigor• Headache• Neck rigidity• Photophobia & mental irritability• N, V(projectile)• Drowsiness• CN palsies & hemiplegia
  • 10. EXMNTendon reflexes -exaggerated during initial stage, later – sluggish or absentPapilloedema – late stages
  • 11. Diagnosis:examination of CSF-culture and antibiotic sesitivity lumbar puncture • Turbid • increased cell count-polymorphs. • Protein level- increased • reduced glucose levels (1.7-3 mmol/l ) • Chloride content - fall from 120 mmol/l to 80mmol/l.CT or MRI
  • 12. Rx• Med -systemic antibiotics-BSA Corticosteroids• Surgical – a/c- CM – c/c- MRM or RM
  • 13. OTOGENIC BRAIN ABSCESS• always develop in the temporal lobe or the cerebellum of the same side of the infected ear. Temporal lobe abscess is twice as common as cerebellar abscess.• In children -25% of brain abscesses are otogenic – a/c• In adults -50% of brain abscess are otogenic- c/c TEMPORAL LOBE ABSCESS CEREBELLAR ABSCESSSpread direct extension -eroded direct extension -Trautmanns tegmen plate. triangle. Retrograde Retrograde thrombophlebitis thrombophlebitisAsso- EDA EDA, perisinus abs, SST or labtrinythitis
  • 14. • PATHOLOGY
  • 15. • C/FRAISED ICT TEMPORAL LOBE ABSCESS CEREBELLAR ABSCESSHEADACHE- generalised, NOMINAL APHASIA- pt fails HEADACHE-subocci. Asso iworse in mrng. to tell name but can neck rigidity demonstrate their useN,V(proj.) SPONT. NYSTAGMUS- irreg, HOMONYMOUS side of lesionDROWSINESS, CONFUSION, HEMIANOPIA- visual fieldSTUPOR, COMA oppo to side of lesion is lost IPSILAT. HYPOTONIA & Due to pr on optic radiations. WEAKNESSPAPPILLOEDEMA- late, early incerebellar abscess CONTRALATERAL MOTOR IPSILAT. ATAXIA PARALYSISSlow pulse Upward-face, arm leg PAST-POINTING & INTENTION TREMOR- finger nose testSubnl temp EPILEPTIC FITS Uncinate gyrus-taste DYSDIADOKOKINESIA- rapid hallucination, mvmt lips & pronation & supination of tongue, generalised fits forearm show slow irreg mvmt on affected side. PUPILLARY CHANGES & OCCULOMOTOR PALSY- transtentorial herniation
  • 16. • INVESTIGATION SKULL X- RAY To see midline shift, if pineal gland is calcified, gas in abscess cavity X-RAY MASTOID Evaluating asso ear d/s CT SCAN & MRI To find the site & size of abscess cavity Asso compl- EDA,SST, LP danger because of the risk of coning. CSF- rise in pr, turbid raised WBC- polymorphs 0r lymphocytes raised protein level nl glucose level
  • 17. TREATMENT:MEDICAL High dose iv antibiotics- Chloramphenicol+3rd gen Cephalosporin bacteroides- Metronidazole pseudomonas , proteus- aminoglycoside- gentamicin Raised ICT- Dexamethasone- 4mg iv 6th hrly or mannitol 20% - 0.5 g/kg body wt. Ear discharge- suction clearence & topical ear dropsNEUROSURGICAL -drained by placement of burr holes, -excision of the necrotic tissue along with the capsule.- -Open incision of abscess and pus evacuation -If abscess is treated by aspiration- repeat CT or MRI to see if it diminish in size. Penicillin is instilled into abscess after aspirationOTOLOGIC a/c- may resolve i antibiotics
  • 18. LATERAL SINUS THROMBOPHLEBITISFORMATION OF PERISINUS ABSCESSENDOPHLEBITIS AND MURAL THROMBUS FORMATIONOBLITERATION OF SINUS LUMEN AND INTRASINUS ABSCESSEXTENSION OF THROMBUS- prox- sup sagittal sinus dist- mastoid emissary vein, to jugular bulb or jugular vein
  • 19. C/FHECTIC PICKET- FENCE TYPE OF FEVER I RIGOR Irregular fever-1 or > peaks/day, in b/w bouts of fever- sense of well being. profuse sweating follows fall of temp. Due to septicaemia-release of septic emboliHEADACHE Early- perisinus abscess Late- raised ICTANAEMIA progressiveGRIESINGER’S SIGN Edema over post part of mastoid Due to thrombosis of mastoid emissary veinsPAPILLOEDEMA Seen when rt sinus is thrombosed or when clot extends to sup sagittal sinusTOBEY- AYER TESTCROWE- BECK TEST Pr on jugular vein of healthy side produce engorgement of retinal veins & supraorbital veins
  • 20. INVESTIGATIONBLOOD SMEAR To rule out malariaBLOOD CULTURE To find causative organism Blood-taken at the time of chillsCSF EXMN Normal except for rise in pr, To exclude meningitisX-RAY MASTOID Asso ear d/sCONTRAST ENHANCED CT SCAN Sinus thrombosis by typical delta sign or empty triangle sign- rim show enhancement on post cranial fossa central low density area on axial cutMRI CONTRAST ENHANCED- Delta sign MR venography- progression or resolution of thrombusCULTURE & ANTIBIOTIC SENSITIVITY Ear swab
  • 21. TREATMENTIV ANTIBIOTICS BSA- continued at least for a week after operationMASTOIDECTOMY CM-a/c or MRM-c/c& EXPOSURE OFSINUS Sinus bony plate is removed to expose dura- perisinus abscess is drained Intrasinus abscess of infected clots- dura is incised & infected clot & abscess drainedIJV- LIGATION When above 2 therapy fail- to control embolic phenomena & rigors OR tenderness & swelling- JV spreadingANTICOAGULANT If thrombus extend to cavernous sinusTHERAPYSUPPORTIVE Anaemia- repeated blood transfusionTREATMENT
  • 22. OTITIC HYDROCEPHALUS• It is a syndrome of raised intracranial pressure during or following middle ear infection.• also known as Pseudotumorcerebri.• Pathogenesis: – lateral sinus thrombosis -affects cerebral venous outflow, – or the extension of the thrombus into the superior sagittal sinus impedes CSF resorption by arachnoid villi
  • 23. SYMPTOMS C/F headache Severe diplopia Paralysis of VI CN blurred vision Papilloedema or optic atrophySIGNS papilloedema. Nystagmus Due to raised ICT LP Pr- >300mm of water (70-120mm water) All other normal
  • 24. TREATMENT• ACETAZOLAMIDE• CORTICOSTERIODS• REPEATED LP OR PLACEMENT OF LUMBAR DRAIN• LUMPOPERITONEAL SHUNT• ASSO EAR INFECTION
  • 25. THANK YOU