OTOGENIC BRAIN ABSCESS by dr.ravindra
Upcoming SlideShare
Loading in...5
×
 

OTOGENIC BRAIN ABSCESS by dr.ravindra

on

  • 1,116 views

c.t.findings of otogenic brain abscess,journal on uses of c.t.in otogenic brain abscess

c.t.findings of otogenic brain abscess,journal on uses of c.t.in otogenic brain abscess

Statistics

Views

Total Views
1,116
Views on SlideShare
1,116
Embed Views
0

Actions

Likes
0
Downloads
40
Comments
0

0 Embeds 0

No embeds

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

OTOGENIC BRAIN ABSCESS by dr.ravindra OTOGENIC BRAIN ABSCESS by dr.ravindra Presentation Transcript

  • MODERATOR:Dr.C.P.DAS PRESENTER:RAVINDRA.D
  • DEFINiTION  Spreading of infection beyond muco-periosteal lining of middle ear cleft to involve bone & neighboring structures like facial nerve, inner ear, dural venous sinuses, meninges, brain tissue & extra-temporal soft tissue .
  •  Severe otalgia, painful swelling around ear,  Vertigo, nausea, vomiting,  Headache + blurred vision + projectile vomiting,  Fever + neck rigidity + irritability / drowsiness,  Facial asymmetry ,  Otorrhoea + Retro-orbital pain + diplopia,  Ataxia.
  •  Congenital bony defects: facial canal, tegmen plate.  Anatomical pathway: oval window, round window, internal auditory canal, suture line, cochlear & vestibular aqueduct  Bony erosion (cholesteatoma destruction, osteitis).  Retrograde Thrombophlebitis.  Acquired bony defects: fracture, neoplasm, stapedectomy  Peri-arteriolar space of Virchow-Robin: spread into brain.
  •  Intra-cranial complications  Extra-cranial complications  Intra-temporal  Extra-temporal  Systemic: septicemia, otogenic tetanus
  • 1. Extra-dural abscess 2. Subdural abscess 3. Meningitis 4. Brain abscess 5. Lateral Sinus thrombophlebitis 6. Otitic hydrocephalus
  • INTRA TEMPORAL 1. Acute mastoiditis 2. Coalescent mastoiditis 3. Masked mastoiditis 4. Facial nerve palsy 5. Labyrinthitis 6. Labyrinthine fistula 7. Petrositis. EXTRA TEMPORAL 1. Post-auricular abscess 2. Bezold abscess 3. Behind the mastoid(Citelli’s)abscess 4. Meatal(Luc’s)abscess 5. Zygomatic abscess
  • PATHOGEN FACTORS PATIENT FACTORS High virulence bacteria Young age Antimicrobial resistance Poor immune status Chronic disease (DM, TB) PHYSICIAN FACTORS Poor socio-economiC status Non-availability Lack of health awareness Injudicious antibiotic use Error in recognizing dangerous symptoms & signs
  • 50-75 % adult brain abscess & 25% in child is otogenic. Temporal abscess is twice as common as cerebellar abscess ROUTES OF INFECTION: 1. Direct spread: via Tegmen plate: Temporal abscess via Trautmann’s triangle: Cerebellar abscess 2. Retrograde spread: via thrombophlebitis
  •  sometimes the infection could extend via the Virchow -Robin spaces in to the cerebral white matter.  Virchow–Robin spaces (VRS) are perivascular, fluid-filled canals that surround perforating arteries and veins in the parenchyma of the brain.  Cerebellar abscess is usually preceded by thrombosis of lateral sinus.  Abscess in the cerebellum may involve the lateral lobe of the cerebellum, and it may be adherent to the lateral sinus or to a patch of dura underneath the Trautmann's triangle.
  • Superiorly: superior petrosal sinus Posteriorly: sigmoid sinus Anteriorly: solid angle (semi-circular canals) It is Pathway to posterior cranial fossa from mastoid cavity
  • 1. INVASION OR ENCEPHALITIS (1-10 days) 2. LOCALIZATION OR LATENT ABSCESS (10-14 days) 3. EXPANSION OR MANIFEST ABSCESS (> 14 days): leads to raised intracranial tension & focal signs 4. TERMINATION OR ABSCESS RUPTURE: leads to fatal meningitis
  •  Anaerobic streptococci  Streptococcus pneumoniae  Staphylococci  Proteus  E. coli  Pseudomonas  Bacteroidis fragilis
  • TEMPORAL LOBE CEREBELLUM Nominal aphasia I/L nystagmus Quadrantic homonymous I/L weakness hemianopia (C/L) I/L hypotonia Epileptic seizures I/L ataxia Pupillary dilatation Intention tremor Hallucination (smell & taste) Past-pointing C/L hemiplegia Dysdiadochokinesia
  • Seen more in cerebellar abscess  Severe persistent headache, worse in morning,  Projectile vomiting,  Blurring of vision & Papilloedema,  Lethargy drowsiness confusion coma  Bradycardia,  Subnormal temperature.
  • CT SCAN OF BRAIN & TEMPORAL BONE WITH CONTRAST  It shows Ring enhancement with central necrosis, and surrounding edema.  It is used for: Site, size & staging of abscess  Observe progression of brain abscess  Associated intra-cranial complications MRI BRAIN  To differentiate pus, abscess ,capsule, edema & normal brain  Spread to ventricles & subarachnoid space AVOID LUMBAR PUNCTURE TO PREVENT CONING
  • TEMPORAL ABSCESS CERBELLAR ABSCESS
  • MEDICAL  High dose broad spectrum I.V. antibiotics: Ceftriaxone + Metronidazole + Gentamicin  I.V. Dexamethasone 4mg Q6H: for decreasing edema  I.V. 20% Mannitol (0.5 gm/kg):for decreasing I.C.T.  Anti-epileptics like Phenytoin sodium  Antibiotic ear drops and aural toilet.
  • SURGICAL  Repeated burr hole aspirations,  Excision of brain abscess with capsule (best T/T) Open incision & evacuation of pus, Radical mastoidectomy after pt becomes stable.
  •  In the 5 yr. period preceding the introduction of antibiotics, approximately 1 in 40 deaths in a large hospital is due to intra cranial complications of C.S.O.M.  The complications develop when middle ear infection spreads from its confined space to adjacent space and structures.  The symtomatology of these complications is slow in development and diagnosis is difficult.  C.T. scan has formed the main stay of diagnosis in recent years.  It offers a highly accurate and rapid means of establishing the diagnosis and following the course of disease.
  •  All cases with h/o C.S.O.M. and having additional symptoms of fever, ear ache, vertigo, head ache, vomitings, altered sensorium were investigated.  Patients with otogenic brain abscess diagnosed with C.T.scan were included in study.  All pts were infused with triple antibiotics(gr.+,gr-ve,anaerobic),  Mannitol , dexamethasone, anti convulsants are used when needed.  Usually trans mastoid route was used to drain the abscess,  Then, cortical mastoidectomy was done.
  •  Status of the dural/sinus plate was observed.  Usually it found eroded…if it is intact,then it was drilled.  Burr hole,craniotomy approaches were used when the abscess Is not approachable through trans mastoid route.  Repeat C.T.scans done after 10 to 14 days of antibiotics to confirm resolution of abscess.  If the size found greater than 1.5c.m.then re aspiration was done.  The canal wall down mastoidectomy was done once the C.T. showed resolution of abscess.  Suitable tympanoplasty, meatoplasty done depending upon middle ear disease.
  •  Symptoms and signs of cerebellar abscess were present in 4 out of 18 cases…but 8 out of 18 were diagnosed on C.T.scan.  Symptoms and signs of temporal lobe abscess were present in 5 out of 18 cases…but 7 out of 18 were diagnosed on C.T.scan.  12 pts.had other intra cranial complications which could be detected by C.T.scan.  This emphasizes the need of C.T.scan in diagnosis of multiple complications.
  •  Repeat C.T.scan after clinical improvement and cessation of pus was done in 15 pts.  Resolution was observed in 10 pts.but 5 showed residual abscess and required re drianage procedure.  After final confirmation of resolution, all had underwent canal wall down mastoidectomy as all have extensive attico antral CSOM.  The pts were followed for an average period of 14 months.  No pt reported with recurrence of intra cranial complications.
  • LEFT TEMPORAL LOBE ABSCESS PRE OP.
  • 14 DAYS AFTER TRANS MASTOID DRIANAGE
  • 26 DAYS AFTER 1ST DRAINAGE
  • LARGE CEREBELLAR ABSCESS PRE OP.
  • RESIDUAL ABSCESS ON 18TH DAY OF DRAINAGE
  • FULLY RESOLVED CEREBELLAR ABSCESS
  •  The procedure of C.T.is non invasive, easily available, relatively cheap and can be repeated with out any hazards to the pts.  The uses of C.T. in a case of otogenic brain abscess are: 1. In coma pts,where history,signs,symptoms are unavailable, it helps in accurate diagnosis. 2. In case of bilateral disease, it helps in deciding which ear to operate first. 3. In case of brain abscess associated with other complications, it helps in deciding which complication to be given priority.
  • 4. By knowing exact size and multiplicity of abscess, it avoids unnecessary surgery. 5. By knowing the stage of abscess, surrounding edema, it helps in deciding timing of surgery. 6. By knowing the size and position we can know the best approach for the drainage of abscess. 7. Follow up C.T. scans help in confirming the resolution of abscess. 8. We can detect residual abscess and treat them adequately thus reducing over all mortality and morbidity.
  •  All the complications of CSOM are decreasing with increased use of antibiotics.  The treatment plan should be tailored according to pt’s condition.  It is recommended to confirm the brain abscess by follow up C.T. scan in all pts.  This will eliminate residual abscess and helps in reducing the mortality and morbidity.
  •  SCOTT&BROWN 7TH EDITION  LUDDMAN  INDIAN JOURNAL OF OTOLARYNGOLOGY AND HEAD&NECK SURGERY(july- sept 2011)