Complications of
Suppurative Otitis
Media
Dr. Vishal Sharma
Definition
Infection spreads beyond muco-periosteal
lining of middle ear cleft to involve bone &
neighboring structures li...
Features of Complications
• Severe otalgia, painful swelling around ear
• Vertigo, nausea, vomiting
• Headache + blurred v...
Classification
• Intra-cranial
• Extra-cranial, Intra-temporal
• Extra-cranial, Extra-temporal
• Systemic: septicemia, oto...
Classification
Intra-cranial Complications
1. Extra-dural abscess
2. Subdural abscess
3. Meningitis
4. Brain abscess
5. Lateral Sinus thr...
Intra-temporal Complications
• Acute mastoiditis
• Coalescent mastoiditis
• Masked mastoiditis
• Facial nerve palsy
• Laby...
Extra-temporal Complications
1. Post-auricular abscess
2. Bezold abscess
3. Citelli abscess
4. Luc abscess
5. Zygomatic ab...
Factors Affecting
Pathogen Factors Patient Factors
High virulence bacteria Young age
Antimicrobial resistance Poor immune ...
Routes of entry
1. Bony erosion (cholesteatoma destruction, osteitis)
2. Retrograde Thrombophlebitis
3. Anatomical pathway...
Erosion of tegmen tympani
Coalescent Mastoiditis
or Surgical Mastoiditis
Pathogenesis
Aditus Blockage
Failure of drainage
Stasis of secretions
Hyperemic decalcification
Resorption of bony septa o...
Pathogenesis
Clinical Features & Investigation
• Otorrhoea > 2 weeks, otalgia & deafness
• Mastoid reservoir sign: pus fills up on mopp...
Mastoid reservoir sign
Sagging of posterior wall
Ironed out appearance
Mastoid cavity
Mastoid cavity
Mastoiditis Furunculosis
H/o otitis media + -
Deafness + -
Position of pinna Down + outward
+ forward
Forward
Post-aural g...
Treatment
• Urgent hospital admission
• Broad spectrum I.V. antibiotics
No response to medical treatment in 48 hrs
Develop...
Sub-periosteal
abscess & fistula
Pathology
Production of pus under tension
hyperaemic decalcification (halisteresis)
+ osteoclastic resorption of bone
sub-...
Sub-periosteal abscess formation
Sub-periosteal fistula: dry
Sub-periosteal fistula: wet
Types of sub-periosteal abscess
• Post-auricular
• Bezold
• Citelli
• Zygomatic
• Luc
• Retro-mastoid
• Parapharyngeal & R...
Types of sub-periosteal abscess
Post-auricular abscess
Commonest. Present behind the ear.
Pinna pushed forward & downward.
Bezold & Citelli abscesses
Bezold: neck swelling
over sternocleido-
mastoid muscle
Citelli: neck swelling
over posterior b...
D/D of Bezold’s abscess
1. Suppurative lymphadenopathy of upper
deep cervical lymph node
2. Para-pharyngeal abscess
3. Par...
Luc: swelling in external auditory canal
Zygomatic: swelling antero-superior to pinna +
upper eyelid oedema
Retro-mastoid:...
Retromastoid abscess
Incision drainage of abscess
Gradenigo syndrome
Persistent otorrhoea: despite adequate
cortical mastoidectomy
Retro-orbital pain: Trigeminal nv involve...
Persistent otorrhoea + Retro-orbital pain +
Convergent squint
Right Convergent squint
Right gaze Central gaze Left gaze
Etiology: Coalescent mastoiditis involving
petrous apex along postero-superior & antero-
inferior tracts in relation to bo...
C.T. scan & M.R.I.
Hearing preserving approaches to petrous apex
• Eagleton’s middle cranial fossa approach
• Frenckner’s subarcuate approach...
Hearing sacrificing approaches to petrous apex
• Trans-cochlear approach
• Trans-labyrinthine approach
Spread of pus
Labyrinthitis
Introduction
Inflammation of endosteal layer of bony labyrinth
Route of infection:
Round window membrane
Pre-formed openin...
• Circumscribed: Fistula commonly involves
lateral SCC. Presents with transient vertigo &
positive fistula test I/L nystag...
Treatment:
Bed rest (affected ear up). Avoid head movement.
Labyrinthine sedative: Prochlorperazine, Cinnarizine
Broad spe...
Lateral SSC Fistula
Facial nerve paralysis
• Within 1st wk: due to nerve sheath edema
• After 2 wks: due to bone erosion
• Lower motor neuron ...
Meningitis
• High grade persistent fever with rigors
• Severe headache & neck stiffness
• Irritability drowsiness confusion coma
• Ne...
Test for neck rigidity
Otogenic brain
abscess
50-75 % adult brain abscess & 25% in child = otogenic
Temporal abscess : Cerebellar abscess = 2:1
Route of infection: 1. D...
Trautmann’s triangle
Superiorly: superior
petrosal sinus
Posteriorly: sigmoid sinus
Anteriorly: solid angle
(semi-circular...
Stages of brain abscess
1. Invasion or Encephalitis (1-10 days)
2. Localization or Latent Abscess (10-14 days)
3. Expansio...
Stages of brain abscess
Clinical Features of ed I.C.T.
Seen more in cerebellar abscess
• Severe persistent headache, worse in morning
• Projectile...
Focal Clinical Features
Temporal Lobe Cerebellum
Nominal aphasia I/L nystagmus
Quadrantic homonymous I/L weakness
hemianop...
Bacteriology
• Anaerobic streptococci
• Streptococcus pneumoniae
• Staphylococci
• Proteus
• E. coli
• Pseudomonas
• Bacte...
CT scan of brain & temporal bone with contrast
Site, size & staging of abscess
Observe progression of brain abscess
Associ...
Temporal abscess in CT scan
Cerebellar abscess
Medical Treatment
• High dose broad spectrum I.V. antibiotics:
Ceftriaxone + Metronidazole + Gentamicin
• I.V. Dexamethaso...
Surgical Treatment
• Repeated burr hole aspirations
• Excision of brain abscess with capsule: best Tx
• Open incision & ev...
Lateral sinus
thrombophlebitis
Lateral sinus = Sigmoid sinus + Transverse sinus
Erosion of sigmoid sinus plate peri-sinus
abscess inflammation of outer w...
Pathogenesis
Proximal: 1. To superior sagittal sinus via torcula
Hirophili hydrocephalus
2. To cavernous sinus proptosis
3. To mastoid ...
Clinical Features
• Remittent high fever with rigors (picket fence)
• Pitting edema over retro-mastoid area & occipital
bo...
Fever charts in C.S.O.M.
Meningitis
Lateral Sinus
Thrombophlebitis
Brain
abscess
Picket fence fever
• High fever, swinging
type
• Chills precedes fever
• Temperature subsides
with sweating
• Each fever s...
Special Tests
• Queckenstedt or Tobey-Ayer test: compression
of I.J.V. rapid rise of C.S.F. pressure (50 – 100
mm water ra...
Tobey Ayer Test
Retinal vein dilation &
optic disc edema
Lumbar puncture: to rule out meningitis
CT brain with contrast: Delta sign or
MRI brain with contrast: Empty triangle sign...
Delta sign
1. Radical mastoidectomy: Removal of disease +
needle aspiration to confirm diagnosis. Sinus wall
incised. Infected clots ...
Extra-dural abscess
Extra-dural abscess
Commonest otogenic intra-cranial complication
Collection of pus b/w skull bone & dura of middle
or posterior cranial fossa...
Extra-dural abscess
Subdural abscess
Subdural abscess
Collection of pus b/w dura & arachnoid by erosion of
bone & dura mater or by retrograde thrombophlebitis
Due to rapid spre...
Subdural abscess
Otitic
Hydrocephalus
Synonym: Benign intra-cranial hypertension
Symond’s syndrome
Etiology: 1. Associated L.S.T. obstruction of
cerebral venous...
Investigations:
1. Lumbar puncture: ed CSF pressure (> 300 mm
H2O). Biochemistry & bacteriology normal
2. CT scan brain: n...
Brain Fungus
• Prolapse of brain into middle ear cavity / mastoid
cavity due to erosion of dural plate.
• Common in pre-an...
Fungus Cerebri
Thank You
13 csom-part-4
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13 csom-part-4
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  1. 1. Complications of Suppurative Otitis Media Dr. Vishal Sharma
  2. 2. Definition Infection spreads 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.
  3. 3. Features of Complications • 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
  4. 4. Classification • Intra-cranial • Extra-cranial, Intra-temporal • Extra-cranial, Extra-temporal • Systemic: septicemia, otogenic tetanus
  5. 5. Classification
  6. 6. Intra-cranial Complications 1. Extra-dural abscess 2. Subdural abscess 3. Meningitis 4. Brain abscess 5. Lateral Sinus thrombophlebitis 6. Otitic hydrocephalus 7. Brain fungus (fungus cerebri)
  7. 7. Intra-temporal Complications • Acute mastoiditis • Coalescent mastoiditis • Masked mastoiditis • Facial nerve palsy • Labyrinthitis • Labyrinthine fistula • Apex Petrositis (Gradenigo syndrome)
  8. 8. Extra-temporal Complications 1. Post-auricular abscess 2. Bezold abscess 3. Citelli abscess 4. Luc abscess 5. Zygomatic abscess 6. Retro-mastoid abscess
  9. 9. Factors Affecting 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
  10. 10. Routes of entry 1. Bony erosion (cholesteatoma destruction, osteitis) 2. Retrograde Thrombophlebitis 3. Anatomical pathway: oval window, round window, internal auditory canal, suture line, cochlear & vestibular aqueduct 4. Congenital bony defects: facial canal, tegmen plate 5. Acquired bony defects: fracture, neoplasm, stapedectomy 6. Peri-arteriolar space of Virchow-Robin: spread into brain
  11. 11. Erosion of tegmen tympani
  12. 12. Coalescent Mastoiditis or Surgical Mastoiditis
  13. 13. Pathogenesis Aditus Blockage Failure of drainage Stasis of secretions Hyperemic decalcification Resorption of bony septa of air cells Coalescence of small air cells to form cavity Empyema of mastoid cavity
  14. 14. Pathogenesis
  15. 15. Clinical Features & Investigation • Otorrhoea > 2 weeks, otalgia & deafness • Mastoid reservoir sign: pus fills up on mopping • Sagging of postero-superior canal wall due to peri- osteitis of bony wall b/w antrum & posterior E.A.C. • Ironed out appearance of skin over mastoid due to thickened periosteum • Mastoid tenderness present • Mastoid cavity in X-ray & CT scan
  16. 16. Mastoid reservoir sign
  17. 17. Sagging of posterior wall
  18. 18. Ironed out appearance
  19. 19. Mastoid cavity
  20. 20. Mastoid cavity
  21. 21. Mastoiditis Furunculosis H/o otitis media + - Deafness + - Position of pinna Down + outward + forward Forward Post-aural groove Deepened Obliterated Ear discharge Muco-purulent Serous / purulent Sagging of EAC wall + - TM congestion + - Tenderness Mastoid Tragal Post-aural lymph node - + X-ray Mastoid Coalescence of cells + cavity Normal
  22. 22. Treatment • Urgent hospital admission • Broad spectrum I.V. antibiotics No response to medical treatment in 48 hrs Development of new complication Presence of sub-periosteal abscess – Myringotomy to drain out painful pus – Incision drainage of sub-periosteal abscess – Cortical Mastoidectomy
  23. 23. Sub-periosteal abscess & fistula
  24. 24. Pathology Production of pus under tension hyperaemic decalcification (halisteresis) + osteoclastic resorption of bone sub-periosteal abscess penetration of periosteum + skin fistula formation
  25. 25. Sub-periosteal abscess formation
  26. 26. Sub-periosteal fistula: dry
  27. 27. Sub-periosteal fistula: wet
  28. 28. Types of sub-periosteal abscess • Post-auricular • Bezold • Citelli • Zygomatic • Luc • Retro-mastoid • Parapharyngeal & Retropharyngeal
  29. 29. Types of sub-periosteal abscess
  30. 30. Post-auricular abscess Commonest. Present behind the ear. Pinna pushed forward & downward.
  31. 31. Bezold & Citelli abscesses Bezold: neck swelling over sternocleido- mastoid muscle Citelli: neck swelling over posterior belly of digastric muscle
  32. 32. D/D of Bezold’s abscess 1. Suppurative lymphadenopathy of upper deep cervical lymph node 2. Para-pharyngeal abscess 3. Parotid tail abscess 4. Infected branchial cyst 5. Internal jugular vein thrombosis
  33. 33. Luc: swelling in external auditory canal Zygomatic: swelling antero-superior to pinna + upper eyelid oedema Retro-mastoid: swelling over occipital bone (? Citelli’s abscess) Parapharyngeal & Retropharyngeal: due to spread of pus along Eustachian tube
  34. 34. Retromastoid abscess
  35. 35. Incision drainage of abscess
  36. 36. Gradenigo syndrome Persistent otorrhoea: despite adequate cortical mastoidectomy Retro-orbital pain: Trigeminal nv involvement Diplopia: convergent squint due to lateral rectus palsy by injury to abducent nv in Dorello’s canal under Gruber’s petro-sphenoid ligament, at petrous apex
  37. 37. Persistent otorrhoea + Retro-orbital pain + Convergent squint
  38. 38. Right Convergent squint Right gaze Central gaze Left gaze
  39. 39. Etiology: Coalescent mastoiditis involving petrous apex along postero-superior & antero- inferior tracts in relation to bony labyrinth Diagnosis: 1. C.T. scan temporal bone for bony details. 2. M.R.I. to differ b/w bone marrow & pus Treatment: Modified radical mastoidectomy & clearance of petrous apex cells
  40. 40. C.T. scan & M.R.I.
  41. 41. Hearing preserving approaches to petrous apex • Eagleton’s middle cranial fossa approach • Frenckner’s subarcuate approach • Thornwaldt’s retro-labyrinthine approach • Dearmin & Farrior’s infra-labyrinthine approach • Farrior’s hypotympanic sub-cochlear approach • Lempert Ramadier’s peri-tubal approach • Kopetsky Almoor’s peri-tubal approach
  42. 42. Hearing sacrificing approaches to petrous apex • Trans-cochlear approach • Trans-labyrinthine approach
  43. 43. Spread of pus
  44. 44. Labyrinthitis
  45. 45. Introduction Inflammation of endosteal layer of bony labyrinth Route of infection: Round window membrane Pre-formed opening (Stapedectomy) Retrograde spread of meningitis via IAC / aqueducts Clinical forms: 1. Circumscribed (labyrinthine fistula) 2. Diffuse serous 3. Diffuse suppurative
  46. 46. • Circumscribed: Fistula commonly involves lateral SCC. Presents with transient vertigo & positive fistula test I/L nystagmus with +ve pressure; C/L nystagmus with -ve pressure • Serous: Reversible, non-purulent, mild vertigo, I/L nystagmus, mild sensori-neural hearing loss • Purulent: Irreversible, purulent, severe vertigo, C/L nystagmus, severe / profound
  47. 47. Treatment: Bed rest (affected ear up). Avoid head movement. Labyrinthine sedative: Prochlorperazine, Cinnarizine Broad spectrum I.V. antibiotics Modified Radical Mastoidectomy: removes infection Open labyrinthine fistula: cover with temporalis fascia Fistula covered with cholesteatoma matrix < 2 mm: remove matrix & cover with temporalis fascia > 2 mm / multiple / over promontory: leave it Rehabilitation by Cawthorne-Cooksey Exercises
  48. 48. Lateral SSC Fistula
  49. 49. Facial nerve paralysis • Within 1st wk: due to nerve sheath edema • After 2 wks: due to bone erosion • Lower motor neuron palsy • Common in tubercular otitis media Treatment: • Modified Radical Mastoidectomy • Facial nerve decompression seldom required
  50. 50. Meningitis
  51. 51. • High grade persistent fever with rigors • Severe headache & neck stiffness • Irritability drowsiness confusion coma • Neck rigidity positive • Kernig sign positive; Brudzinski sign positive • Papilloedema • Lumbar Puncture: cell count, protein, sugar • I.V. Ceftriaxone + Metronidazole + Gentamicin • Radical Mastoidectomy once patient is stable
  52. 52. Test for neck rigidity
  53. 53. Otogenic brain abscess
  54. 54. 50-75 % adult brain abscess & 25% in child = otogenic Temporal abscess : Cerebellar abscess = 2:1 Route of infection: 1. Direct spread: via Tegmen plate: Temporal abscess via Trautmann’s triangle: Cerebellar abscess 2. Retrograde thrombophlebitis Introduction
  55. 55. Trautmann’s triangle Superiorly: superior petrosal sinus Posteriorly: sigmoid sinus Anteriorly: solid angle (semi-circular canals) Pathway to posterior cranial fossa from mastoid cavity
  56. 56. Stages of brain abscess 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
  57. 57. Stages of brain abscess
  58. 58. Clinical Features of ed I.C.T. Seen more in cerebellar abscess • Severe persistent headache, worse in morning • Projectile vomiting • Blurring of vision & Papilloedema • Lethargy drowsiness confusion coma • Bradycardia • Subnormal temperature
  59. 59. Focal Clinical Features 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
  60. 60. Bacteriology • Anaerobic streptococci • Streptococcus pneumoniae • Staphylococci • Proteus • E. coli • Pseudomonas • Bacteroidis fragilis
  61. 61. CT scan of brain & temporal bone with contrast Site, size & staging of abscess Observe progression of brain abscess Associated intra-cranial complications MRI brain D/D: pus, abscess capsule, edema & normal brain Spread to ventricles & subarachnoid space Avoid lumbar puncture to prevent coning Investigations
  62. 62. Temporal abscess in CT scan
  63. 63. Cerebellar abscess
  64. 64. Medical Treatment • High dose broad spectrum I.V. antibiotics: Ceftriaxone + Metronidazole + Gentamicin • I.V. Dexamethasone 4mg Q6H: es oedema • I.V. 20% Mannitol (0.5 gm/kg): es I.C.T. • Anti-epileptics: Phenytoin sodium • Antibiotic ear drops & aural toilet
  65. 65. Surgical Treatment • Repeated burr hole aspirations • Excision of brain abscess with capsule: best Tx • Open incision & evacuation of pus • Radical mastoidectomy after pt becomes stable
  66. 66. Lateral sinus thrombophlebitis
  67. 67. Lateral sinus = Sigmoid sinus + Transverse sinus Erosion of sigmoid sinus plate peri-sinus abscess inflammation of outer wall endophlebitis mural thrombus occlusion of sinus lumen intra-sinus abscess propagating infected thrombus Pathogenesis
  68. 68. Pathogenesis
  69. 69. Proximal: 1. To superior sagittal sinus via torcula Hirophili hydrocephalus 2. To cavernous sinus proptosis 3. To mastoid emissary vein Griesinger’s sign Distal: To internal jugular vein & subclavian vein pulmonary thrombo-embolism & septicaemia Spread of thrombus
  70. 70. Clinical Features • Remittent high fever with rigors (picket fence) • Pitting edema over retro-mastoid area & occipital bone due to mastoid emissary vein thrombosis (Griesinger’s sign) • Tenderness along Internal Jugular Vein • Headache • Anaemia
  71. 71. Fever charts in C.S.O.M. Meningitis Lateral Sinus Thrombophlebitis Brain abscess
  72. 72. Picket fence fever • High fever, swinging type • Chills precedes fever • Temperature subsides with sweating • Each fever spike due to release of fresh septic embolus
  73. 73. Special Tests • Queckenstedt or Tobey-Ayer test: compression of I.J.V. rapid rise of C.S.F. pressure (50 – 100 mm water rapid fall on release of compression. In L.S.T. no rise / rise by only 10 – 20 mm water. • Lillie – Crowe - Beck test: pressure on I.J.V. on normal side engorgement of retinal veins + papilloedema seen in fundoscopy due to L.S.T. on opposite side.
  74. 74. Tobey Ayer Test
  75. 75. Retinal vein dilation & optic disc edema
  76. 76. Lumbar puncture: to rule out meningitis CT brain with contrast: Delta sign or MRI brain with contrast: Empty triangle sign MR angiography Blood culture Culture & sensitivity of ear discharge Peripheral blood smear: to rule out malaria Investigations
  77. 77. Delta sign
  78. 78. 1. Radical mastoidectomy: Removal of disease + needle aspiration to confirm diagnosis. Sinus wall incised. Infected clots removed & abscess drained. 2. I.V. Ceftriaxone + Metronidazole + Gentamicin 3. Anticoagulants: in cavernous sinus thrombosis 4. Internal jugular vein ligation: for embolism not responding to antibiotics & surgery 5. Blood transfusion: for anaemia Treatment
  79. 79. Extra-dural abscess
  80. 80. Extra-dural abscess
  81. 81. Commonest otogenic intra-cranial complication Collection of pus b/w skull bone & dura of middle or posterior cranial fossa Majority asymptomatic. Suspected in case of: Profuse, intermittent, pulsatile, purulent, otorrhoea Low grade fever I/L Persistent headache Recurring meningococcal meningitis CT scan brain shows extra-dural abscess Tx: I.V. Ceftriaxone + Metronidazole + Gentamicin Modified Radical mastoidectomy Drill tegmen or sinus plate pus drained
  82. 82. Extra-dural abscess
  83. 83. Subdural abscess
  84. 84. Subdural abscess
  85. 85. Collection of pus b/w dura & arachnoid by erosion of bone & dura mater or by retrograde thrombophlebitis Due to rapid spread of pus, symptoms of raised intra- cranial tension & meningeal irritation develop quickly CT scan brain shows subdural abscess Tx: I.V. Ceftriaxone + Metronidazole + Gentamicin Burr hole evacuation of pus Radical mastoidectomy after pt becomes stable
  86. 86. Subdural abscess
  87. 87. Otitic Hydrocephalus
  88. 88. Synonym: Benign intra-cranial hypertension Symond’s syndrome Etiology: 1. Associated L.S.T. obstruction of cerebral venous return. 2. Superior sagittal sinus thrombosis ed C.S.F. absorption Clinical Features: 1. Severe headache, vomiting 2. Blurred vision, papilloedema, optic atrophy 3. Abducens palsy & diplopia due to raised intra-cranial tension (False localizing sign)
  89. 89. Investigations: 1. Lumbar puncture: ed CSF pressure (> 300 mm H2O). Biochemistry & bacteriology normal 2. CT scan brain: normal ventricles Treatment: 1. Tx of L.S.T.: I.V. antibiotics & MRM 2. se CSF pressure (prevents optic atrophy) by: I.V. Dexamethasone 4mg Q6H I.V. 20% Mannitol 0.5 gm/kg Repeated lumbar puncture / lumbar drain Ventriculo-peritoneal shunt
  90. 90. Brain Fungus • Prolapse of brain into middle ear cavity / mastoid cavity due to erosion of dural plate. • Common in pre-antibiotic era. Rarely seen now in resistant infections. • Diagnosis: C.T. scan temporal bone. • Treatment: Removal of necrotic tissue, replacement of healthy prolapsed brain into cranial cavity & repair of bone defect.
  91. 91. Fungus Cerebri
  92. 92. Thank You
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