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    13 csom-part-4 13 csom-part-4 Presentation Transcript

    • Complications of Suppurative Otitis Media Dr. Vishal Sharma
    • 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.
    • 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
    • Classification • Intra-cranial • Extra-cranial, Intra-temporal • Extra-cranial, Extra-temporal • Systemic: septicemia, otogenic tetanus
    • Classification
    • 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)
    • Intra-temporal Complications • Acute mastoiditis • Coalescent mastoiditis • Masked mastoiditis • Facial nerve palsy • Labyrinthitis • Labyrinthine fistula • Apex Petrositis (Gradenigo syndrome)
    • Extra-temporal Complications 1. Post-auricular abscess 2. Bezold abscess 3. Citelli abscess 4. Luc abscess 5. Zygomatic abscess 6. Retro-mastoid abscess
    • 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
    • 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
    • Erosion of tegmen tympani
    • Coalescent Mastoiditis or Surgical Mastoiditis
    • 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
    • Pathogenesis
    • 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
    • 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 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
    • 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
    • Sub-periosteal abscess & fistula
    • Pathology Production of pus under tension hyperaemic decalcification (halisteresis) + osteoclastic resorption of bone sub-periosteal abscess penetration of periosteum + skin fistula formation
    • 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 & Retropharyngeal
    • 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 belly of digastric muscle
    • 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
    • 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
    • Retromastoid abscess
    • Incision drainage of abscess
    • 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
    • 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 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
    • C.T. scan & M.R.I.
    • 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
    • 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 opening (Stapedectomy) Retrograde spread of meningitis via IAC / aqueducts Clinical forms: 1. Circumscribed (labyrinthine fistula) 2. Diffuse serous 3. Diffuse suppurative
    • • 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
    • 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
    • Lateral SSC Fistula
    • 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
    • Meningitis
    • • 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
    • 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. Direct spread: via Tegmen plate: Temporal abscess via Trautmann’s triangle: Cerebellar abscess 2. Retrograde thrombophlebitis Introduction
    • Trautmann’s triangle Superiorly: superior petrosal sinus Posteriorly: sigmoid sinus Anteriorly: solid angle (semi-circular canals) Pathway to posterior cranial fossa from mastoid cavity
    • 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
    • Stages of brain abscess
    • 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
    • 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
    • Bacteriology • Anaerobic streptococci • Streptococcus pneumoniae • Staphylococci • Proteus • E. coli • Pseudomonas • Bacteroidis fragilis
    • 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
    • Temporal abscess in CT scan
    • Cerebellar abscess
    • 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
    • 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
    • Lateral sinus thrombophlebitis
    • 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
    • Pathogenesis
    • 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
    • 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
    • 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 spike due to release of fresh septic embolus
    • 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.
    • 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 MR angiography Blood culture Culture & sensitivity of ear discharge Peripheral blood smear: to rule out malaria Investigations
    • Delta sign
    • 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
    • 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 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
    • 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 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
    • Subdural abscess
    • Otitic Hydrocephalus
    • 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)
    • 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
    • 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.
    • Fungus Cerebri
    • Thank You