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
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
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
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. 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
24. Pathology
Production of pus under tension
hyperaemic decalcification (halisteresis)
+ osteoclastic resorption of bone
sub-periosteal abscess
penetration of periosteum + skin
fistula formation
31. Bezold & Citelli abscesses
Bezold: neck swelling
over sternocleido-
mastoid muscle
Citelli: neck swelling
over posterior belly
of digastric muscle
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. 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
46. 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
47. • 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
48. 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
51. 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
60. 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
67. 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
72. 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
73. 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
75. Picket fence fever
• High fever, swinging
type
• Chills precedes fever
• Temperature subsides
with sweating
• Each fever spike due
to release of fresh
septic embolus
76. 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.
79. 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
88. 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
91. 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)
92. 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
93. 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.
