Complications of Chronic Otitis Media Classification of complications of COM Pathways of spread of infection Anatomical relations of mastoid and mastoid antrum intratemporal complications acute mastoiditis bezold abscess citelli's abscess luc's abscess subperiosteal abscess petrositis gradenigo's syndrome petrous apicectomy circumbscribed labyrinthitis diffuse serous labyrinthitis diffuse suppurative labyrinthitis meningitis kernig's sign brudzinski's sign sigmoid sinus thrombophlebitis lateral sinus thrombophlebitis picket fence fever griesinger's sign tobey ayer test crowe beck test otogenic brain abscess subdural extradural abscess temporal abscess cerebellar abscess otitic hydrocephalous encephalocele brain fungus

1. Complications of
Chronic Otitis Media
- Dr. Alka Kapil
( Assistant Professor,
Dept. of ENT & Head Neck Surge

2. Relations of Mastoid Antrum
 Superiorly : Tegmen antri/Dural plate
 Posteriorly : Sinus plate
 Medially : Solid angle and posterior fossa dural plate
 Laterally : Skin ,subcutaneous tissue & Mac Ewan’s triangle
 Anteriorly : posterior wall of middle ear & facial canal

4. Pathways of spread of infection

5. INTRATEMPORAL COMPLICATIONS

6. Mastoiditis
 When infection spreads from the mucosal lining the mastoid air cells to
involve the bony walls of the mastoid air cell system it is called Mastoiditis.
 Can be :
Acute mastoiditis or
Chronic mastoiditis or
Coalescent mastoiditis or
Masked mastoiditis

7.  Acute inflammation of the mastoid bone
 Streptococcus pneumoniae > β haemolytic streptococcus
 Pathology :
1. Production of pus under tension
2. Hyperaemic decalcification and osteoclastic resorption of bony walls
Acute Mastoiditis

8. Accumulation of pus under tension
hyperaemia of mucosal lining
venous stasis
local acidosis and dissolution of calcium from the bone
hyperaemic decalcification
destruction of bony septa
Coalescent mastoiditis

9. Clinical presentations Signs
i. Mastoid tenderness
ii. Ear discharge
iii. Reservoir sign & Light house sign
iv. Tympanic membrane perforation
v. Swelling of mastoid/ ironed out appearance
vi. Hearing loss
vii. Fever
viii. Sagging of posterosuperior wall of EAC
Symptoms
i. Pain behind the ear
ii. Fever
iii. Ear discharge

10. BEZOLD ABSCESS
Abscesses in Relation to Mastoid Infection

11. (A) Abscesses in relation to mastoid: (1) postauricular, (2) zygomatic and (3) Bezold abscess
(B) Citelli, postauricular and Bezold abscesses seen from behind.

12. 1. Blood culture to find causative organisms
2. Routine hematological investigations ( CBC & ESR)
3. X-ray mastoids
4. Imaging studies : CT scan Temporal bone - MRI
5. Culture and sensitivity of ear swab
Investigations

13. Treatment
1. Intravenous culture directed antibiotics
2. Myringotomy if TM is intact and bulging with pus in tension
3. ± Mastoid exploration
done if : (a) Subperiosteal abscess
(b) Sagging of posterosuperior meatal wall.
(c) Positive reservoir sign
(d) No change in condition of patient or it worsens in spite of adequate medical
treatment for 48 h.
(e) Mastoiditis, leading to complications
4. Drainage of neck abscesses in case they are present

14. Petrositis
 Spread of infection from middle ear and mastoid to the petrous part of temporal
bone is called petrositis

15. Clinical presentations
Gradenigo syndrome is the classical presentation, and consists of a triad of
(i) external rectus palsy (VIth nerve palsy)
(ii) deep-seated ear or retro-orbital pain (Vth nerve involvement) &
(iii) persistent ear discharge

16. 1. Routine blood investigations
2. Blood culture to find the
causative organisms
3. X-ray mastoids
4. Imaging studies : CT scan & MRI
Investigations

17. 1. Intravenous culture directed antibiotics
2. Mastoid exploration / Petrous apicectomy
Treatment

18. Facial palsy

19. Labyrinthitis
CIRCUMSCRIBED
LABYRINTHITIS
DIFFUSE SEROUS
LABYRINTHITIS
DIFFUSE SUPPURATIVE
LABYRINTHITIS
Thinning or erosion of bony capsule
of labyrinth
diffuse intralabyrinthine inflammation
without pus
formation
diffuse pyogenic infection of the
labyrinth
exposure
of a localised part of membranous
labyrinth due to
erosion of the overlying bone
toxins from middle ear
infection
complete destruction of
membranous labyrinth
(Labyrinthitis OSSIFICANS )
reversible condition if treated early permanent loss of vestibular and
cochlear functions
Vertigo + Vertigo + Vertigo & imbalance +
Partial SNHL + Parital SNHL + SNHL +
Fistula test + nystagmus is
towards the same side of lesion
nystagmus towards the normal side
Mastoid exploration with closure of
fistula
Antibiotics, Labyrinthine sedatives,
mastoid exploration
Same as serous

20. INTRACRANIAL COMPLICATIONS

21. Meningitis
 It is inflammation of leptomeninges (pia and arachnoid) usually with bacterial invasion of
CSF in subarachnoid space
 MC organism causing otogenic meningitis is Streptococcus pneumoniae > H. influenzae

22. 1.There is rise in temperature (102-104 °F) often with chills and rigors
2. Headache
3. Neck rigidity
4. Photophobia and mental irritability
5. Nausea and vomiting (sometimes projectile)
6. Drowsiness which may progress to delirium or coma
7. Cranial nerve palsies and hemiplegia
Clinical presentations

23.  Signs :
(i) Neck rigidity
(ii) positive Brudzinski’s sign (flexion of neck causes flexion of hip and knee)
(iii) positive Kernig’s sign (extension of leg with thigh flexed on abdomen causing pain)
(iv) tendon reflexes exaggerated initially but later sluggish or absent
(v) papilloedema

24. Investigations
1. CT scan & MRI
2. Lumber Puncture & CSF examination
CSF finding - turbid
- cell count is raised
- predominance of polymorphs
- protein level is raised
- sugar & chlorides reduced
Treatment
Mainly medical management

25. Lateral Sinus Thrombophlebitis
 Also called as Sigmoid Sinus Thrombophlebitis
 It is an inflammation of inner wall of lateral venous sinus with formation of intrasinus thrombus
 Pathology :

26. Pathology

27. Clinical presentations
i. Picket Fence fever pattern (diurnal temperature spikes that exceed 103°F/39.4°C)
ii. Headache
iii. Progressive anemia and emaciation
iv. Griesinger’s sign : oedema over mastoid d/t thrombosis of mastoid emissary vein
v. Papilloedema
vi. Tobey-ayer test
vii. Crowe-beck test
viii. Tenderness along jugular vein

29. Investigations
1. Blood smear to rule out malaria
2. Blood culture to find causative organisms
3. CSF examination
4. X-ray mastoids
5. Imaging studies : CT scan & MRI
Delta sign / Empty Delta sign
6. Culture and sensitivity of ear swab
The pathognomonic "delta" sign is seen (2 small arrows)
The contralateral sigmoid sinus is patent (single large arrow)

30. Treatment
1. Intravenous culture directed antibiotics
2. Mastoid exploration
3. ± Anticoagulation therapy

31. Otogenic brain abscess

32. Clinical features
fever
headache
vomiting
focal neurological
signs
Mostly silent
Common : LOC - Lethargy & confusion
Nausea and vomiting
Papilloedema
Slow pulse and subnormal temperature
headache
Spontaneous nystagmus
I/L hypotonia &
weakness
Pastpointing &
intentional tremors
Dysdiadochokinesia
Nominal aphasia
Homonymous
hemianopia
C/L motor
paralysis
Epileptic fits

33. 1. Blood smear & Haemogram
2. Blood culture to find causative organisms
3. CSF examination
4. X-ray mastoids
5. Imaging studies : CT scan & MRI
6. Culture and sensitivity of ear swab
1. High doses of Antibiotics
2. Corticosteroids 4mg iv QID & mannitol 20% @ 0.5 g/kg
3. I &D of abscess & aural toileting
Investigations
Treatment

34. Otitic Hydrocephalus
 It is characterized by raised intracranial pressure with normal CSF findings

35. Encephalocele
 Erosion leading to defects of tegmen tympani or tegmen mastoideum can lead to encephalocele or even
CSF leakage
 Investigation – CT scan & MRI
 Surgical repair

36. Clinicals
1. Given is the CECT of a patient of foul smelling ear discharge with
convulsions. He should be managed :
a. Abscess drainage followed by MRM
b. MRM followed by abscess drainage
c. Myringoplasty
d. Only MRM

37. 2. Treatment of Brain fungus in mastoid cavity is:
a. Amphotericin therapy
b. Miconazole powder application
c. Surgical repair
d. Syringing

38. 3. Treatment of choice for CSOM with vertigo and facial palsy is :
a. Antibiotics and labyrinthine sedatives
b. Myringoplasty
c. Immediate mastoid exploration
d. Labyrinthectomy

39. Thank You