Successfully reported this slideshow.
COMPLICATIONS OF COM
Dr. AJAY MANICKAM
JUNIOR RESIDENT, DEPT OF ENT
RG KAR MEDICAL COLLEGE
INTRODUCTION
 Infection spreads beyond muco-periosteal lining of
middle ear cleft to involve bone & neighboring
structure...
Complications
ExtracranialIntracranial
• Meningitis
• Extradural abscess
• Subdural empyema
• Lateral sinus thrombophlebit...
Routes of access
• Bony defects
anatomical dehiscences (jugular bulb, dural plate, Fallopian
canal)
erosion (cholesteatoma...
SPREAD OF INFECTION
FACTORS
Pathogen Factors Patient Factors
 High virulence bacteria  Young age
Antimicrobial resistance  Poor immune stat...
EXTRADURAL
ABSCESS
EXTRA DURAL ABSCESS
 2nd Most common otogenic
intracranial complication
 Acute infection by
demineralization and
chronic...
MIDDLE CRANIAL FOSSA
• Tegmen tympani (lateral to the arcuate eminence)
• Petrous apicitis (medial to the arcuate eminence...
• 2nd most common intracranial complication
• Coalescence, cholesteatoma, granulation
• Non-specific symptoms (unilateral ...
SUBDURAL
EMPYEMA
SUBDURAL EMPYEMA
 Least common complication
 Non hemolytic streptococci
 Inflammatory reaction underneath
dura- granula...
CLINICAL FEATURES
 Dramatic presentation , rapid detioration
 Severe headache, fever, drowsiness, follwed by
focal neuro...
• along the falx
• loculated
• hypodense
• ring enhancement
• contrast imaging
• mass effect
• blunted sulci
Gd-DTPA enhan...
DIAGNOSIS AND MANAGEMENT
 CT scan
 CSF culture sterile
 With neurosurgeons
 Systemic antibiotics + removal of subdural...
MENINGITIS
MENINGITIS
 Most common intracranial complication
 In children following acute and adults following
chronic infection
 ...
 Routes of entry into the meninges –
haematogenous (MC)
direct extension by bone erosion (cholesteatoma, encephalocoel)
p...
DIAGNOSIS AND TREATMENT
CSF study by LP (cytology, chemistry, smear, culture)
Broad spectrum IV antibiotics, steroids (to ...
LATERAL SINUS
THROMBOPHLEBITIS
LATERAL SINUS THROMBOPHLEBITIS
Lateral sinus = Sigmoid sinus + Transverse sinus
sinus plate  peri-sinus abscess  inflamm...
PATHOGENESIS
Lateral sinus
thrombophlebitis
Sagittal sinus
(papilloedema,
visual loss)
Petrosal and cavernous
sinus
(proptosis, chemosi...
LATERAL SINUS THROMBOPHLEBITIS
Proximal: 1. To superior sagittal sinus via torcula
Herophili  hydrocephalus
2. To caverno...
CLINICAL FEATURES
 Remittent high fever with rigors (picket fence)
 Pitting edema over retro-mastoid area & occipital
bo...
SYMPTOMS & SIGNS
 High fever, swinging type
 Chills precedes fever
 Temperature subsides with sweating
 Each fever spi...
INVESTIGATIONS
 Queckenstedt or Tobey-Ayer test: compression of
I.J.V.  rapid rise of C.S.F. pressure (50 – 100 mm
water...
INVESTIGATIONS
Lumbar puncture: to rule out
meningitis
CT brain with contrast: Delta sign
or Empty triangle sign
MRI brain...
• Intravenous antibiotics
• Surgery
• Anticoagulants
• Ligation of internal jugular vein
Treatment
Algorithm for Surgery
Mastoidectomy Inspection of the sinus wall
NORMAL
(compressible, healthy-looking)
DISEASED
(inflamme...
OTOGENIC BRAIN ABSCESS
OTOGENIC BRAIN ABSCESS
50-75 % adult brain abscess & 25% in child = otogenic
Temporal abscess : Cerebellar abscess = 2:1
R...
TRAUTMANN’S TRIANGLE
Superiorly: superior
petrosal sinus
Posteriorly: sigmoid sinus
Anteriorly: solid angle
(semi-circular...
4 STAGES (NEELY, MAWSON)
1. Invasion or Encephalitis (1-10
days)
2. Localization or Latent Abscess
(10-14 days)
3. Expansi...
RAISED ICT
Seen more in cerebellar abscess
 Severe persistent headache, worse in morning
 Projectile vomiting
 Blurring...
DIFFERENT FINDINGS
Temporal Lobe Cerebellum
 Nominal aphasia  I/L nystagmus
 homonymous  I/L weakness
hemianopia (C/L)...
INVESTIGATIONS
CT scan of brain & temporal bone with
contrast
 Site, size & staging of abscess
 Observe progression of b...
DIFFERENTIAL DIAGNOSIS
 Meningitis- high fever, neck stiffness , CSF findings
 Subdural abscess – the progression
 Late...
MANAGEMENT
• High dose broad spectrum I.V. antibiotics: Ceftriaxone
+ Metronidazole + Gentamicin
• I.V. Dexamethasone 4mg ...
SURGICAL MANAGEMENT
•Repeated burr hole aspirations – safer for ill patients
• Excision of brain abscess with capsule: bes...
OTITIC
HYDROCEPHALUS
• syn. Benign intracranial hypertension
• Symptomatic ↑ in ICT (>240 mm H2o in LP), papilloedema,
normal CSF studies, in a...
OTITIC HYDROCEPHALUS
Clinical Features: 1. Severe headache, vomiting
2. Blurred vision, papilloedema, optic atrophy
3. Abd...
MANAGEMENT
Investigations:
1. Lumbar puncture: ed CSF pressure (> 300 mm
H2O). Biochemistry & bacteriology normal
2. CT s...
CSF OTORRHOEA
• More common with COM
• Cholesteatoma → tegmen dehiscence → middle or
posterior cranial fossa dural tear → CSF
leak/encep...
BRAIN FUNGUS
 Prolapse of brain into middle ear cavity / mastoid
cavity due to erosion of dural plate.
 Common in pre-an...
SUBPERIOSTEAL
ABSCESS
• Extension of mastoid infection through the cortex and air cells into the
subperiosteal region
• Types –
Mastoid abscess ...
PATHOGENESIS
Production of pus under tension
 hyperaemic decalcification
+ osteoclastic resorption of bone
 sub-perioste...
SUBPERIOSTEAL FISTULA
Subperiosteal abscess
(lateral wall)
Bezold’s abscess (tip cells)
Zygomatic abscess (zygomatic cells)
Luc’s (meatal) absce...
POSTAURICULAR ABSCESS
Commonest. Present behind the ear.
Pinna pushed forward & downward
BEZOLD & CITELLI’S ABSCESS
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’S ABSCESS
Luc: swelling in external auditory canal
Zygomatic: swelling antero-superior to pinna +
upper eyelid oedema
...
CLINICAL FEATURES & TREATMENT
• Late feature of neglected COM
• CT scan (extent of the lesion, intracranial and
 intratem...
MASTOIDITIS
• Mastoiditis = mucositis of mastoid cavity and air
cells + effusion
part of the spectrum of uncomplicated otitis media
pe...
PATHOGENESIS
Aditus Blockage
 Failure of drainage
 Stasis of secretions
 Hyperemic decalcification
 Resorption of bony...
 Disease of childhood (>2 years, peak at 6 years)
 Mostly a sequelae of ASOM (Pneumococcus,
Haemophilus)
 25% of coales...
Fate of an inflammed mastoid cavity
Acute mastoiditis
Spontaneous resolution, perforation of tympanic
membrane
Persists
Bl...
SYMPTOMS & SIGNS
 Otorrhoea > 3 weeks, pain behind the ear & fever
 Mastoid reservoir sign: pus fills up on mopping
 Sa...
MASTOID RESERVOIR SIGN
POSTERIOR SAGGING OF POSTERIOR CANAL
WALL
MASTOIDITIS
COALESCENCE OF CELLS
Mastoiditis Furunculosis
H/o otitis media + -
Deafness + -
Position of pinna Down + outward
+ forward
Forward
Ear discharg...
MANAGEMENT
 Urgent hospital admission
 Broad spectrum I.V. antibiotics
 Cortical mastoidectomy
 No response to medical...
 Masked mastoiditis
Natural progress of acute mastoiditis halted by antibiotics
Middle ear apparently free from infection...
PETROSITIS
Pneumatisation of the petrous pyramid
30% (anterior petrous apex), 10% (posterior petrous apex)
after 3 years of age
conti...
ACUTE PETROSITIS
• Gradenigo’s syndrome
deep-seated retro-orbital/aural pain (50%)
diplopia (lateral rectus palsy) (25%)
o...
PETROSITIS
• Pneumatisation of petrous apex not
a prerequisite
ALTERNATIVE ROUTES OF SPREAD
Thrombophlebitis
Osteitis
• Lo...
• Long term, high dose systemic antibiotics
• Myringotomy (± grommet), corticosteroids (neuropathy)
• Surgery –
petrous ab...
INVOLVEMENT OF
THE LABYRINTH
(Otitis interna)
• Most common complication of COM with
cholesteatoma
• Arch of the horizontal semicircular canal most
commonly affected (~...
• Presentations of labyrinthine fistula
sensorineural hearing loss
subjective episodic vertigo
positive fistula test
Tulli...
Fistula test in relation to labyrinthine fistula
• Tragal pressure, Politzer bag with ear canal
adapter,
pneumatic speculu...
Treatment of labyrinthine fistula
• Tympanomastoidectomy (CWD) + addressing the fistula
• Removal of cholesteatoma, exteri...
SEROUS LABYRINTHITIS
• Translocation of toxins and inflammatory mediators
Associated perilabyrinthine infection, especiall...
SUPPURATIVE LABYRINTHITIS
Comparatively less common (<1%)
• Invasion of bacteria into the labyrinth
• Tympanogenic (round ...
FACIAL NERVE
PARALYSIS
• Otitis media → 3-5% of incidences of facial palsy
• More common in children, after ASOM
• Acute onset (<1 week) in AOM, ...
Causes of Facial nerve palsy
AOM
• Neurotoxic effect (inflammatory mediators, bacterial toxins
through natural dehiscences...
• Clinical diagnosis
• Role of CT scan
not a routine procedure
investigation of choice
<2mm cuts, with proper exposure of ...
Thank
you
Complications of csom
Upcoming SlideShare
Loading in …5
×

Complications of csom

791 views

Published on

COMPLICATIONS OF EAR INFECTION

Published in: Health & Medicine

Complications of csom

  1. 1. COMPLICATIONS OF COM Dr. AJAY MANICKAM JUNIOR RESIDENT, DEPT OF ENT RG KAR MEDICAL COLLEGE
  2. 2. INTRODUCTION  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  Mortality due to intracranial complication is still high
  3. 3. Complications ExtracranialIntracranial • Meningitis • Extradural abscess • Subdural empyema • Lateral sinus thrombophlebitis • Brain abscess • Otitic hydrocephalus • CSF otorrhoea Extratemporal • Subperiosteal abscesses Intratemporal • Mastoiditis • Labyrinth involvement • Petrous apicitis • Facial nerve paralysis • Sensorineural hearing loss
  4. 4. Routes of access • Bony defects anatomical dehiscences (jugular bulb, dural plate, Fallopian canal) erosion (cholesteatoma, granulation tissue) trauma (accidental, dural plate breach during mastoidectomy) • Normal anatomical pathways oval window round window aqueducts • Haematogenous infected thrombus venous spread (sinus, emissary veins, systemic ) • Periarteriolar spread (of Virchow-Robin) seeding in the white matter of brain
  5. 5. SPREAD OF INFECTION
  6. 6. FACTORS Pathogen Factors Patient Factors  High virulence bacteria  Young age Antimicrobial resistance  Poor immune status  Chronic disease (DM, TB)  Poor socio-economic status  Lack of health awareness
  7. 7. EXTRADURAL ABSCESS
  8. 8. EXTRA DURAL ABSCESS  2nd Most common otogenic intracranial complication  Acute infection by demineralization and chronic by erosion
  9. 9. MIDDLE CRANIAL FOSSA • Tegmen tympani (lateral to the arcuate eminence) • Petrous apicitis (medial to the arcuate eminence) POSTERIOR CRANIAL FOSSA • Sinus plate (perisinus abscess, lateral sinus thrombophlebitis) • Trautmann’s triangle ANTERIOR CRANIAL FOSSA • Pott’s puffy tumour
  10. 10. • 2nd most common intracranial complication • Coalescence, cholesteatoma, granulation • Non-specific symptoms (unilateral headache, fever, otorrhoea) • Often diagnosed peroperatively (silent abscess) • MRI (Gadolinium-enhanced) > CT scan • Systemic antibiotics + surgery (mastiodectomy + removal of necrosed bone and non-adherant granulation tissue over dura)
  11. 11. SUBDURAL EMPYEMA
  12. 12. SUBDURAL EMPYEMA  Least common complication  Non hemolytic streptococci  Inflammatory reaction underneath dura- granulation- fibrosis-necrosis of bone  Seropurulent – purulent collection • Subdural space, along tentorium cerebelli and interhemispheric spaces
  13. 13. CLINICAL FEATURES  Dramatic presentation , rapid detioration  Severe headache, fever, drowsiness, follwed by focal neurological symptoms  Much more rapid than brain abscess  Jacksonian fits  Hemianopia ,hemianaesthesia , aphasia  Mortality 15%
  14. 14. • along the falx • loculated • hypodense • ring enhancement • contrast imaging • mass effect • blunted sulci Gd-DTPA enhanced T1 weighted MRI CECT
  15. 15. DIAGNOSIS AND MANAGEMENT  CT scan  CSF culture sterile  With neurosurgeons  Systemic antibiotics + removal of subdural fluid (burr hole) + ear infections acute by myringotomy and cortical mastiodectomy  Now craniotomy abscess excision  Radical mastoidectomy after patient is stable
  16. 16. MENINGITIS
  17. 17. MENINGITIS  Most common intracranial complication  In children following acute and adults following chronic infection  Mortality 5-30 %  Otogenic meningitis is most serious than meningococcal meningitis  Hemophilus influenzae , streptococcus pneumonia type iii – acute  Chronic – proteus and pseudomonas  Anaerobic – bacteroid
  18. 18.  Routes of entry into the meninges – haematogenous (MC) direct extension by bone erosion (cholesteatoma, encephalocoel) preformed channels (Hyrtl’s fissures) labyrinth, aqueduct (suppurative labyrinthitis, Mondini malformation)  Suspicious signs – persistent/intermittent fever lethargy nausea and vomiting persistent headache irritability  Ominous signs – visual changes ataxia new onset seizures altered sensorium nuchal rigidity  Associted intracranial complications in 50% of cases Meningitis
  19. 19. DIAGNOSIS AND TREATMENT CSF study by LP (cytology, chemistry, smear, culture) Broad spectrum IV antibiotics, steroids (to prevent subsequent hearingloss) Myringotomy Mastoidectomy (cholesteatoma, coalescent mastoiditis, extension through bone erosion, failure of maximal medical therapy)
  20. 20. LATERAL SINUS THROMBOPHLEBITIS
  21. 21. LATERAL SINUS THROMBOPHLEBITIS Lateral sinus = Sigmoid sinus + Transverse sinus sinus plate  peri-sinus abscess  inflammation of Erosion of sigmoid outer wall  endophlebitis  mural thrombus  occlusion of sinus lumen  intra-sinus abscess  propagating infected thrombus
  22. 22. PATHOGENESIS
  23. 23. Lateral sinus thrombophlebitis Sagittal sinus (papilloedema, visual loss) Petrosal and cavernous sinus (proptosis, chemosis) Mastoid emissary vein (Griesinger’s sign) Internal jugular vein Subclavian vein Systemic spread (bacteraemia, septicaemia, septic embolisation) Torcula
  24. 24. LATERAL SINUS THROMBOPHLEBITIS Proximal: 1. To superior sagittal sinus via torcula Herophili  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
  25. 25. 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
  26. 26. SYMPTOMS & SIGNS  High fever, swinging type  Chills precedes fever  Temperature subsides with sweating  Each fever spike due to release of fresh septic embolus
  27. 27. INVESTIGATIONS  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.  Low sensitivity and specificity
  28. 28. INVESTIGATIONS Lumbar puncture: to rule out meningitis CT brain with contrast: Delta sign or Empty triangle sign MRI brain with contrast MR angiography Blood culture Culture & sensitivity of ear discharge
  29. 29. • Intravenous antibiotics • Surgery • Anticoagulants • Ligation of internal jugular vein Treatment
  30. 30. Algorithm for Surgery Mastoidectomy Inspection of the sinus wall NORMAL (compressible, healthy-looking) DISEASED (inflammed, immobile, pale, opaque) Wide bore needle aspiration Free flow blood No blood, pus Conservative Thrombectomy, drainage (healthy thrombus, free flow blood) Dry tap
  31. 31. OTOGENIC BRAIN ABSCESS
  32. 32. 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 and 3. virchow robin space
  33. 33. TRAUTMANN’S TRIANGLE Superiorly: superior petrosal sinus Posteriorly: sigmoid sinus Anteriorly: solid angle (semi-circular canals) Pathway to posterior cranial fossa from mastoid cavity
  34. 34. 4 STAGES (NEELY, MAWSON) 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
  35. 35. RAISED ICT Seen more in cerebellar abscess  Severe persistent headache, worse in morning  Projectile vomiting  Blurring of vision & Papilloedema  Lethargy  drowsiness  confusion  coma  Bradycardia  Subnormal temperature
  36. 36. DIFFERENT FINDINGS Temporal Lobe Cerebellum  Nominal aphasia  I/L nystagmus  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
  37. 37. INVESTIGATIONS 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
  38. 38. DIFFERENTIAL DIAGNOSIS  Meningitis- high fever, neck stiffness , CSF findings  Subdural abscess – the progression  Lateral sinus thrombosis – precursor of cerebellar abscess  Otitic hydrocephalous absence of focal neurological sign , CT scan findings and CSF features
  39. 39. MANAGEMENT • 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
  40. 40. SURGICAL MANAGEMENT •Repeated burr hole aspirations – safer for ill patients • Excision of brain abscess with capsule: best Tx – extensive damage to cerebral tissue , residual neurological deficit • Open incision & evacuation of pus • Radical mastoidectomy after pt becomes stable
  41. 41. OTITIC HYDROCEPHALUS
  42. 42. • syn. Benign intracranial hypertension • Symptomatic ↑ in ICT (>240 mm H2o in LP), papilloedema, normal CSF studies, in absence of brain abscess or meningitis • A misnomer • Lateral sinus thrombophlebitis → torcula → sagittal sinus thrombosis → inhibition of CSF resorption through arachnoid villi → ↑ICT [Symonds] Otitic hydrocephalus
  43. 43. OTITIC HYDROCEPHALUS Clinical Features: 1. Severe headache, vomiting 2. Blurred vision, papilloedema, optic atrophy 3. Abducens palsy & diplopia due to raised intra-cranial tension (Falselocalizing sign) • Conservative (acetazolamide, fluid restriction, diuretics,mannitol, serial LP, ± systemic anticoagulants in case of sagittal sinus thrombosis) • Mastoidectomy ± thrombectomy (in COM with cholesteatoma)
  44. 44. MANAGEMENT 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 ,acetazolamide , diuretics  Repeated lumbar puncture / lumbar drain  Ventriculo-peritoneal shunt
  45. 45. CSF OTORRHOEA
  46. 46. • More common with COM • Cholesteatoma → tegmen dehiscence → middle or posterior cranial fossa dural tear → CSF leak/encephalocoel • Iatrogenic • Presentations clear, colourless, watery fluid from mastoid cavity or external auditory canal through nose, in intact TM middle ear/myringotomy fluid rich in glucose • Proper exposure → temporalis muscle/fascia graft with gelfoam compression • Sinodural angle tear most difficult to control • Repair via intracranial route (extradural/intradural)
  47. 47. 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.
  48. 48. SUBPERIOSTEAL ABSCESS
  49. 49. • Extension of mastoid infection through the cortex and air cells into the subperiosteal region • Types – Mastoid abscess (subperiosteal abscess “proper”) [MC] von Bezold’s abscess Luc’s (meatal) abscess Zygomatic abscess Citelli’s abscess Para-/retropharyngeal abscess • Haematogenous spread (perforators, especially in children) • Differential diagnosis – Mastoiditis without abscess Suppurative lymphadenopathy Superficial abscess Infected sebaceous cyst
  50. 50. PATHOGENESIS Production of pus under tension  hyperaemic decalcification + osteoclastic resorption of bone  sub-periosteal abscess  penetration of periosteum + skin  fistula formation
  51. 51. SUBPERIOSTEAL FISTULA
  52. 52. Subperiosteal abscess (lateral wall) Bezold’s abscess (tip cells) Zygomatic abscess (zygomatic cells) Luc’s (meatal) abscess Parapharyngeal/retropharyngeal abscess (peritubal cells)
  53. 53. POSTAURICULAR ABSCESS Commonest. Present behind the ear. Pinna pushed forward & downward
  54. 54. BEZOLD & CITELLI’S ABSCESS Bezold: neck swelling over sternocleido- mastoid muscle Citelli: neck swelling over posterior belly of digastric muscle
  55. 55. 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
  56. 56. LUC’S ABSCESS Luc: swelling in external auditory canal Zygomatic: swelling antero-superior to pinna + upper eyelid oedema Parapharyngeal & Retropharyngeal: due to spread of pus along Eustachian tube
  57. 57. CLINICAL FEATURES & TREATMENT • Late feature of neglected COM • CT scan (extent of the lesion, intracranial and  intratemporal complications) • Subperiosteal abscess + cholesteatoma   Drainage + cortical mastoidectomy + IV antibiotics • Subperiosteal abscess – cholesteatoma   Drainage + cortical mastoidectomy + IV antibiotics  Drainage + myringotomy + IV antibiotics  Aspiration + myringotomy + IV antibiotics
  58. 58. MASTOIDITIS
  59. 59. • Mastoiditis = mucositis of mastoid cavity and air cells + effusion part of the spectrum of uncomplicated otitis media per se, not a complication • Acute (clinical) mastoiditis red, oedematous soft tissue over mastoid antrum painful/tender pinna directed laterally, downward and forward loss of post-auricular crease otorrhoea localised reactive lymphadenopathy pain the only presentation in adults (thicker cortex)
  60. 60. 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
  61. 61.  Disease of childhood (>2 years, peak at 6 years)  Mostly a sequelae of ASOM (Pneumococcus, Haemophilus)  25% of coalescent mastoiditis seen in sclerotic temporal bone with COM and cholesteatoma
  62. 62. Fate of an inflammed mastoid cavity Acute mastoiditis Spontaneous resolution, perforation of tympanic membrane Persists Blockage of aditus by granulation/cholesteatoma Mastoid empyema Acute coalescent mastoiditis Acidosis Osteoclast activity Pressure of pent-up pus DEMINERALISATION Subperiosteal abscess Petrositis Intratemporal & intracranial complications
  63. 63. SYMPTOMS & SIGNS  Otorrhoea > 3 weeks, pain behind the ear & fever  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  Blood counts , ESR raised , Mastoid cavity in X-ray & CT scan , ear swab culture & sensitivity
  64. 64. MASTOID RESERVOIR SIGN
  65. 65. POSTERIOR SAGGING OF POSTERIOR CANAL WALL
  66. 66. MASTOIDITIS
  67. 67. COALESCENCE OF CELLS
  68. 68. Mastoiditis Furunculosis H/o otitis media + - Deafness + - Position of pinna Down + outward + forward Forward 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
  69. 69. MANAGEMENT  Urgent hospital admission  Broad spectrum I.V. antibiotics  Cortical mastoidectomy  No response to medical treatment in 48 hrs , sagging of post meatal wall  Development of new complication  Presence of sub-periosteal abscess  Myringotomy to drain out painful pus  Incision drainage of sub-periosteal abscess
  70. 70.  Masked mastoiditis Natural progress of acute mastoiditis halted by antibiotics Middle ear apparently free from infection Persistence of symptoms of mastoiditis TM fails to return to normalcy Blockage of aditus by granulation/cholesteatoma
  71. 71. PETROSITIS
  72. 72. Pneumatisation of the petrous pyramid 30% (anterior petrous apex), 10% (posterior petrous apex) after 3 years of age continuous with the middle ear cleft POSTEROSUPERIOR/INFRALABYRINTHINE CHAIN (attic, antrum → semicircular canal → apex) ANTEROINFERIOR/PERITUBAL CHAIN (hypotympanum, PT tube → cochlea → apex)
  73. 73. ACUTE PETROSITIS • Gradenigo’s syndrome deep-seated retro-orbital/aural pain (50%) diplopia (lateral rectus palsy) (25%) otorrhoea TYPICAL GRADENIGO’S SYNDROME IS RARE NOT PATHOGNOMONIC OF APICITIS SIMILAR PRESENTATIONS WITH EXTRADURAL ABSCESS AT THE APEX • Cochleo-vestibular symptoms, facial weakness, constitutional symptoms
  74. 74. PETROSITIS • Pneumatisation of petrous apex not a prerequisite ALTERNATIVE ROUTES OF SPREAD Thrombophlebitis Osteitis • Long standing persistent otorrhoea (discharging petrous tract), with indolent symptoms
  75. 75. • Long term, high dose systemic antibiotics • Myringotomy (± grommet), corticosteroids (neuropathy) • Surgery – petrous abscess, necrosis, failure of medical traetment • Simple mastoidectomy • Surgery in a hearing ear – approaches following the infected air-cells • Surgery in a non-hearing ear – translabyrinthine & transcochlear approaches
  76. 76. INVOLVEMENT OF THE LABYRINTH (Otitis interna)
  77. 77. • Most common complication of COM with cholesteatoma • Arch of the horizontal semicircular canal most commonly affected (~90%) [nearest to the antrum • Breach of the otic capsule Resorptive osteitis (inflammatory mediators in COM with cholesteatoma/granulation tissue) Pressure necrosis (cholesteatoma mass) • Cholesteatoma and/or granulation
  78. 78. • Presentations of labyrinthine fistula sensorineural hearing loss subjective episodic vertigo positive fistula test Tullio phenomenon • Preoperative CT scan (30° tilted) (57-60% sensitivity, even with 1mm cuts) • Intraoperative diagnosis • The presence of labyrinthine fistula to be assumed to be present in every case of COM with cholesteatoma
  79. 79. Fistula test in relation to labyrinthine fistula • Tragal pressure, Politzer bag with ear canal adapter, pneumatic speculum • Conjugate ocular movements with vertigo • Not sensitive; its absence does not rule out a labyrinthine fistula • False positive fistula sign (Hennebert’s sign) intact tympanic membrane no fistula characteristic, though not diagnostic, of labyrinthine syphilis • False negetive fistula sign inadequate sealing cholesteatoma blocking the fistula wax in the external canal dead labyrinth
  80. 80. Treatment of labyrinthine fistula • Tympanomastoidectomy (CWD) + addressing the fistula • Removal of cholesteatoma, exteriorising the fistula covered by matrix (single sitting in open cavity/staged in closed cavity) – prevents aggravation of SNHL by minimising tissue handling removal of cholesteatoma itself releives pressure keeping matrix safe until no granulation tissue lies underneath • Complete removal of cholesteatoma including matrix (single or staged/2nd look sitting), repair of fistula (fascia, bone pâté) prevention of bone erosion and infection prevention of SNHL in the long term
  81. 81. SEROUS LABYRINTHITIS • Translocation of toxins and inflammatory mediators Associated perilabyrinthine infection, especially fistula • Meningogenic (Pneumococcal mengitis → aqueducts) Tympanogenic (round window, internal auditory canal) • Clinical diagnosis : Sudden onset vertigo in a patient with AOM • IV antibiotics + myringotomy ± mastoidectomy (in progressive cases) • Hearing loss, vertigo and imbalance are reversible
  82. 82. SUPPURATIVE LABYRINTHITIS Comparatively less common (<1%) • Invasion of bacteria into the labyrinth • Tympanogenic (round window, fistula) • Haematogenic (venous channels) • Endolymphatic hydrops (resistence of Reissner’s membrane to bacterial invasion ) • Meningitis, intracranial (cerebellar) abscess • Clinical diagnosis (aided by CT scan) sudden onset severe rotatory vertigo with vomiting profound unilateral deafness disorder of balance spontaneous horizontal nystagmus • Tissue destruction and loss of functions are permanent • IV antibiotics + myringotomy + corticosteroids + labyrinthine sedatives + mastoidectomy ± drainage/labyrinthectomy
  83. 83. FACIAL NERVE PARALYSIS
  84. 84. • Otitis media → 3-5% of incidences of facial palsy • More common in children, after ASOM • Acute onset (<1 week) in AOM, chronic protracted course in COM • Cholesteatoma, granulation tissue, suppurative labyrinthitis (sequestra), petrous osteomyelitis • Congenital petrous cholesteatoma (progressive palsy with longstanding severe deafness, without otorrhoea) • Facial nerve exposed by cholesteatoma mostly escapes palsy (epineurium replaced by matrix)
  85. 85. Causes of Facial nerve palsy AOM • Neurotoxic effect (inflammatory mediators, bacterial toxins through natural dehiscences and vascular channels) • Mass effect on the bare nerve COM Osteitis, erosion, direct pressure Oedema, neuropraxia, neuronotmesis • Cholesteatoma > granulation tissue • Acquired Fallopian canal dehiscence • Tubercular otitis media
  86. 86. • Clinical diagnosis • Role of CT scan not a routine procedure investigation of choice <2mm cuts, with proper exposure of tympanic cavity & facial canal • IV antibiotics + myringotomy ± grommet [AOM] • Surgical exploration [COM] CWD modified radical mastoidectomy Removal of cholesteatoma and granulation tissue Facial nerve decompression by removing matrix from epineurium Nerve repair, if needed The management
  87. 87. Thank you

×