Slides prepared and compiled by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal , for teaching undergraduate and postgraduate ENT students in the field of otorhinolaryngology. A clear and concise explanation of the basic concepts in the subject matter concerned. He is the Head of department with a sound knowledge in the field of ENT to teach both undergraduate and postgraduate ENT students

1. Complications Of CSOM
Dr. Krishna Koirala
MBBS, MS ( ENT )
2018-08-28

2. • Complications occur when infection spreads beyond
the muco - periosteal lining of middle ear cleft
– To involve the bone
– Into neighboring structures e.g. facial nerve, inner
ear, dural venous sinuses, meninges, brain tissue,
soft tissue
• Multiple complications occur in 1/3 of patients
• Children more commonly affected than adults

3. 1. Pathogen Factors
– High Virulence of Bacteria
– Antimicrobial Resistance
2. Patient Factors
– Young Children
– Poor Immune Status
– Concurrent Chronic Disease
– Poor socio- economic status
– Lack of health awareness
3. Physician Factors
– Non- Availability in
remote areas
– Injudicious Antibiotic
use “Masking Effect”
– Error in recognizing
“Danger symptoms /
signs”
Factors Affecting Complications

4. Etiology
• ASOM
– Streptococcus Pyogenes
– Haemophilus Influenzae
– Moraxella Catarrhalis
– Staphylococcus aureus
• CSOM
– Multiple agents
•Pseudomonas
aeruginosa
•Bacteroides fragilis
•Proteus Mirabilis
•Klebsiella
•E.Coli

5. Routes of spread of infections
1. Direct bone erosion
– Hyperemic decalcification - acute infection
– Resorption by cholesteatoma or osteitis - chronic
infection
2. Thrombophlebitis
– From lateral sinus to cerebellum
– From superior petrosal sinus to temporal lobe

6. 3. From normal anatomical pathways
– Oval and round windows , cochlear and vestibular
aqueducts, dehiscence of tegmen tympani etc
4. Non anatomical bony defects
– Accident/ surgery/neoplasm
5. Into brain tissue along the periarteriolar spaces of
Virchow-Robin

7. Classification
A) Intra- Temporal
1. Coalescent Mastoiditis
2. Petrositis
3. Labyrinthitis
4. Labyrinthine Fistula
5. Facial Nerve Paralysis
B) Extra- Temporal
1. Sub- periosteal Abscess
2. Citelli's Abscess
3. Bezold’s Abscess
4. Luc’s Abscess
5. Zygomatic Abscess
6. Occipital Abscess
C) Intra-Cranial
1. Meningitis
2. Extra-Dural Abscess
3. Sub- Dural Abscess
4. Brain Abscess
5. Lateral Sinus
Thrombophlebitis
6. Otitic Hydrocephalus
7. Brain Fungus
D) Systemic
1 . Septicemia
2. Otogenic Tetanus

8. Acute Coalescent Mastoiditis
• Acute osteitis of mastoid air cells
• Coalescence - destruction of walls of trabecular air
cells and their joining together to form a single,
irregular mastoid cavity
• Occurs in
– Children
– Well pneumatized mastoids
– ASOM

9. Aditus Blockage
Failure of Drainage
Stasis of Secretions
Hyperemic Decalcification
Resorption of bony walls of air cells
Coalescence of small air cells
to form an irregular cavity

10. Symptoms
• Otalgia
– Compared to ASOM
•Persistent pain > 2 weeks
•Increased intensity of pain
•Recurrence of pain within 3 weeks
• Post aural pain
• Fever
• Ear discharge
•Increased: Reservoir sign
•Decreased: Aditus block
• Decreased hearing
• Masked mastoiditis
– Absence of classical symptoms due to Antibiotic use

11. • Signs
– Pinna : protruded forwards and downwards
– Obliteration of postauricular groove
– Mastoid Tenderness
– Smooth ironed out feel of the mastoid
– Sagging of posterosuperior bony canal wall
– Reservoir sign : Purulent discharge refills EAC
after cleaning
– TM FINDINGS USUALLY UNRELIABLE !!!!!!

12. Pinna -Forward & Downward - Ironed Out Mastoid
- Obliteration of Retro auricular
Groove
bulge

13. ASOM ASOM + MASTOIDITIS

14. Investigations
• CBC: TLC and ESR raised
• X-ray Mastoid
– Historical Interest
•Clouding of air cells
•Indistinct partitions in air cells
•Irregular walled cavity
• HRCT temporal Bone
– Investigation of choice
• Pus Culture : Helps select appropriate antibiotic

16. 1. Sub- Periosteal
Mastoid Abscess
2. Bezold Abscess
3. Citteli’s Abscess
4. Luc Abscess
5. Zygomatic Abscess
6.Occipital Abscess
Abscesses in relation to Mastoid

17. • Post-aural Sub-periosteal Mastoid Abscess
– Most common abscess
– Most common site – Mac Ewan’s Triangle
– Cause: Direct Cortex erosion / through vessels in mastoida
cribrosa
– Occurs in ~ 50 % of cases of Acute Coalescent Mastoiditis
• Subcutaneous Mastoid Abscess + Fistula
• Bezold’s Abscess – Along sternocleidomastoid muscle
• Citelli’s Abscess – Along Posterior belly of digastric muscle

18. • Temporo -zygomatic Abscess
– Along root of Zygomatic bone
• Occipital Abscess
– Along Mastoid Emissary Vein
• Deep Neck Space Abscess
– Parapharyngeal, Carotid Space

19. Post- Aural Fistula Mastoid Abscess

20. Treatment
• Medical Treatment : First line
• Admission, Broad spectrum I.V. Antibiotics, AntiInflammatory
agents
• Surgical
– Indications
•No response to medical treatment in 24- 48 hours
•Poor response to 2 weeks of medical treatment
•Any new complication/abscess formation
– Myringotomy, I &D Of Abscess, Cortical mastoidectomy

21. Features Acute Mastoiditis Furunculosis
History of ASOM + ---
Pinna Forward, Downward Forward
Discharge Mucoid -- / purulent (thick)
Sagging EAC wall + --
TM congestion + --
X-ray Mastoid Haziness,
Coalescence of cells,
Irregular cavity
Diplopic/ Sclerotic
Pain Pinna -- +
Lymphadenopathy -- +
Tenderness Mastoid Antrum Diffuse

22. Acute Petrositis (Gradenigo’s syndrome)
• Involvement of petrous apex air cells (pneumatized
in 20% cases only)
• Difficult to manage due to
– Poor drainage
– Proximity to neurovascular structures
• Clinical Features
– Gradenigo’s Syndrome

24. 1. Persistent Ear Discharge in
spite of adequate cortical
mastoid surgery
2. Retro - Orbital Pain due to V
cranial nerve involvement
3. Medial Squint due to
Abducens Nerve involvement
Gradenigo’s Syndrome

26. Treatment
• Medical
•I.V. Antibiotics / Anti-Inflammatory agents
• Surgical
– Without residual hearing
•Trans-labyrinthine Route - Posterior cells
•Trans- cochlear Route - Anterior cells
– With residual hearing
•Retro-labyrinthine Route /Sub - arcuate Route - Posterior
cells
•Infra-cochlear Route /Sub- temporal Route - Anterior cells

27. • Erosion of Dome of Lateral Semicircular Canal
• Usually asymptomatic
• Symptomatic : Episodic Vertigo lasting for seconds to
minutes
• Fistula Test : Positive
(In all patients of CSOM with vertigo, a labyrinthine fistula must
be presumed unless proven otherwise)
Labyrinthine Fistula

28. • Management: Surgical Only
– CWD Mastoidectomy:
•Large Fistula>2mm
•Multiple Fistulae / Promontory Fistula
( DON’T REMOVE MATRIX )
– CWU Mastoidectomy:
•Small fistula < 2mm only
(MATRIX CAN BE REMOVED)

29. Facial Paralysis
• ASOM
– Congenital Dehiscence
– Edema within fallopian canal
– Purulent erosion of fallopian canal
• CSOM
– Cholesteatoma erodes fallopian canal
– Granulations
– Osteitis
• Cholesteatoma matrix may protect the facial nerve

30. • Investigation : HRCT Temporal Bone
• Treatment
– ASOM
•I.V. Antibiotics/Myringotomy /Cortical Mastoidectomy
•Facial nerve exploration & Decompression not needed
– CSOM
•Urgent Facial nerve exploration & Decompression
•Canal Wall Down Mastoidectomy and exploration of
facial nerve from 1st genu to stylo -mastoid foramen
•Repair of facial nerve : Re-routing, End to end
anastomosis ,Nerve grafting

31. Intra-cranial Complications
• Features
– High grade fever
– Altered sensorium
– Irritability
– Generalized malaise
– Photophobia
– Neck Stiffness
– Seizures / Focal Neurological Symptoms
– Deep Boring Headache

32. • Meningitis
– Most Common Intracranial
Complication
• Otogenic Intracranial Abscesses
– Extra-Dural Abscess
– Sub- Dural Abscess
– Brain Abscess
• Temporal lobe abscess
• Cerebellar abscess

33. Intra- Cranial Abscess
• 75% Brain Abscess - Otogenic
• CT/ MRI Diagnostic
• Treatment
– Antibiotics
– Dexamethasone (↓ Cerebral edema)
– Mannitol (Decrease CSF pressure)
– Mastoid Exploration
– Abscess Drainage - Burr Holes /
Craniotomy
Temporal lobe Abscess
Cerebellar abscess

34. 1. Superior Petrosal Sinus
2. Transverse Sinus
3. Sigmoid Sinus
4. Inferior Petrosal Sinus
Lateral sinus ( Sigmoid
sinus+ Transverse sinus)
Lateral Sinus Thrombophlebitis

35. Fate of thrombus in lateral sinus
thrombosis

36. • Clinical Features
• Symptoms
– Long standing discharging ear (foul smell)
– High and swinging fever (Picket fence) with chills and rigors
( simulating malaria)
– Headache ,otalgia, neck pain, torticolis
– Wasting illness
– Impaired mental awareness( drowsiness, lethargy, coma)
– Decreased vision

37. Signs
• Anemic ,wasted pt
• Ear discharge s/o CSOM AA
• Tenderness at the mastoid process and neck along the
sternomastoid muscle (Universal finding)
• Signs of meningeal irritation( 50% chance of other intracranial
complications)
• Papilledema : 50%
• Griesinger’s Sign
– Pitting edema over the occipital region behind the mastoid
process(d/t clotting within a large mastoid emissary vein)

38. • Investigations
• FBC : Anemia, raised WBC, raised ESR
• Blood culture
• Lumbar puncture if not contraindicated
• Crowe - Beck Test
– Compression of normal IJV  engorgement of
retinal vessels (seen on ophthalmoscopy)

39. • Tobey- Ayer test (Queckenstedt test) : Measuring the CSF
pressure and observing its changes on compression of one or
both IJV on the neck
– Normal subject: compression of each IJV rapid rise of
CSF ( 50-100mmH20) above normal level followed by rapid
fall on release, normal diff in 2 sides being <50mmH2O
– Lateral Sinus Thrombosis : Pressure over the vein draining
the occluded sinus  non or very slow rise of pressure (
10-20 mmH2O) but on Compression of normal IJV rapid
pressure rise 2 or 3 times the normal pressure
– False + and –ve results ( Low sensitivity and specificity)

40. • CT Scan of head Contrast
– Increased density of fresh clot/filling defects within the sinus
– Empty Delta sign : Intense inflammatory enhancement of
the sinus wall and adjacent dura but not the contents of the
sinus
• Digital subtraction Angiography /venography
– Site and extent of obstruction
• MRI
– Increased signal intensity in both T1 and T2
– Venous flow
• Radio-isotope scan (Ga) : Hot spots of sepsis, blocked venous
flow

42. Treatment
• High dose broad spectrum intravenous antibiotics
• Surgical : Complete mastoidectomy performed, sinus exposed
, abscess drained and clot is removed ( ENT emergency)
• Anticoagulants
– No regular place except Cavernous sinus thrombosis
• Internal Jugular vein ligation
– Septicemia not responding to antibiotics and surgery
– Children showing signs of embolisation

43. Otitic Hydrocephalus
• Occurs due to raised ICP due to failure of Arachnoid villi to
absorb CSF
• C/F
– Headache, nausea, vomiting, blurring of vision
– Lumbar Puncture: High pressure but normal lab findings
• Treatment
– Acetazolamide
– Dexamethasone
– Lumbar Drain, Lumbar - peritoneal Shunt

44. Brain Fungus
• Brain Herniation in Middle Ear / Mastoid usually after
mastoid surgery due to defect in the dura
• Common in pre-antibiotic era but rare nowadays
• Diagnosis
– CT scan of head and temporal bone
• Treatment
– Cautery & Removal of prolapsed brain & repair of
defect