This is a presentation about complications of otitis media. It is aimed towards helping the undergraduates and postgraduates pursuing medicine and otolaryngology.

1. COMPLICATIONS
OF OTITIS MEDIA

2. HISTORICAL NOTES
● Hippocrates (460 B.C)
“Acute pain of the ear with
continued high fever is to be
dreaded for the patient may
become delirious & die”

3. ● Roman physicist celcus (25 AD)
“Inflammation & pains of the ear lead sometimes to insanity &
death”.
● Arabian physician Avicenna (980-1037 AD) stated that the ear
discharge was due to the brain disease.
● Morgagni (1682-1771), noted that the ear infection comes first
before the brain abscess.
● McEwen in 1881 showed great surgical success - 18 patients
recovered out of 19 operated cases of brain abscess.

4. Factors influencing development of complications
● Infective organism
● Virulence
● Susceptibility to antibiotics
● Adequacy of medication
● Resistance of host
● Type of pneumatization
● History of previous otitis media.

5. DEFENSE MECHANISM
● Ability of mucous membrane to localise & overcome infection.
● Intact bony walls of tympanic cavity & pneumatic cells.
● Granulation tissue.

6. PATHWAYS OF SPREAD
OSTEO
THROMBOPHLEBITIS
BONE EROSION
PREFORMED PATHWAYS

7. OSTEOTHROMBOPHLEBITIS
➢ Infection pass from lining mucosa of the middle ear & mastoid
through intact bone by progressive thrombophlebitis of small
venules.
➢ Occur in acute middle ear infection or acute exacerbations of
chronic infection.
➢ Complication occurs early.
➢ Prodromal period is lacking.
➢ Bony walls of the middle ear & mastoid is intact.
➢ Bone & mucoperiosteum lining of mastoid air cells are inflamed and
bleed easily.

8. BONE EROSION
➢ Nearly always the manner of spread in COM.
➢ Complication occurs several weeks later.
➢ A prodromal period of partial or intermittent involvement precedes
diffuse involvement.
➢ At operation, dehiscence of the bony barrier is found.
➢ A layer of granulation cover the exposed soft tissue of neighbouring
structure.
➢ Treatment should always include the removal of suppurating, bone
eroding focus.

9. PREFORMED PATHWAYS
● Normal anatomical pathways.
● Developmental dehiscence.
● Acquired.

10. COMPLICATIONS
● MENINGITIS
● OTOGENIC BRAIN ABSCESS
● OTOGENIC SUPPURATIVE THROMBOPHLEBITIS
● OTITIC HYDROCEPHALUS
● SUBDURAL EMPYEMA
● EPIDURAL (EXTRADURAL) ABSCESS

12. MENINGITIS
❖ MC intracranial complication of otitis media.
❖ Spreads directly through necrotic bone of middle ear.
❖ As a complication of suppurative labyrinthitis, through Internal
Acoustic meatus, vestibular & cochlear aqueducts.

13. contd...
Pia-arachnoid inflamed
Outpouring of fluid in the subarachnoid space
Raised intracranial pressure
White blood cells & multiplying organisms in CSF
Irritation of upper cervical nerve roots

15. symptoms:
❖ Headache
❖ Fever
❖ Vomiting
❖ Photophobia
❖ irritability
❖ Neck pain
❖ Stiffness
❖ General hyperesthesia

16. SIGNS:
❖ KERNIG SIGN
❖ BRUDZINSKI SIGN

17. INVESTIGATIONS
❖ HRCT.
❖ MRI with gadolinium contrast.
❖ Lumbar puncture
➢ Turbid,purulent
➢ Glucose nearly to zero
➢ Protein content
➢ Polymorphs in CSF
➢ Gram staining
➢ Culture & sensitivity.

18. TREATMENT
❖ HIGH DOSE ANTIBIOTICS
➢ Empirical therapy:
3rd generation cephalosporins + vancomycin.
❖ CORTICOSTEROIDS
➢ A 4 day regime of 0.6 mg/kg/day in four divided doses
started before or with the antibiotics.
SURGERY : surgical exterenation of the diseased mastoid once
patient is stabilised.

19. OTOGENIC BRAIN ABSCESS
➢ Focal suppurative process within the brain parenchyma
surrounded by a region of encephalitis.
➢ Often the result of venous thrombophlebitis rather than direct
dural extension.
➢ Can occur in temporal lobe or cerebellum.
➢ Polymicrobial culture including anaerobes:
○ Gram +ve-> streptococcus & staphylococcus species
○ Gram -ve -> E coli, proteus, klebsiella & pseudomonas.
○ Anaerobic -> bacteroides.

20. STAGES

21. SYMPTOMS
● GENERAL : toxic, drowsy, deep bony pain, triad of headache,
high grade fever, focal neurological deficits,papilloedema.
● TEMPORAL LOBE ABSCESS:
○ seizures.
○ Nominal aphasia.
○ Quadrantic Homonymous hemianopia.
○ Motor paralysis of contralateral side.
● CEREBELLAR ABSCESS:
○ Ataxia.
○ Nystagmus.
○ Dysmetria.
○ Dysdiadochokinesia.

22. INVESTIGATIONS
CT BRAIN WITH CONTRAST: RING SIGN
-

23. TREATMENT
➢ MEDICAL
○ High dose IV broad spectrum antibiotics
○ Dexamethasone
○ Anti epileptic- phenytoin.
➢ SURGICAL:
○ Neurosurgical intervention of draining the abscess is quintessential
○ Once the patient is stable , mastoidectomy can be done.

24. OTOGENIC SUPPURATIVE THROMBOPHLEBITIS
➢ Simultaneous presence of venous thrombosis & suppuration in
the intracranial cavity.
➢ Often associated with perisinus extradural abscess.
➢ Can also occur by osteo thrombophlebitic extension via small
venules.
➢ The infected mural thrombus can extend cranially to sagittal
sinus or cavernous sinus via superior & inferior petrosal sinus.
➢ It can also extend caudally to Internal Jugular vein thereby to
the right atrium.

25. DURAL VENOUS SINUSES

27. PATHOGENESIS
Erosion of the bone covering the sigmoid sinus
Immune status of host osteothrombophlebitic extension
Perisinus abscess/inflammation
Inflammation of outer wall (dura) of sinus
Inflammation of intima (inner wall of sinus)
Platelet, RBCs,fibrin,WBCs
Adhere to inflamed area
MURAL THROMBUS
Mural thrombus propagates, obliterating lumen

28. CLINICAL FEATURES
➢ Picket fence fever, with diurnal temp exceeding 103℉
➢ Headache
➢ Griesinger ’s sign
➢ Papilloedema
➢ Vision loss
➢ Tenderness along the anterior border of sternomastoid muscle
➢ Proptosis & chemosis - CST
➢ Otalgia
➢ Queckenstedt or Tobey-ayer test.

30. INVESTIGATION
➢ Blood culture
➢ Lumbar puncture test
➢ CECT - DELTA “𝚫” sign in lateral sinus thrombosis
➢ MR angiography.

31. TREATMENT
➢ High dose antibiotics
➢ Anticoagulation if CST
present.
➢ Surgical exploration &
removal of clot.
➢ Internal jugular vein ligation.

32. OTITIC HYDROCEPHALUS
➢ Raised intracranial pressure with normal CSF findings.
➢ Benign raised intracranial tension.
➢ Commonly associated with sigmoid sinus thrombosis.
➢ Spontaneous recovery.

33. MECHANISM
➢ SYMOND: retrograde extension of thrombophlebitis from sigmoid sinus
to superior sagittal sinus
Blockage of arachnoid villi
CSF absorption & secretion
➢ Increase in CSF volume
➢ Secondary to brain edema
➢ Disruption in venous circulation.

34. CLINICAL FEATURES
➢ Headache
➢ Drowsiness
➢ Vomiting
➢ Blurring of vision
➢ Diplopia
➢ Papilloedema
➢ 6th cranial nerve palsy
➢ Optic atrophy

35. INVESTIGATIONS
➢ LUMBAR PUNCTURE
○ Elevated CSF pressure with normal biochemistry.
○ Done with caution.
➢ CT SCAN
➢ MRI:
○ Imaging modality of choice.
○ Allows superior evaluation of venous sinuses.

36. TREATMENT
➢ Eradicate ear disease.
➢ Lowering of CSF pressure:
○ Decompression of sigmoid sinus.
○ CSF drainage procedures.
○ Optic sheath decompression : to prevent optic atrophy.
➢ MEDICAL:
○ Corticosteroids.
○ Mannitol.
○ Acetazolamide.
○ Diuretics.

37. EPIDURAL (EXTRADURAL) ABSCESS
➢ Occurs after bone demineralisation or bone erosion adjacent to the
middle or posterior fossa sura.
➢ Middle fossa extradural abscess:
○ Lateral: erosion of tegmen tympani, strip a large area of dura
from the inner surface of squamous temporal bone.
○ Medial: infection of petrous apex causes middle fossa
extradural abscess medial to arcuate eminence, irritates
trigeminal nerve & 6th cranial nerve. ( gradenigo syn).
➢ Posterior fossa extradural abscess:
○ In close association with lateral sinus.
○ Spread is laterally limited by internal acoustic meatus.

38. CLINICAL FEATURES
➢ Usually asymptomatic
➢ Gradenigo syndrome:
○ Otorrhea
○ Retro orbital pain
○ Diplopia
➢ Persistent headache on the side of otitis media.
➢ General malaise with low grade fever.
➢ Disappearance of headache with free flow of pus from the ear (
spontaneous abscess drainage).

39. ➢ DIAGNOSIS:
Contrast enhanced CT or MRI.
➢ TREATMENT:
Antimicrobial therapy.
Surgical exploration.

40. SUBDURAL EMPYEMA
➢ Collection of pus between dura and arachnoid mater.
➢ Spread of infection through the dura with formation of granulation
tissue in the subdural space.

41. PATHOLOGY:
OTITIS MEDIA
EROSION OF TEGMEN BRAIN ABSCESS THROMBOPHLEBITIS
EROSION OF DURA BRAIN ABSCESS RUPTURES
INFECTION IN SUBDURAL SPACE
EXPANDING MASS LESION

42. CLINICAL FEATURES
➢ Meningeal irritation:
○ Fever.
○ Headache.
○ Malaise, drowsiness.
○ Kernig sign
➢ Thrombophlebitis:
○ Aphasia
○ Hemianopia
○ Hemiplegia
○ Jacksonian convulsions
➢ Raised ICP
○ 3rd nerve involvement
○ papilloedema

43. DIAGNOSIS by CT or MRI
➢ TREATMENT:
○ Surgical drainage of abscess.
○ High dose IV antibiotics.
○ Once stabilised neurologically, then underlying ear disease
managed.
○ Antiepileptic medication

44. Extracranial (intratemporal) complications
● Mastoiditis
● Petrositis
● Labyrinthitis
● Facial paralysis

45. Extracranial ( extratemporal) complications
● Subperiosteal abscess
● Bezold’s abscess
● Zygomatic ( Luc’s abscess/Meatal)
● Digastric ( Citelli’s abscess)

46. ACUTE MASTOIDITIS
● It is the extension of middle ear inflammation into antrum &
mastoid air cells.
● Mastoid antrum & epitympanum communicate freely through
aditus ad antrum.
● Common in children.
● Causative organisms include strep. pneumoniae , strep
pyogenes, staph aureus, Haemophilus influenzae, and
pseudomonas aeruginosa.

47. Pathogenesis
● Following otitis media - tympanomastoiditis.
● Blockade of aditus - loculation of mucopurulent material within
antrum and air cells.
● Persistent blockade of aditus - retrograde thrombophlebitis -
edema and cellulitis of tissues overlying mastoid.
● If pus not drained - necrosis and demineralisation of bony
trabeculae - ‘coalescent mastoiditis’.
● Where the entire mastoid becomes a single cavity filled with pus.

48. Clinical features
Symptoms:
● Earache
● Fever
● Ear discharge - profuse and purulent
Signs:
● Mastoid tenderness.
● Sagging of postero-superior meatal wall
● TM perforation
● Swelling, redness, bulging over the mastoid (ironed out mastoid)
● Hearing loss ( conductive)

49. investigations
● Aural swab for culture & sensitivity
● HRCT temporal bone

50. TREATMENT
● Hospitalization.
● IV antibiotics.
● Myringotomy.
● Cortical mastoidectomy.

51. Sequelae of acute coalescent mastoiditis
● Subperiosteal abscess
● Bezold’ abscess
● Citelli’s abscess
● Luc’s abscess
● Petrositis
● Labyrinthitis
● Facial paralysis
● Meningitis
● Brain abscess
● Sigmoid sinus thrombophlebitis.

52. Sites of pneumatization of mastoid air cell system in
relation to types of mastoid abscess

53. MASKED MASTOIDITIS
Slow destruction of mastoid air cells.
Acute sign & symptoms of acute mastoiditis are absent.
Inadequate antibiotic therapy - dose, frequency, duration.
Pain, discharge, fever, mastoid swelling - absent.
Mostly progress to complication.
Mastoidectomy - extensive destruction of air cells
Granulation tissue
Dark gelatinous material filling the mastoid.

54. PETROSITIS
Inflammation of pneumatized spaces of the petrous part of the temporal
bone.
Petrous bone - two groups of air cell tracts- communicate mastoid &
middle ear to the petrous apex.
Postero superior tract: in continuity with mastoid antrum, epitympanum
that clusters around semicircular canals at the base of pyramid.
Antero inferior tract: In continuity with the mesotympanum,
protympanum, and hypotympanum & passes around the cochlea to
petrous apex.
Petrositis may be acute or chronic.

55. ● Acute petrositis
● Middle ear inflammation- antrum and mastoid
air cells - medial progression involving petrous
pyramid.
● If inflammatory products are retained- osteitis
of petrous apex .
● Gradenigo syndrome -
● Ear discharge
● Retro Orbital pain (Trigeminal nerve)
● Diplopia ( lateral rectus palsy -
Abducens nerve)
● Chronic petrositis
● In addition to inflammatory changes - new bone
formation & resorption

56. Management :
Investigations:
● CT temporal bone.
Treatment :
● Systemic antibiotics.
● Radical mastoidectomy with skeletonization
of semicircular canals to remove disease
from middle ear and petrous apex.
● Approaches to petrous apex
● Eagleton’s approach.
● Thornwalt’s operation.
● Almoor’s approach.
● Ramadier’ s operation.
● Freckner’s operation.

57. Surgical approaches to petrous apex

58. FACIAL NERVE PARALYSIS
Complication of both acute and chronic otitis media.
ROUTES OF SPREAD:
● Natural dehiscence - dehiscence of fallopian canal.
● Natural pathways - ex, canal for stapedius, neurovascular bundle.
● Direct extension - ex, osteitis around fallopian canal.
Toxins and ischemia probably have an ancillary role.
TREATMENT:
In AOM- myringotomy & appropriate antibiotic for 10 days.
In COM - CWD mastoidectomy with decompression of the fallopian
canal, antibiotics.

59. LABYRINTHITIS
Inflammation of inner ear/ labyrinth.
Pathogenesis:
-spread through round window, fistula, preformed pathways.
-inflammatory products pass into perilymph of scala tympani by
diapedesis from adjacent labyrinthine vessels.
- fibrillary precipitate accumulates in perilymphatic and
endolymphatic spaces.

60. Symptoms & signs
● Vertigo
● Loss of balance
● nausea/ vomiting
● nystagmus
● High frequency SNHL
● Hearing distortion
● diplacusis

61. Treatment
● Complete bed rest - with restriction of head movement
● Parenteral chlorperazine / cinnarizine
● Dehydration - IV fluids.
● IV antibiotics.
● Acute infection - Myringotomy
● Chronic infection - mastoid exploration

62. Labyrinthine fistula
Complication of COM
Results from erosion of endochondral bone of bony labyrinth- movement
of perilymph and structures of endolymphatic compartments when
pressure in EAC changes.
Most commonly - dome of lateral SCC.
Cholesteatoma found in all cases.
Incidence of fistula in cholesteatoma is 7-10%

63. symptoms/signs
● Short periods of imbalance.
● Vertigo
● Tullio’s phenomenon - feeling of imbalance on sudden exposure to
loud noises.
● Fistula sign - positive.
● Investigations
● CT - erosion of lateral SCC
● cholesteatoma

64. Treatment
Canal wall down mastoidectomy
- All cholesteatoma is removed except for small area around fistula
site. After careful removal of cholesteatoma debri without
disturbing matrix. Matrix is elevated. A small piece of tissue / thin
cap of bone placed over site and secured with fibrin glue / packing
after the cholesteatoma is removed.
- Risk of removing cholesteatoma from fistula is total / partial loss of
hearing.

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