Complications of Chronic Otitis Media

1. Complications Of CSOM
1
DR.PRASANNA DATTA

2. Classification
2
• Intra cranial
• Extra-cranial, Intra-temporal

3. Factors affecting
3
Pathogen Factors
• High virulence bacteria
• Antimicrobial resistance
Patient Factors
• Young age/Elderly
• Poor immune status
• Chronic disease(DM,TB)
• Poor socio-economic status

4. Routes of entry
4
• Bony erosion (cholesteatoma,osteitis)
• Anatomical pathway: oval window, round window,
internal auditory canal, suture line, cochlear &
vestibular aqueduct
• Retrograde Thrombophlebitis
• Congenital bony defects: facial canal, tegmen plate
• Acquired bony defects: fracture, neoplasm,
stapedectomy

5. Extra-Cranial
5

6. Mastoiditis
6
• It is the inflammation of mucosal lining of mastoid antrum
and air cells system.
• Pathology
o Production of pus under tension
o Hyperaemic decalcification
o Osteoclastic resorption of bony walls

7. Clinical Features
• Otorrhoea > 2 weeks, otalgia & deafness
• Mastoid reservoir sign: pus fills up on mopping
• Sagging of postero-superior canal wall
• Ironed out appearance of skin over mastoid due to
thickened periosteum
• Mastoid tenderness
Investigation
• X-ray & CT scan
7

8. 8

9. Mastoid reservoir sign Sagging of posterior wall
9

10. Ironed out appearance Mastoid cavity
10

11. Treatment
11
• Urgent hospital admission
• Broad spectrum I.V. antibiotics
No response to medical treatment in 48 hrs
• Cortical Mastoidectomy

12. Facial Nerve
Paralysis
12

13. • Seen in AOM,COM(both mucosal and squamosal
variety)
• Predisposing factors:
1.congenital dehescence of FC
2.canal erosion by cholesteatoma/granulation
13

14. • AOM: sudden onset, full recovery
• COM: gradual onset, paralysis persist(erosion)
14
Treatment:
• Medical(Corticosteroids)
• Modified Radical Mastoidectomy(Sq CSOM)
• Facial nerve decompression if required
• Physioyheraphy

15. Labrynthitis
15

16. • Inflammation of bony labyrinth
Route of infection:
• Round window membrane
• Pre-formed opening (Stapedectomy)
• Retrograde spread of meningitis
types:
• Serous labyrinthitis
• Otogenic suppurative labyrinthitis
• Meningitic suppurative labyrinthitis
16

17. • Serous labyrinthitis occurs during acute or chronic
otitis media. It is presumed that bacterial exotoxins
enter the inner ear via the oval or round window or a
labyrinthine fistula.
• there is no clinical method for differentiating serous
from suppurative labyrinthitis. If vestibular and
auditory functions are partially or completely
retained, it can be assumed that the infection was
serous.
17

18. Treatment
18
• Bed rest (affected ear up). Avoid head movement.
• Labyrinthine sedative: Prochlorperazine, Cinnarizine
• Broad spectrum I.V. antibiotics
• Modified Radical Mastoidectomy: removes infection

19. PETROSITIS
19

20. • Spread of infection from middle ear and mastoid to the
(peumatised) petrous part of temporal bone.
• Petrous bone are of three types;
1.Well peumatised(25-30%)
2. Diploic
3. Sclerotic(Most common)
20

21. Gradenigo syndrome
21
• It is triad of,
• Persistent otorrhoea
• Retro-orbital pain: Trigeminal nerve involvement
• Diplopia: Convergent squint due to lateral rectus palsy
by injury to abducent nerve

22. Etiology:
22
• mastoiditis involving petrous apex along postero-
superior & anteroinferior tracts in relation to bony
labyrinth
• Anteroinferior tract : starts at the hypotympanum
near the eustachian tube runs around the cochlea to
reach the petrous .
• Posterosuperior tract :starts in the mastoid and
runs behind or above the bony labyrinth to the
petrous apex.

23. Diagnosis:
23
• C.T. scan temporal bone
• M.R.I. to differ b/w bone marrow & pus
Treatment:
• Modified radical mastoidectomy & clearance of petrous
apex cells

24. Sub-Periosteal
abscess & Fistula
24

25. Pathology
Production of pus under tension
hyperaemic decalcification (halisteresis)
osteoclastic resorption of bone
sub-periosteal abscess
penetration of periosteum + skin
fistula formation
25

26. Sub-periosteal fistula: dry Sub-periosteal fistula: wet
26

27. Types of sub-periosteal
abscess
27
• Post-auricular
• Bezold
• Citelli
• Zygomatic
• Luc

28. Post-auricular Abscess
• Commonest.
• Present behind
the ear.
• Pinna pushed
forward &
downward.
28

29. • Luc: swelling in external auditory canal
• Bezold absceses-swelling over sternocleidomastoid
muscle
• Citelli absceses-swelling over posterior belly of
digastric muscle
• Parapharyngeal & Retropharyngeal: due to spread of
pus along Eustachian tube
29

30. Intra Cranial
30

31. Meningitis
31
It defined as inflammation of leptomeninges (Pia &
Arachnoid) with bacterial invasion of CSF in
subarachnoid space.

32. Mode of invasion
32
• Preformed pathway (patent petro squamus suture or
labyrinth)
• Venous thrombophlebitis
• Direct erosion of bone by cholesteatoma

33. Clinical features
1. Fever with chills and rigor
2. Headache
3. Neck rigidity
4. Photophobia, irritability
5. Nausea, Vomiting
33

34. On examination
1. Kernig’s sign– Extension of leg with thigh flexed
causes pain
2. Brudzinski’s sign– Flexion of neck causes flexion
of hip and knee.
3. Exaggerated tendon reflex
4. Papilloedema
34

35. Otogenic brain abscess
35
• 50-70 % adult & 25% in child abscess are otogenic
• Route of infection:
1. Direct spread:
• via Tegmen plate: Temporal abscess
• via Trautmann’s triangle: Cerebellar abscess
2. Retrograde thrombophlebitis

36. Trautmann’s Triangle
• Superiorly: superior
petrosal sinus
• Posteriorly: sigmoid sinus
• Anteriorly: semi-circular
canals)
• Pathway to posterior
cranial fossa from
mastoid cavity
36

37. Stages of Brain Abscess
37
• Early cerebritis(invasion)- 1-3 days
• Late cerebritis(Localization)-4-10days
• Early capsule formation(Enlargement)-10-13 days
• Late capsule formation(termination)-14 days.

38. Investigations
38
• CT scan of brain
• MRI brain
• Avoid lumbar puncture to prevent coning

39. Medical Treatment
39
• High dose broad spectrum I.V. antibiotics:
Ceftriaxone + Metronidazole + Gentamicin
• I.V. Dexamethasone : reduce oedema
• I.V. Mannitol : reduce I.C.T.
• Anti-epileptics: Phenytoin sodium
• Antibiotic ear drops & aural toilet

40. Surgical Treatment
40
• Repeated burr hole aspirations
• Excision of brain abscess with capsule
• Open incision & evacuation of pus
• Radical mastoidectomy after pt becomes stable

41. Otitic Hydrocephalus
41
• Defined as raised intracranial pressure with normal
CSF finding
• Seen in children and adolescent with acute and
chronic middle ear infection

42. Mechanism
Retrograde extension of thrombophibittis from
sigmoid sinus to superior sagittal sinus
Blockage of arachnoid villi
Dec CSF absorption/Inc Secretions
Raised CSF pressure
42

43. Symptoms
43
• Severe headache,
• Drowsines
• Vomiting
• Blurring of vision,Diplopia
Signs
• Papilloedema
• Nystagmus
• CSF pressure > 300 mm of water.

44. Treatment
44
I.V. antibiotics & MRM
• Reducing CSF pressure (prevents optic atrophy) by:
I.V. Dexamethasone
I.V. Mannitol
Repeated lumbar puncture / lumbar drain
Ventriculo-peritoneal shunt

45. Extradural Abscess
45
• It is collection of pus between dura matter and the
bone of the IC
Pathology
• Bone over the dura destroyed by decalcification
(Acute) or cholesteatoma (Chronic)
• Spread of infection by venous thrombophlebitis
Clinical features
1. Persistent headache
2. Severe pain in the ear
3. Low grade fever and malaise.

46. Subdural abscess
46
• Collection of pus between dura and arachnoid
• Erosion of bone and dura by thrombophlebitic
process
• Pus may get loculated at various places in subdural
space
Clinical features –
1. Due to meningeal irritation – Fever, malaise,
headache, neck rigidity, positive kernig’s sign
2. Due to raised intra cranial tension – papilloedema,
ptosis.

47. Lateral sinus thrombosis
47
• Syn – Sigmoid sinus thrombosis
• Definition – It is an inflammation of inner wall of
lateral venous sinus with thrombus formation.
• Aetiology –CSOM with cholesteatoma.

48. Pathology
1. Formation of perisinus abscess(outer wall sinus)
2. Endophlebitis and mural thrombus formation(inner
Wall)
3. Thrombus enlarges to Obliterate the sinus lumen
and leads to intrasinus abscess
4. Extension of the thrombus-Septicemia.
48

49. • Clinical features
• Rise of temperature
• Headache, neck pain
• Papilloedema
• Tenderness along jugular vein
Investigation –
 CSF examination
 X-ray mastoid
 CECT scan, MRI
 Culture and sensitivity of ear swab
49

50. THANK YOU
50