Complications of csom dr.sithanandha kumar 29.02.2016

2. Dr . Sithananda Kumar.R
Complications Of otitis media

3. “Acute pain in the ear with continued high
fever is to be dreaded for the patient may
become delirious and die”

5. Define complications with reference to otitis media
Enumerate the complications
Identify a case of otitis media with complications
Evaluation & management of otitis media
with complications
OBJECTIVES

6. Spread of infection beyond the confines
of the mucosal spaces of middle ear
cleft
Definition

7. Complications of csom

8.  Meningitis
 Sigmoid sinus thrombosis
 Brain abscess
 Extradural abscess
 Subdural abscess
 Otitic hydrocephalus
Intra cranial complications

9. Mastoiditis
Petrositis
Labyrinthitis
Facial paralysis
Extracranial ( Intratemporal ) complications

10. Sub periosteal abscess
Bezold’s abscess
Zygomatic ( Luc’s abscess/ Meatal )
Digastric ( Cittelli’s abscess)
Extracranial ( Extratemporal ) complications

11. Attico antral disease ( cholesteatoma )
Highly virulent organism
Poor host immune response
Presence of preformed pathways for spread
Extremes of age
poor socioeconomic status
Predisposing factors

12.  Bone erosion
 Suppurative retrograde thrombophlebitis
 Preformed pathways
Routes of spread

13.  In ASOM-Hyperemic decalcification
 In CSOM-Cholesteatoma or granulation tissue.
Direct bone erosion

14. Suppurative retrograde thrombophlebitis

15.  Congenital dehiscence: facial canal and over the jugular bulb
 Patent sutures: Petro squamous suture
 Temporal bone fractures: fibrous scar permits infection
 Surgical defects: Stapedectomy, fenestration and exposure of dura
 Perilymphatic fistula: Congenital or acquired
 Normal anatomical openings: Oval and round windows
Internal acoustic meatus
Enlarged Cochlear aqueduct
Preformed pathways

16.  Ear pain
 Fever
 Severe headache
 Projectile vomiting
 Neck stiffness
 Photophobia
 Irritability / altered consciousness.
Features of impending complications

17.  when infection spreads from the mucosa lining the mastoid air cells
to involve bony walls of the mastoid air cell system
Mastoiditis

18. Acute coalescent mastoiditis

19. Clinical Features
Symptoms
 Earache
 Fever
 Ear discharge-profuse & purulent
Signs
 Mastoid tenderness
 Sagging of postero-superior meatal wall
 Eardrum perforation
 Swelling, redness and bulging over the mastoid ( ironed out mastoid )
 Hearing loss (conductive)
The persistence of otorrhea beyond 3 weeks in a case of AOM indicates mastoiditis

20.  HRCT Temporal Bone Aural swab for culture &
sensitivity
strept. pneumoniae
Beta hemolytic strept
pseudomonas
Investigations

21. Acute mastoiditis Furuncle
Ear discharge Mucoid / Mucopurulent BLOOD STAINED SEROUS
DISACHARGE
Ear pain Post Auricular Region In the EAC
Conductive hearing loss
Always Seen Only If Canal Fully Occluded
Tenderness Cymba concha
tenderness
Tragal tenderness
Post auricular groove
Pseudo deepening Obliterated
Tympanic membrane
Perforation Normal
EAC
Sagging of postero
superior bony meatal wall
Swelling in cartilaginous part

22.  Hospitalization
 I.V antibiotics
 Myringotomy
 Cortical mastoidectomy
TREATMENT

23.  Subperiosteal abscess
 Bezold’s abscess
 Cittelli's abscess
 Luc’s abscess
 Petrositis
 Labyrinthitis
 Facial paralysis
Sequelae of acute coalescent mastoiditis
Luc’s
abscess
Luc’s
abscess
Subperiosteal
abscess
Subperiosteal
abscess
Bezold’s abscessBezold’s abscess

25. Bezold’s abscess

26. slow destruction of mastoid air cells
acute sign and symptoms of acute mastoiditis are absent
Inadequate antibiotic therapy - Dose, frequency ,duration
pain, discharge, fever , mastoid swelling - Absent
mastoidectomy -Extensive destruction of the air cells
Granulation tissue
Dark gelatinous material filling the mastoid
Masked mastoiditis

27.  Petrous bone - pneumatized in about 30% individuals
 Two groups of air cells’ tracts -communicate mastoid and
middle ear to the petrous apex
 Postero superior tract: From the attic and antrum the tract
passes around semicircular canals to petrous apex
 Antero inferior tract: From the hypotympanum the tract
passes around the ET and cochlea to the petrous apex
 Infection may pass through these cell tracts and reach petrous
apex
Petrositis

28. Petrou
s
apex
Petrou
s
apex
antrumantrum

29. Cranial nerve VI palsy
Deep seated ear or retro-orbital pain
Persistent ear discharge
Due to Extra Dural pus collection
Persistent ear discharge in cases of post cortical or modified
radical mastoidectomy may be due to Petrositis.
Gradenigo’s syndrome or triad

30. Management
HRCT
I.V antibiotics
Surgical exploration

31. complication of both acute and chronic otitis media
Due to dehiscent facial canal-ASOM
Destruction of facial canal- CSOM-AAD
Treatment- in ASOM- myringotomy
- in CSOM- Cortical Mastoidectomy
Facial nerve paralysis

32.  Acute inflammation of the labyrinth
 Diffusion of toxins via the round window from the middle ear –
Serous Labyrinthitis
 Labyrinthine fistula caused by hyperemic decalcification-
Circumscribed Labyrinthitis
 Pyogenic infection of the labyrinth- suppurative Labyrinthitis
 Retrospective diagnosis –with treatment improves in serous
Labyrinthitis
LABYRINTHITIS

33. Inflammation of leptomeninges (pia-arachnoid)and CSF of
subarachnoid space
Most common intracranial complication
One third cases of meningitis are
Otogenic in origin
Otogenic meningitis

34.  Circumscribed meningitis: no bacteria in CSF.
 Generalized meningitis: bacteria are present in CSF

35. Serous stage: characterized by outpouring of fluid and
increased CSF pressure.
Cellular stage: characterized by increased number of
cells especially lymphocytes.
Bacterial stage: bacteria and polymorph nuclear
leucocytes are present in large numbers
stages of generalized meningitis

36. Rise in temperature (102–104°F) often with chills and rigors
Headache
Neck rigidity/stiffness
Photophobia and mental irritability
Nausea and vomiting (sometimes projectile)
Cranial nerve palsies and hemiplegia
Symptoms

37. neck rigidity
positive Kernig’s sign
positive Brudzinski’s sign
tendon reflexes are exaggerated initially but later
become sluggish or absent
papilloedema (usually seen in late stages).
Signs

39. HRCT Temporal bone
Funduscopic examination
Lumbar puncture is diagnostic:
CSF is cloudy and
CSF pressure is increased.
Contains bacteria and many polymorphs.
Protein concentration is raised but
Glucose and chlorides are decreased.
Investigations

41. Thrombophlebitis of the lateral venous sinus
Secondary to direct extension from a perisinus abscess
due to otitis media
Acute otitis media: Hemolytic streptococcus, Pneumococci
Cholesteatoma: Bacillus proteus, Pseudomonas pyocynea,
Escherichia coli and Staphylococci
Lateral sinus thrombosis

44. CLINICAL FEATURES
 Fever (spiking) with rigors and chills-PICKET FENCE FEVER
 Positive Greisinger’s sign
 Signs of increased ICT: Headache, vomiting, and papilledema
 Clot extension to the jugular vein- vein felt in the neck as a tender
cord.

45. Diagnosis
 CT scan with contrast - “delta” sign
 MRI
 Angiography
 Blood cultures is positive during the febrile phase.

46. Treatment
Medical:
• High dose IV antibiotics and supportive treatment
• Anticoagulants
Surgical:
• Mastoidectomy with exposure of the affected sinus and
the intra-sinus abscess is drained.

48.  focal suppurative process within the brain parenchyma
surrounded by a region of encephalitis
 Involve temporal lobe, cerebellum, parietal lobe and
occipital lobe
 Multiple organisms isolated– anaerobes , streptococcus,
staphylococcus , E.coli , Klebsiella , pseudomonas
 Most lethal complication of suppurative otitis media
Otogenic brain abscess

49. Stages of brain abscess
 Early cerebritis (invasion)
 Late cerebritis (localization)– quiescent
 Early capsule formation (enlargement)-manifest
 Late capsule formation (termination)

54. Brain abscess…
 First stage
Fever with chills, headache & nausea , non projectile vomiting,
Apathy , drowsiness, convulsion, neck stiffness.
 Second stage
Malaise , poor appetite, intermittent headache, listlessness,
drowsiness
 Third stage
Severe headache, projectile vomiting, bradycardia
Chyne stroke breathing, fever, disorientation, Jacksonian fits
ocular paralysis, papilledema

55. Treatment
Medical:
• Broad-spectrum antibiotics
• Measures to decrease intracranial pressure
Surgical:
• Neurosurgical drainage or excision of the abscess
• Mastoidectomy operation after subsidence of the acute stage.

56. Brain abscess..
Treatment:-
 Aqueous Penicillin G + Metronidazole
or
 Third generation Cephalosporin + Metronidazole
 I/V Dexamethasone
 I.V mannitol
 Antibiotics for 4-6 weeks

57. Otitic hydrocephalus

58. Syndrome associated with raised intracranial pressure,
normal CSF findings, spontaneous recovery& no abscess
(Symonds)
Head ache, sixth nerve palsy, papilloedema
Treatment – acetazolamide , steroids
Ventriculoperitoneal shunt
Otitic hydrocphelus

59. Extradural/ subdural empyema

60. CONCLUSION