complications of suppurative otitis media l.
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Complications of Suppurative Otitis Media. Dr. Vishal Sharma. Definition . 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.

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definition
Definition

Infection spreadsbeyond muco-periosteal lining of middle ear cleftto involve bone & neighboring structures like facial nerve, inner ear, dural venous sinuses, meninges, brain tissue & extra-temporal soft tissue.

features of complications
Features of Complications
  • Severe otalgia, painful swelling around ear
  • Vertigo, nausea, vomiting
  • Headache + blurred vision + projectile vomiting
  • Fever + neck rigidity + irritability / drowsiness
  • Facial asymmetry
  • Otorrhoea + Retro-orbital pain + diplopia
  • Ataxia
classification
Classification
  • Intra-cranial
  • Extra-cranial, Intra-temporal
  • Extra-cranial, Extra-temporal
  • Systemic: septicemia, otogenic tetanus
intra cranial complications
Intra-cranial Complications
  • Extra-dural abscess
  • Subdural abscess
  • Meningitis
  • Brain abscess
  • Lateral Sinus thrombophlebitis
  • Otitic hydrocephalus
  • Brain fungus (fungus cerebri)
intra temporal complications
Intra-temporal Complications
  • Acute mastoiditis
  • Coalescent mastoiditis
  • Masked mastoiditis
  • Facial nerve palsy
  • Labyrinthitis
  • Labyrinthine fistula
  • Apex Petrositis (Gradenigo syndrome)
extra temporal complications
Extra-temporal Complications
  • Post-auricular abscess
  • Bezold abscess
  • Citelli abscess
  • Luc abscess
  • Zygomatic abscess
  • Retro-mastoid abscess
factors affecting
Factors Affecting

Pathogen FactorsPatient Factors

 High virulence bacteria  Young age

 Antimicrobial resistance  Poor immune status

 Chronic disease (DM, TB)

Physician Factors Poor socio-economic status

 Non-availability Lack of health awareness

 Injudicious antibiotic use

 Error in recognizing dangerous symptoms & signs

routes of entry
Routes of entry

1. Bony erosion (cholesteatoma destruction, osteitis)

2. Retrograde Thrombophlebitis

3. Anatomical pathway: oval window, round window, internal auditory canal, suture line, cochlear & vestibular aqueduct

4. Congenital bony defects: facial canal, tegmen plate

5. Acquired bony defects: fracture, neoplasm, stapedectomy

6. Peri-arteriolar space of Virchow-Robin: spread into brain

pathogenesis
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

clinical features investigation
Clinical Features & Investigation
  • Otorrhoea > 2 weeks, otalgia & deafness
  • 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
  • Mastoid cavity in X-ray & CT scan
treatment
Treatment
  • Urgent hospital admission
  • Broad spectrum I.V. antibiotics

 No response to medical treatment in 48 hrs

 Development of new complication

 Presence of sub-periosteal abscess

    • Myringotomy to drain out painful pus
    • Incision drainage of sub-periosteal abscess
    • Cortical Mastoidectomy
pathology
Pathology

Production of pus under tension

 hyperaemic decalcification (halisteresis)

+ osteoclastic resorption of bone

 sub-periosteal abscess

 penetration of periosteum + skin

 fistula formation

types of sub periosteal abscess
Types of sub-periosteal abscess
  • Post-auricular
  • Bezold
  • Citelli
  • Zygomatic
  • Luc
  • Retro-mastoid
  • Parapharyngeal & Retropharyngeal
post auricular abscess
Post-auricular abscess

Commonest. Present behind the ear.

Pinna pushed forward & downward.

bezold citelli abscesses
Bezold & Citelli abscesses

Bezold: neck swelling

over sternocleido-

mastoid muscle

Citelli:neck swelling

over posterior belly

of digastric muscle

d d of bezold s abscess
D/D of Bezold’s abscess
  • Suppurative lymphadenopathy of upper deep cervical lymph node
  • Para-pharyngeal abscess
  • Parotid tail abscess
  • Infected branchial cyst
  • Internal jugular vein thrombosis
slide33
Luc: swelling in external auditory canal

Zygomatic:swelling antero-superior to pinna +

upper eyelid oedema

Retro-mastoid: swelling over occipital bone

(? Citelli’s abscess)

Parapharyngeal & Retropharyngeal: due to spread

of pus along Eustachian tube

gradenigo syndrome
Gradenigo syndrome

 Persistent otorrhoea:despite adequate

cortical mastoidectomy

 Retro-orbital pain: Trigeminal nv involvement

 Diplopia: convergent squint due to lateral rectus

palsy by injury to abducent nv in Dorello’s canal under

Gruber’s petro-sphenoid ligament, at petrous apex

right convergent squint
Right Convergent squint

Right gaze

Central gaze

Left gaze

slide39
Etiology:Coalescent mastoiditis involving petrous apex along postero-superior & antero-inferior tracts in relation to bony labyrinth

Diagnosis: 1. C.T. scan temporal bone for bony

details. 2. M.R.I. to differ b/w bone marrow & pus

Treatment:Modified radical mastoidectomy & clearance of petrous apex cells

slide41
Hearing preserving approaches to petrous apex
  • Eagleton’s middle cranial fossa approach
  • Frenckner’s subarcuate approach
  • Thornwaldt’s retro-labyrinthine approach
  • Dearmin & Farrior’s infra-labyrinthine approach
  • Farrior’s hypotympanic sub-cochlear approach
  • Lempert Ramadier’s peri-tubal approach
  • Kopetsky Almoor’s peri-tubal approach
slide43
Hearing sacrificing approaches to petrous apex
  • Trans-cochlear approach
  • Trans-labyrinthine approach
introduction
Introduction

Inflammation of endosteal layer of bony labyrinth

Route of infection:

 Round window membrane

 Pre-formed opening (Stapedectomy)

 Retrograde spread of meningitis via IAC / aqueducts

Clinical forms:

1. Circumscribed (labyrinthine fistula)

2. Diffuse serous 3. Diffuse suppurative

slide47
Circumscribed: Fistula commonly involves lateral SCC. Presents with transient vertigo & positive fistula test  I/L nystagmus with +ve pressure; C/L nystagmus with -ve pressure
  • Serous: Reversible, non-purulent, mild vertigo, I/L nystagmus, mild sensori-neural hearing loss
  • Purulent: Irreversible, purulent, severe vertigo, C/L nystagmus, severe / profound hearing loss
slide48
Treatment:

Bed rest (affected ear up). Avoid head movement.

Labyrinthine sedative:Prochlorperazine, Cinnarizine

Broad spectrum I.V. antibiotics

Modified Radical Mastoidectomy:removes infection

Open labyrinthine fistula:cover with temporalis fascia

Fistula covered with cholesteatoma matrix

< 2 mm: remove matrix & cover with temporalis fascia

> 2 mm / multiple / over promontory:leave it

Rehabilitation by Cawthorne-Cooksey Exercises

facial nerve paralysis
Facial nerve paralysis
  • Within 1st wk: due to nerve sheath edema
  • After 2 wks: due to bone erosion
  • Lower motor neuron palsy
  • Common in tubercular otitis media

Treatment:

  • Modified Radical Mastoidectomy
  • Facial nerve decompression seldom required
slide53
High grade persistent fever with rigors
  • Severe headache & neck stiffness
  • Irritability  drowsiness  confusion  coma
  • Neck rigidity positive
  • Kernig sign positive; Brudzinski sign positive
  • Papilloedema
  • Lumbar Puncture:cell count,  protein,  sugar
  • I.V. Ceftriaxone + Metronidazole + Gentamicin
  • Radical Mastoidectomy once patient is stable
introduction56
Introduction

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

trautmann s triangle
Trautmann’s triangle

Superiorly: superior petrosal sinus

Posteriorly: sigmoid sinus

Anteriorly: solid angle

(semi-circular canals)

Pathway to posterior

cranial fossa from mastoid

cavity

stages of brain abscess
Stages of brain abscess

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

clinical features of ed i c t
Clinical Features of ed I.C.T.

Seen more in cerebellar abscess

  • Severe persistent headache, worse in morning
  • Projectile vomiting
  • Blurring of vision & Papilloedema
  • Lethargy  drowsiness  confusion  coma
  • Bradycardia
  • Subnormal temperature
focal clinical features
Focal Clinical Features

Temporal Lobe Cerebellum

 Nominal aphasia I/L nystagmus

 Quadrantic 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

bacteriology
Bacteriology
  • Anaerobic streptococci
  • Streptococcus pneumoniae
  • Staphylococci
  • Proteus
  • E. coli
  • Pseudomonas
  • Bacteroidis fragilis
investigations
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

medical treatment
Medical Treatment
  • 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
surgical treatment
Surgical Treatment
  • Repeated burr hole aspirations
  • Excision of brain abscess with capsule: best Tx
  • Open incision & evacuation of pus
  • Radical mastoidectomy after pt becomes stable
pathogenesis69
Pathogenesis

Lateral sinus = Sigmoid sinus + Transverse sinus

Erosion of sigmoid sinus plate peri-sinus abscess inflammation of outer wall endophlebitis mural thrombusocclusion of sinus lumenintra-sinus abscess propagating infected thrombus

spread of thrombus
Spread of thrombus

Proximal:1. To superior sagittal sinus via torcula Hirophili 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

clinical features
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
fever charts in c s o m
Fever charts in C.S.O.M.

Brain abscess

Meningitis

Lateral Sinus Thrombophlebitis

picket fence fever
Picket fence fever
  • High fever, swinging type
  • Chills precedes fever
  • Temperature subsides with sweating
  • Each fever spike due to release of fresh septic embolus
special tests
Special Tests
  • 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.
  • Lillie – Crowe - Beck test:pressure on I.J.V. on normal sideengorgement of retinal veins + papilloedema seen in fundoscopy due to L.S.T. on opposite side.
investigations79
Investigations

Lumbar puncture: to rule out meningitis

CT brain with contrast:Delta sign or

MRI brain with contrast:Empty triangle sign

MR angiography

Blood culture

Culture & sensitivity of ear discharge

Peripheral blood smear: to rule out malaria

treatment81
Treatment

1. Radical mastoidectomy:Removal of disease + needle aspiration to confirm diagnosis. Sinus wall incised. Infected clots removed & abscess drained.

2. I.V. Ceftriaxone + Metronidazole + Gentamicin

3. Anticoagulants:in cavernous sinus thrombosis

4. Internal jugular vein ligation:for embolism not responding to antibiotics & surgery

5. Blood transfusion: for anaemia

slide84
Commonest otogenic intra-cranial complication

Collection of pus b/w skull bone & dura of middle or posterior cranial fossa

Majority asymptomatic. Suspected in case of:

 Profuse, intermittent, pulsatile, purulent, otorrhoea

 Low grade fever  I/L Persistent headache

 Recurring meningococcal meningitis

CT scan brain shows extra-dural abscess

Tx:I.V. Ceftriaxone + Metronidazole + Gentamicin

Modified Radical mastoidectomy Drill tegmen or sinus plate  pus drained

slide88
Collection of pus b/w dura & arachnoid by erosion of bone & dura mater or by retrograde thrombophlebitis

Due to rapid spread of pus, symptoms of raised intra-cranial tension & meningeal irritation develop quickly

CT scan brain shows subdural abscess

Tx:I.V. Ceftriaxone + Metronidazole + Gentamicin Burr hole evacuation of pus Radical mastoidectomy after pt becomes stable

slide91
Synonym: Benign intra-cranial hypertension  Symond’s syndrome

Etiology: 1. Associated L.S.T.  obstruction of cerebral venous return. 2. Superior sagittal sinus thrombosis  ed C.S.F. absorption

Clinical Features:1. Severe headache, vomiting

2. Blurred vision, papilloedema, optic atrophy

3. Abducens palsy & diplopia due to raised intra-cranial tension(False localizing sign)

slide92
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

 Repeated lumbar puncture / lumbar drain

 Ventriculo-peritoneal shunt

brain fungus
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.