Department of Otorhinolaryngology

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Department of Otorhinolaryngology
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COMPLICATIONS of Suppurative Otitis Media

• Ossama
  Mahmoud
• Professor of
  Otorhinolaryngology
• Ain Shams
  University

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Complications of Otitis Media

• The temporal bone is a complex anatomic
  region with close proximity to a variety of
  critical structures. These structures are at
  risk during both acute and chronic suppurative
  otitis media.

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Complications of Otitis Media

• Due to antibiotics, the incidence of
  complications has greatly declined. (also
  treating surgical problems with antibiotics alone
  or giving incomplete courses that mask the
  infection lead to complications)
• Complications are usually associated with
  granulation tissue formation and/or the presence
  of a cholesteatoma (bone erosion).

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Complications of Otitis Media

• Complications arise mostly due to
• -- Infection spreading by direct extension from
  the middle ear or mastoid cavity to adjacent
  structures.
• - Thrombophlebitis (haematogenous)

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Complications of Otitis Media

• Patients appear more ill than expected
• fever, new onset vertigo, sensorineural hearing
  loss, fetid drainage, facial nerve weakness,
  proptotic ear
• lethargy and mental status changes
• CT and MRI are indicated
• CT is superior for evaluating the bony details of
  the middle ear and mastoid space
• MRI is more sensitive for diagnosing suspected
  intracranial complications.

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Complications of Otitis Media

• Treatment is
• Parentral Broad Spectrum Antibiotics
  and
• Surgery are required

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Complications of Suppurative O.M.

• Cranial (or Temporal bone) complications
• 1- Acute Mastoiditis.
• 2- Acute Petrositis.
• 3- Otitic Facial paralysis.
• 4- Acute Labyrinthitis.

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Complications of Suppurative O M (cont.)

• Intracranial Complications
• 1- Extra-dural (epidural) abscess.
• 2- Meningitis.
• 3- Brain abscess (cerebral or cerebellar).
• 4- Lateral sinus thrombosis.
• Extracranial complications
• 1- External otitis.
• 2- Jugular vein thrombophlebitis
• 3- Bezolds abscess
• 4-Retropharyngeal abscess.

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Acute Mastoiditis
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Acute Mastoiditis

• Extension of the suppurative inflammatory
  process beyond the mucous membrane lining of the
  mastoid air cells leading to osteitis of the bony
  septa.
• N.B. At this early stage resolution is possible
  without surgery, if proper medical treatment is
  given.

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Acute Mastoiditis (cont.)

• The bony inter-cellular septa will
  break down with coalescence of the infected
  cells to form one cavity full of pus leading to
  Coalescent Mastoiditis or Mastoid Abscess.

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Acute Mastoiditis (cont.)

• In early Coalescent Mastoiditis the outer
  cortex of mastoid is intact but with extension
  of the disease pus may erode outer cortex of
  mastoid leading to Subperiosteal Mastoid
  Abscess which can extend by perforating
  the periosteium to became Subcutaneous
  Mastoid Abscess. If it opens through
  the skin Mastoid Fistula will result.

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Clinical Picture

• Exaggerated symptoms of ASOM (fever, pain and
  HL)
• 1- Tenderness over mastoid antrum and
• 2-External swelling
• A- Post-auricular abscess
• - Auricle is displaced outwards, forwards and
  downwards (erect auricle).
• - Post-auricular groove is preserved but if
  the abscess ruptures through periosteum and
  becomes subcutaneous , the groove will be
  obliterated.
• - DD. Post auricular lymphadenitis 2ry to
  Furunculosis of external auditory meatus.

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Clinical Picture

• Early stage of Mastoiditis

• Mastoid fistula

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Mastoid Abscess
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Clinical Picture

• B- Zygomatic abscess
• It is due inflammation of the zygomatic air
  cells. The swelling is above and in front of
  the ear.
• C- Bezolds abscess
• Pus pierces the tip or inner surface of
  mastoid and form abscess in the
  sternomastoid muscle In the neck.
• D- Retropharyngeal abscess
• Pus tracking from the peritubal cells along
  the Eustachian tube.

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Clinical Picture

• 3- Internal swelling
• Sagging of posterosuperior bony meatal wall,
  due to periostitis and edema over the anterior
  antral wall.
• 4- Ear discharge usually profuse ,
  "Mucopurulent or purulent and may be pulsating
  with reservoir sign rapid re-accumulation "
• 5- Drum membrane perforated (small with
  pulsating discharge) or intact and bulging.

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Investigations

• 1- CS of ear discharge
• 2- CT scan of the temporal bone to detect any
  additional cranial or intracranial complications

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Treatment of Acute Mastoiditis

• 1- Conservative treatment
• is to be tried for 48 hours in mild cases
  without evidences of abscess formation parentral
  broad spectrum antibiotics.
• Myrigotomy if DM found intact and bulging.
• 2- Cortical Mastoidectomy operation
• is the standard treatment if the patient is
  not responding to conservative treatment, or if a
  mastoid abscess is evident or if other
  complications are suspected to be present.

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Masked Mastoiditis

• It Is the result of INCOMPLETE TREATMENT
  of ASOM with antibiotics leading to masking of
  the acute symptoms while the pathological process
  is progressing in the mastoid.
• Clinical picture
• - Slight pain and tenderness over the
  mastoid.
• - Intra-cranial complications may occur and
  may be the presenting symptom.

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Chronic Mastoiditis

• There is thick unhealthy chronically inflamed
  mucosa with granulation tissue and osteitis
  with sclerosis of mastoid air cells.(sclerosed
  mastoid in X-Ray)
• It is condition which may be present in CSOM
  (tubo-tympanic type and attico-antral types).
• Persistent ear discharge is the main presenting
  symptom

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Cortical Mastoidectomy Operation

• It is a drainage operation in which exentration
  of the mastoid air cells is done.
• It is a preliminary step in most of ear surgeries
  

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INDICATIONS

• 1- Acute Mastoiditis with failure of medical
  treatment (persistent pain, tenderness and
  fever , etc , for more than 2 days).
• 2- Subperiosteal Mastoid abscess.
• 3- Mastoid fistula.
• 4- Mastoiditis with complications as facial
  paralysis, meningitis or lateral sinus thrombosis.

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INDICATIONS

• 5- Persistent ear discharge in cases of ASOM
  or CSOM (tubo-tympanic) for more than one
  month despite proper conservative treatment
• 6-Resistant cases of OME.
• 7- Part of ear surgeries (e.g. Sac operations
  in Menieres disease ------- etc.).

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Petrositis

• It is inflammation of the air cells in
  the petrous apex of the temporal bone , the 6th
  (abducent) and 5th (trigeminal) cranial nerves
  are affected as they are closely related to
  the petrous apex.

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Petrositis (cont.)

• Clinical Picture
• The condition is called GRADINIGO SYNDROME
• Triade of
• 1- Diplopia with convergent squint due to 6th
  nerve paralysis.
• 2- Trigeminal neuralgia
• (retro-orbital pain and headache) due to
  irritation of the trigeminal ganglion.
• 3- Discharging ear.

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Petrositis (cont.)

• Investigations
• 1- CT scan of temporal bone
• 2- CS of ear discharge
• Treatment
• 1- Conservative in mild and early cases
• 2- Mastoidectomy with exentration of petrous apex
  air cells or subtotal petrosectomy

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Otitic Labyrinthitis

• It is a complication of ASOM or more
  common CSOM.
• Types
• 1.Circumscribed
• Labyrinthitis.
• (labyrinthine fistula).
• 2.Diffuse serous
• Labyrinthitis.
• 3.Diffuse suppurative Labyrinthitis.

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Circumscribed Labyrinthitis Labyrinthine
Fistula/ Para-labyrinthitis

• It results from erosion of the bony wall of
  one of the SSC (usually the lateral) , or less
  commonly the promontory by cholesteatoma.
• The inflammatory process is outside the
  endosteal lining of the labyrinth (intact inner
  ear function).

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Labyrinthine Fistula Clinical Picture

• In addition to the clinical picture of OM new
  symptoms appear in the form of
• Intermittent attacks of vertigo
• Usually not accompanied by nausea and
  vomiting and usually precipitated by
  pressure on the tragus or sudden head
  movement.

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Labyrinthine Fistula Clinical Picture

• Nystagmus accompanies the vertigo and usually
  horizontal with rapid component to the
  affected side (irritant lesion).

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Labyrinthine Fistula Clinical Picture

• Fistula test is positive (pressure on
  tragus, use of pneumatic otoscope or
  manipulating an aural polyp induces
  vertigo and nystagmus).

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Diffuse serous LabyrinthitisCatarrhal
Labyrinthitis

• It is a serous inflammation of the membranous
  labyrinth (inflamatory cells in the peri-lymph
  without organisms).
• Clinical Picture
• 1. That of ASOM or CSOM.
• 2. Vertigo, nausea vomiting are severe.
• 3. Nystagmus is usually horizontal with rapid
  component to affected side (irritant lesion).
• 4. Deafness becomes severe and mixed
  (Conductive SNHL).

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Diffuse purulent Labyrinthitis

• At first the previous symptoms increase markedly
  and HL may be severe or total.
• Nystagmus is beating first towards the affected
  side (irritant) but changes to the other side
  (dead labyrinth) when destruction of the
  labyrinth becomes complete.
• Nystagmus will disappear later as it will
  be compensated by the healthy side.

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Diffuse Purulent Labyrinthitis

• Absent or minimal toxic manifestations as the
  surface area of the inner ear is small so there
  is no or little diffusion of toxins.
• Presence of fever and other toxic manifestations
  may suggest occurrence of meningitis.

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Treatment of Labyrinthitis

• Conservative Treatment
• - Antibiotics that cross the BBB to guard
  against meningitis.
• - Labyrinthine sedatives and anti-emetics
  as Dramamine , stugeron, diazepam
  valium and zofran (4mg) amp. .
• Surgical Treatment either
• Cortical mastoidectomy for control of suppurative
  otitis media, or
• Radical mastoidectomy and labyrinthectomy in
  cases of supprative labyrinthitis with dead
  labyrinth to prevent intracranial extension of
  infection

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Otitic Facial Nerve Paralysis

• As a complication of ASOM facial nerve paralysis
  occurs in children if there is congenital
  dehiscence in the bony canal of the nerve
  (20 of population). Paralysis is usually
  incomplete and is due to inflammation of the
  nerve sheath and compression by pus.
• Treatment
• Early myringotomy (usually with Grommets tube)
• Antibiotics (parentral) and steroids.
• Cortical mastoidectomy if the paralysis
  persist in spite of other lines of treatment
  or if there is acute mastoiditis.

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Facial Nerve Paralysis as a complication of CSOM

• Destruction of the bony
• canal and pressure on
• the nerve is either by
• 1) Cholesteatoma
• 2) Osteomylitis of the mastoid.
• 3) Tuberculous OM. (Multiple Drum M.
  perforations pale mucosa).

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Facial Nerve Paralysis as a complication of CSOM

• Treatment
• 1- Mastoidectomy operation with exposure and
  decompression of the facial nerve.
  
• 2- In case of tuberculous OM Anti-tuberculous
  ttt usually gives cure of the paralysis.
  Surgical ttt is only for cases showing no
  recovery after the disease has been cured.

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Post operative Facial Paralysis (Iatrogenic)

• 1.Immediate after the operation is due to
  direct trauma to the nerve.
• Treatment
• If Partial corticosteroids antibiotics.
• If Complete Immediate exploration of the
  nerve and remove any bone specule compressing
  the nerve or do nerve suturing or
  nerve graft if needed (from Greater
  Auricular nerve).

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Post-operative facial paralysis

• 2. Delayed (few hours or days after recovery)
• usually due to pressure on the nerve by
  edema ,haematoma or tight pack.
• Treatment
• 1) Removal of the pack.
• 2) Antibiotics Cortisone.

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Extradural Abscess

• It is collection of pus and /or granulation
  tissue between skull bone and dura.

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Extradural Abscess

• Clinical Picture
• The condition is usually symptomless and
  accidentally discovered during mastoidectomy.
• Presentations
• There may be persistent
• 1- Earache or headache.
• 2- Low grade Fever (about 37.5 - 38C).
• 3- Pulsating ear discharge.

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Extradural Abscess

• Treatment
• 1- Antibiotics (Injection) that cross BBB.
• 2- Cortical Mastoidectomy operation , abscess
  must be evacuated and bone must be
  removed until healthy dura is reached.

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Diffuse Leptomeningitis

• It is diffuse inflammation of the arachnoid,
  subarachnoid space pia mater.
• Symptoms
• 1) Symptoms of infection e.g. high fever,
  malaise. etc.
• 2) Symptoms of increased intracranial
  tension
• - Severe headache. - Vomiting.
  - Blurring
  of vision.
• 3) Symptoms of meningeal irritation Irritability
  , Photophobia , neck rigidity and retraction.

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Diffuse Leptomeningitis

• Signs
• 1) High fever (gt 39 C) and tachycardia.
• 2) Neck Rigidity.
• 3) Signs of meningeal irritation
• a- Kernigs sign
• Flex hip and knee ,then trying to extend
  the knee will produce severe pain and will
  be resisted by the patients.
• b- Brudziniskis sign
• Flex the neck , hip and knee will become
  flexed.
• 4- Papilloedema (edema of optic disc) on fundus
  examination.

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Investigations of Meningitis

• A- CT Temporal Bone Brain (To detect
  probable intracranial complication if any).
• B- Lumbar Puncture
• 1- CSF examination.
• 2- Culture Sensitivity.

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C.S.F. In meningitis normal CSF
Aspect Turbid. Clear.
Pressure High. 60-180mm Of CSF.
Cells Thousands, mainly polymorphs. 1-5 lymphocytes per c mm.
Proteins Increased (due to the bacteria). 40 mg/100 ml.
Sugar Decreased ( nutrition of bacteria). 80 mg/100 ml.
Chloride Decreased (due to vomiting). 750 mg/l00 ml.
Organisms Can be cultured. Absent.
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Treatment of Meningitis

• 1- Antibiotics
• i- Intrathecal injection of crystalline
  penicillin
• ii- Intravenous injection of drugs crossing BBB
  as, 3rd generation cephalosporins Flagyl
  for anerobes
• 2- Measures to reduce the increased intracranial
  tension
• i- Repeated lumbar punctures.
• ii- Hypertonic glucose solution IV Diuretics.
• iii- Dexamethason injections.

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Brain Abscess

• It is either Temporal or Cerebellar

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Brain Abscess

• Clinical Picture
• I- Stage of encephalitis
• 1- High fever rapid pulse.
• 2- Rigors or convulsions specially in children.
• 3- Headache.

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Brain Abscess Clinical Picture (cont.)

• II- Latent Stage
• (weeks to months)
• Due to localization of the abscess with
  diminished brain. Most of symptoms disappear
  and patient may feel some headache and lack of
  concentration.

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Brain Abscess Clinical Picture

• III- Manifest Stage
• Due to increase in the size of the abscess.
• A- Manifestations of Toxaemia
• i. Anorexia and loss of weight.
• ii. Mental dullness , slow cerebration and
  delirium.
• iii. Leucocytosis which may reach 20.000 or more.

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Brain Abscess Clinical Picture

• B- Manifestations of Increased Intracranial
  Tension
• 1- Headache which is severe and not relieved by
  analgesics.
• 2- Projectile vomiting (not preceded by nausea
  and not related to meals).
• 3- Blurring of vision due to papilloedema.

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Brain Abscess Clinical Picture

• Prolonged increased ICT may lead to
• Slow full pulse(40/min.)
• Subnormal temperature
• Slow cerebration
• Slow deep respiration

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Brain Abscess

• C- Manifestations of Localization
• Temporal Lobe Abscess
• Nominal Aphasia (inability to name objects due to
  pressure on Brocas area)
• Homonymous hemi-anopia( defect in field of
  vision)
• Uncinate fits (epileptic fits preceeded by aura)
• Hemiplegia
• Hemianesthesia

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Brain Abscess Clinical Picture

• Cerebellar Abscess
• Tremors with muscle weekness (hypotonia).
• Slurred speech
• Incoordination of movements (asynergia and
  dysmetria) can be shown by finger nose test.
• Ataxia unsteadiness of gait with deviation to
  the side of lesion.
• Vertigo and nystagmus.
• Dysdiadokokinesis ( patient is unable to do
  rapid pronation and supination ).

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Brain AbscessClinical Picture

• IV- Terminal Stage
• Due to rupture of the abscess resulting in
  either
• 1) Diffuse encephalitis. or
• 2) Diffuse meningitis.
• Coma and death will occur.

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Brain Abscess Investigations

• CT scan with contrast / or MRI show site ,
  size of abscess and whether acute or chronic
• Fundus examination show Papilloedema.
• Field of vision examination show
  homonymmous hemianopia.
• CBC show marked leucocytosis (20000).
• C/S from pus from abscess after drainage or
  from ear discharge.
• N.B. Never do Lumber Puncture as
  CONIZATION of medulla may occur due to marked
  rise of I.C.T.

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Brain Abscess
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Brain Abscess Treatment

• Acute Abscess
• Antibiotics that cross BBB.
• Measures to Lower the increased ICT.
• Repeated Tapping of abscess through burr
  holes by neurosurgery or through mastoidectomy
  (N.B. Repeated CT must be done to ensure complete
  drainage).
• Mastoidectomy of the affected ear as a treatment
  for otitis media when the condition of the
  patient allows.

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Brain AbscessTreatment

• B. Chronic Abscess
• Excision
• Antibiotics (Parentral-crossing BBB) .
• Mastoidoidectomy for affected ear when the
  condition of the patient allows.

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Lateral Sinus Thrombophlebitis

• It is infective thrombosis of the lateral
  (sigmoid) venous sinus.

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Lateral Sinus Thrombophlebitis

• Pathogenesis
• Peri-sinus abscess (type of extra-dural abscess)
  is formed as an extension from infected mastoid
• Infection extends into the sinus wall and lumen
  causing thrombophlebitis.
• Infected thrombus may be fragmented with
  detachment of septic emboli in blood stream
• Extension of thrombosis to cavernous , supermay
  take placeior petrosal, superior sagittal sinus
  or to the internal jugular vein may occur

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Lateral Sinus ThrombosisClinical Picture

• 1- Pyaemic Type (Malarial like)
• - Remittent fever and rigors occurring at
  irregular intervals, between them temp. reach
  near the base line ( remains above 37C).
• - Multiple pyaemic abscesses in different
  parts of the body due to separation of septic
  emboli.

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Lateral Sinus Thrombosis Clinical Picture

• D.D. from Malaria
• a- Fever and rigors in malaria occurs at regular
  intervals and between them temp. can reach
  37C.
• b- Leucopenia in malaria instead of
  leucocytosis in thrombosis.
• c- Blood film will show malaria
  parasites. (during the attack)

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Lateral Sinus Thrombosis Clinical Picture (cont.)

• 2- Septicaemic or Typhoid Type
• Continuous fever without remissions or
  rigors.
• D.D. from Typhoid fever
• a- Widal test Is positive in typhoid.
• b- Leucopenia in typhoid.
• 3- Latent Type
• Condition may be asymptomatic and discovered
  only during Mastoid Operation for acute
  mastoiditis.

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Lateral Sinus Thrombosis Clinical Picture

• 4- If Septic thrombosis extend to the Jugular
  vein in the neck.
• a- Cord like mass in the neck.
• b- Torticollis.
• c- Cervical lymphadenitis may occur.

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Lateral Sinus Thrombosis Treatment

• 1) Antibiotics (according to blood culture??? )
• 2) Antipyretic analgesics, light diet, fluids.
• 3) Anticoagulants as heparin may be given in
  cases with extension of the thrombus ????.
• 4) Mastoidectomy operation and exposure of the
  sinus with removal of bone until healthy
  dura is reached.
• Incision of the sinus and evacuation of the
  infected clot is done until unclotted blood is
  reached.

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Lateral Sinus Thrombosis Treatment

• Ligation of the internal Jugular vein can be
  done if we cannot reach the lower limit
  of the thrombus and it must be ligated below
  the level of common facial vein which must be
  ligated also to avoid cross thrombosis to the
  cavernous sinus.

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Lateral Sinus Thrombosis Treatment

• N.B. During operation we must differentiate
  between thrombosed sinus and healthy one by
  the following
• Thrombosed sinus is
• 1)Grayish and dull instead of bluish and
  glistening.
• 2)Firm and pulsating instead of soft and not
  pulsating.