13 csom-part-4

Complications of Suppurative Otitis

MediaDr. 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.

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

• Intra-cranial

• Extra-cranial, Intra-temporal

• Extra-cranial, Extra-temporal

• Systemic: septicemia, otogenic tetanus

Classification

Intra-cranial Complications1. Extra-dural abscess

2. Subdural abscess

3. Meningitis

4. Brain abscess

5. Lateral Sinus thrombophlebitis

6. Otitic hydrocephalus

7. Brain fungus (fungus cerebri)

Intra-temporal Complications• Acute mastoiditis

• Coalescent mastoiditis

• Masked mastoiditis

• Facial nerve palsy

• Labyrinthitis

• Labyrinthine fistula

• Apex Petrositis (Gradenigo syndrome)

Extra-temporal Complications1. Post-auricular abscess

2. Bezold abscess

3. Citelli abscess

4. Luc abscess

5. Zygomatic abscess

6. Retro-mastoid abscess

Factors AffectingPathogen Factors Patient 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 entry1. 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

Erosion of tegmen tympani

Coalescent Mastoiditis or Surgical Mastoiditis

PathogenesisAditus 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

Pathogenesis

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

Mastoid reservoir sign

Sagging of posterior wall

Ironed out appearance

Mastoid cavity

Mastoid cavity

Mastoiditis FurunculosisH/o otitis media + -

Deafness + -Position of pinna Down + outward

+ forward Forward

Post-aural groove Deepened Obliterated

Ear discharge Muco-purulent Serous / purulent

Sagging of EAC wall + -

TM congestion + -

Tenderness Mastoid Tragal

Post-aural lymph node - +

X-ray Mastoid Coalescence of cells + cavity

Normal

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

Sub-periosteal abscess & fistula

PathologyProduction of pus under tension

hyperaemic decalcification (halisteresis)

+ osteoclastic resorption of bone

sub-periosteal abscess

penetration of periosteum + skin

fistula formation

Sub-periosteal abscess formation

Sub-periosteal fistula: dry

Sub-periosteal fistula: wet

Types of sub-periosteal abscess• Post-auricular

• Bezold

• Citelli

• Zygomatic

• Luc

• Retro-mastoid

• Parapharyngeal & Retropharyngeal

Types of sub-periosteal abscess

Post-auricular abscess

Commonest. Present behind the ear. Pinna pushed forward & downward.

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

1. Suppurative lymphadenopathy of upper

deep cervical lymph node

2. Para-pharyngeal abscess

3. Parotid tail abscess

4. Infected branchial cyst

5. Internal jugular vein thrombosis

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

Retromastoid abscess

Incision drainage of abscess

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

Persistent otorrhoea + Retro-orbital pain + Convergent squint

Right Convergent squint

Right gaze Central gaze Left gaze

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

C.T. scan & M.R.I.

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

Hearing sacrificing approaches to petrous apex• Trans-cochlear approach• Trans-labyrinthine approach

Spread of pus

Labyrinthitis

IntroductionInflammation 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

• 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

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

Lateral SSC Fistula

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

Meningitis

• 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

Test for neck rigidity

Otogenic brain abscess

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

Introduction

Trautmann’s triangleSuperiorly: superior

petrosal

sinus

Posteriorly: sigmoid sinus

Anteriorly: solid angle

(semi-circular canals)

Pathway to posterior

cranial fossa from mastoid

cavity

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

Stages of brain abscess

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 FeaturesTemporal 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• Anaerobic streptococci

• Streptococcus pneumoniae

• Staphylococci

• Proteus

• E. coli

• Pseudomonas

• Bacteroidis fragilis

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

Investigations

Temporal abscess in CT scan

Cerebellar abscess

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

• Repeated burr hole aspirations

• Excision of brain abscess with capsule: best Tx

• Open incision & evacuation of pus

• Radical mastoidectomy after pt becomes stable

Lateral sinus thrombophlebitis

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

Pathogenesis

Pathogenesis

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

Spread of thrombus

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.

Meningitis

Lateral Sinus Thrombophlebitis

Brain abscess

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• 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.

Tobey Ayer Test

Retinal vein dilation & optic disc edema

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

Investigations

Delta sign

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

Treatment

Extra-dural abscess

Extra-dural abscess

Commonest otogenic intra-cranial complicationCollection of pus b/w skull bone & dura of middle

or posterior cranial fossaMajority asymptomatic. Suspected in case of: Profuse, intermittent, pulsatile, purulent, otorrhoea Low grade fever I/L Persistent headache Recurring meningococcal meningitisCT scan brain shows extra-dural abscessTx: I.V. Ceftriaxone + Metronidazole + Gentamicin Modified Radical mastoidectomy

Drill tegmen or sinus plate pus drained

Extra-dural abscess

Subdural abscess

Subdural abscess

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

Subdural abscess

Otitic Hydrocephalus

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)

Investigations:1. Lumbar puncture: ed CSF pressure (> 300 mm

H2O). Biochemistry & bacteriology normal

2. CT scan brain: normal ventriclesTreatment: 1. Tx of L.S.T.: I.V. antibiotics & MRM2. 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• 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.

Fungus Cerebri

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