Intracranial Complications of Otitis Media

Department of ENT

Presenter-Surendra Poudel

(2010/58)

Intracranial Complications of OtitisMedia

Meningitis

Otogenic brain abscess

Lateral sinus thrombophlebitis

Epidural abscess

Subdural abscess

Otitic hydrocephalus

1. Meningitis

Inflammation of leptomeninges(piamater and arachnoid mater) .

Most common and serious intracranial complication.

Follows Acute otitis media (AOM) in children and infants (blood borne spread);

And Chronic suppurative otitis media(CSOM) in adults. (bone erosion or retrograde thrombophlebitis).

Clinical features

Rise in temperature(102-104∙F)often with chills and rigor

Headache

Neck rigidity

Photophobia and mental irritability

Nausea and vomiting(sometimes projectile)

Drowsiness which may progress to delirium or coma

Cranial nerve palsies and hemiplegia

On examination Neck rigidity

Kernig’s sign positive

Brudzinski’s sign positive

Tendon reflexes exaggerated initially but later become sluggish or absent

Diagnosis History and clinical presentation

Investigation;

lumbar puncture: cell count , protein, sugar

CT scan , MRI

Treatment Antimicrobials with Dexamethasone

Surgical controversial) only in cases of antimicrobials failing to respond in 48 hrs

2. Otogenic Brain Abscess

Develops in the temporal lobe or the cerebellum of the affected side .

Temporal lobe abscess is twice as common as cerebellar abscess.

In children, 25% of brain abscesses are otogenic;

50% in case of adults

Brain abscess develops through 4 stages

1. Stage of invasion (initial encephalitis)

-usually asymptomatic

2. Stage of localisation(latent abscess)

3. Stage of enlargement(manifest abscess) -aggravation of symptoms

4. Stage of termination(rupture of abscess) - fatal meningitis

Pathology

Diagram showing evolution of brain abscess

Clinical features

Due to raised ICP;

Headache

Nausea and vomiting

Level of consciousness

Papilloedema

Slow pulse and subnormal temperature

Localising features

Temporal lobe abscess Cerebellar abscess

Nominal aphasia Headache

Homonymous hemianopia Spontaneous nystagmus

Contralateral motor paralysis Ipsilateral hypotonia and weakness

Epileptic fits Ipsilateral ataxia

Pupillary changes andoculomotor palsy

Past pointing and intentiotremor

Dysdiadochokinesia

InvestigationsSkull X ray, CT scan , X ray mastoids or CT scan, lumbar pubcture

TreatmentMedical -

high dose intravenous broad spectrum antibiotics

ceftriaxone +metronidazole+gentamicin

Dexamethasone

Anti epileptics: phenytoin

Antibiotics ear drop andayral toilet

Surgical-

Multidisciplinary(Neurosurgeon +ENT surgeon)

- surgical drainage of the abscess, followed by mastoidectomy to clear the ear disorder.

3. Lateral sinus thrombophlebitis

Inflammation of inner wall of lateral venous sinus with formation of an intrasinus thrombus

PathophysiologyErosion of sigmoid sinus plate peri-sinus abscess inflammation of

outer wall endophlebitis mural thrombus infect, Propagateor size occlusion of sinus lumen intra-sinus abscess propagating infected thrombus

Clinical features Hectic Picket-fence type of fever with rigors

Headache

Progressive anaemia and emaciation

Griesinger’s sign(pathognomic)

Papilloedema

Tobey-Ayer test

Crowe-Beck test

Tenderness along jugular vein

Investigations

Blood smear, culture

CSF examination

X ray mastoids

Imaging

Culture and sensitivity of ear swab

Treatment

IV antibiotics

Mastoidectomy: Cortical (AOM), R/MRM (COM)

Expose the sinus Confirm by look, feel &

aspiration Evacuation

4. Epidural abscess

Collection of pus between the bone and duramater

Pathophysiology

The affected dura is covered with granulation and appear unhealthy and discolored

In AOM, bone over dura- destroyed by hyperemic decalcification.

In COM, destroyed by cholesteatoma.

Clinical features

Usu. Asymptomatic, and discovered accidentally during surgery(cortical or modified radial mastoidectomy)

However , presence is suspected when there is,

1. Persistent headache on the side of OM

2. Severe pain in the ear

3. General malaise with low grade fever

4. Pulsatile purulent ear discharge

5. Disappearance of headache with free flow of pus from the ear(spontaneous abscess drainage)

Diagnosis :

contrast enhanced CT or MRI

Treatment:

Antimicrobial therapy

surgical exploration

5. Subdural abscess

Collection of pus between dura and arachnoid mater

Pathology

Clinical featuresMeningeal irritation •Fever(102*F or more)

•Headache•Malaise, drowsiness•Neck rigidity•Kernig’s sign positive

Thrombophlebitis(cortical veins of cerebrum)

•aphasia•Hemianopia•Hemiplegia•Jacksonian type of epileptic fits

Raised ICP 3rd nerve involvement;papilloedema, ptosis,dilated pupil

Diagnosis by CT or MRI

Treatment

surgical emergency: managed by neurosurgeon

Treatment of choice:

High dose iv antibiotics

Once stabilised neurologically, then underlying ear disease managed

Surgery of ear

Antiepileptic medication

Otitic hydrocephalus

Characterised by raised intracranial pressure with normal CSF findings.

It is seen in children and adolescents with acute or chronic middle ear infections

Mechanism:lateral sinus thrombosis -> obstruction of venous return. If thrombosis extends to superior sagittalsinus,it will also impede the function of arachnoidvilli->Raised ICP

Cliniacal features

Headache

Drowsiness

Nausea & Vomiting

Blurring of vision

Diplopia

Papilloedema

6th CN nerve palsy

Eventually optic atrophy

Investigations

Lumbar Puncture

Elevated CSF pressures with normal biochemistry

Done with caution (herniation)

CT scan

MRI:

Imaging modality of choice

Allows for superior evaluation of venous sinuses

Management

Goal Eradication of ear disease and Lowering elevated intracranial pressure

Recommendations Decompression of sigmoid sinus CSF fluid drainage – shunts Optic Sheath decompression: To prevent optic

atrophy

Medical:MannitolDiuretics Corticosteroids Acetazolamide

Thank you