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Dr . Sithananda Kumar.R
Complications Of otitis media
“Acute pain in the ear with continued high fever is to be dreaded for the patient may become delirious and die”
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
Spread of infection beyond the confines of the mucosal spaces of middle ear cleft
Definition
Complications of csom
Meningitis
Sigmoid sinus thrombosis
Brain abscess
Extradural abscess
Subdural abscess
Otitic hydrocephalus
Intra cranial complications
Mastoiditis
Petrositis
Labyrinthitis
Facial paralysis
Extracranial ( Intratemporal ) complications
Sub periosteal abscess
Bezold’s abscess
Zygomatic ( Luc’s abscess/ Meatal )
Digastric ( Cittelli’s abscess)
Extracranial ( Extratemporal ) complications
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
Bone erosion
Suppurative retrograde thrombophlebitis
Preformed pathways
Routes of spread
In ASOM-Hyperemic decalcification
In CSOM-Cholesteatoma or granulation tissue.
Direct bone erosion
Suppurative retrograde thrombophlebitis
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
Endolymphatic duct and sac
Preformed pathways
Ear pain
Fever
Severe headache
Projectile vomiting
Neck stiffness
Photophobia
Irritability / altered consciousness.
Features of impending complications
when infection spreads from the mucosa lining the mastoid air cells to involve bony walls of the mastoid air cell system
Mastoiditis
Acute coalescent mastoiditis
Clinical FeaturesSymptoms 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
HRCT Temporal Bone Aural swab for culture & sensitivity
strept. pneumoniae Beta hemolytic strept pseudomonas
Investigations
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 groovePseudo deepening Obliterated
Tympanic membrane Perforation Normal
EACSagging of postero superior bony meatal wall
Swelling in cartilaginous part
Hospitalization
I.V antibiotics
Myringotomy
Cortical mastoidectomy
TREATMENT
Subperiosteal abscess
Bezold’s abscess
Cittelli's abscess
Luc’s abscess
Petrositis
Labyrinthitis
Facial paralysis
Meningitis, brain abscess , sigmoid sinus thrombosis
Sequelae of acute coalescent mastoiditis
Luc’s abscess
Subperiostealabscess
Bezold’s abscess
Bezold’s abscess
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
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
Petrous
apex
antrum
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
Management HRCT
I.V antibiotics
Surgical exploration
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
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
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
Circumscribed meningitis: no bacteria in CSF.
Generalized meningitis: bacteria are present in CSF
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
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
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
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
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
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.
Diagnosis CT scan with contrast - “delta” sign
MRI
Angiography
Blood cultures is positive during the febrile phase.
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.
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
Stages of brain abscess Early cerebritis (invasion) Late cerebritis (localization)– quiescent Early capsule formation (enlargement)-manifest Late capsule formation (termination)
Brain abscess… First stage Fever with chills, headache & nausea , non projectile vomiting,Apathy , drowsiness, convulsion, neck stiffness.
Second stageMalaise , poor appetite, intermittent headache, listlessness,
drowsiness
Third stageSevere headache, projectile vomiting, bradycardiaChyne stroke breathing, fever, disorientation, Jacksonian fits
ocular paralysis, papilledema
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.
Brain abscess..Treatment:- Aqueous Penicillin G + Metronidazole or
Third generation Cephalosporin + Metronidazole
I/V Dexamethasone
I.V mannitol
Antibiotics for 4-6 weeks
Otitic hydrocephalus
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
Extradural/ subdural empyema
CONCLUSION