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