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Complications
of Chronic Otitis Media
Chunfu Dai
Three categories
on an anatomic basis
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Extratemporal extracranial
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Intratemporal
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Bezold abscess
Subperiosteal abscess
Mastoiditis, labyrinthitis, sensorineural hearing loss,
petrositis
Facial paralysis, cholesteatoma, labyrinthine fistula
Intracranial
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Epidural abscess, lateral sinus thrombosis, otitic
hydrocephalus,
meningitis, brain abscess, subdural abscess
Causes
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Hyper-function of immune system
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Strong bacteria
Damaged structures
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Infant, older
cholesteatoma
Unreasonable interventions
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Drug resistant,
Poor drainage
Transmission course
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Pathways of spread
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Direct extension of
infection to structure
(bone erosion)
Hemogenous routine
(microbiologic an host
factors)
Bacteria gain access to
intracranial through
unsealed gap, inner ear
Bezold abscess
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Definition:
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Erosion the tip of the
mastoid bone
Infects the soft tissue of
the neck,
Deep to the
sternocleidomastoid muscle
Diagnosis
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Ear infection
Mass in the neck
Fever, neck stiff, otorrhea
CT scan
Bezold abscess
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Treatment
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Antibiotic
Abscess cavity should be
evacuated
An external drainage
should be placed
Mastoidectomy
Antrum drainage required,
via epitympanum to the
middle ear
Supperiosteal abscess
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Definition: Bone erosion,
via osteitis or necrosis,
leads to a dehiscence into
the postauricular soft tissue.
Diagnosis
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Fever, pain and otorrhea
Followed by appearance of
the postauricular mass,
displacing the auricle
anteriorly
CT scan
Supperiosteal abscess
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Managements
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Antibiotic
Drainage, using postauriclar incision
After achieving effective drainage of the mastoid
infection, the site of suppuration can be addressed
 Necrotic tissues require debridement
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Labyrinthitis
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Classifications
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Cirvumscribed labyrinthitis
(fistula of labyrinth)
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Serous labyrinthitis
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Communication of middle ear
with perilymphatic space
Toxin, inflammatory media
Suppurative labyrinthitis
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Bacteria
Fistula of labyrinth
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Including bone erosion,
exposure of the endosteal
membrane and a true fistula
into the fluid compartment
of the inner ear.
It occurs in 5-10% of cases
with cholesteatoma
Lateral semicircular canal is
the most common location
(90%)
Mechanism of bone erosion
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Osteolysis
resorptive osteitis
Fistula of labyrinth
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Diagnosis
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Vertigo (intermittent or
constant)
Hearing loss
Fistula test (only 50%
of patients are positive)
CT scan may
demonstrate evidence
of fistula, however,
small fistula can be
overlooked
Fistula of labyrinth
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Managements
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Surgical invervention
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mastoidectomy
Removal cholesteatoma matrix at
the primary operation, fistula
closed with temporal fascia
Leaving cholesteatoma matrix
undisturbed. 9-12 months later,
second operation is performed.
antibiotic
Serous labyrinthitis
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Occurs from inflammation,
rather than infection
Caused by bacterial toxins,
inflammtory mediators
Inflammatory cells rather than
bacteria are found in the
labyrintine fluids
Vertigo, sensorineural hearing
loss
Suppurative labyrinthitis
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Bacteria infiltrates the fluid space
of inner ear
Vestibular symptoms
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Acute phase of inflammation:
Vertigo, nausea
The phase of central compensation:
imbalance or unsteadiness
Recovery phase: severe
perturbation, patients experiences
a brief sensation of vertigo.
Suppurative labyrinthitis
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Symptoms associated with
cochlea
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Permanent sensorineural
hearing loss
Tinnitus
Suppurative labyrinthitis
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Interventions
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Antibiotic
Address the problem of the underlying COM
and cholesteatoma
Electrolyte (due to vomiting)
Prevention
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Early and effective treatment of the COM and
cholesteatoma
Petrous apicitis
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The most medial and
anterior portion of the
temporal bone
30% of temporal bones
with pneumatization of the
petrous apex
Proximity to the posterior
and middle cranial fossae
Petrous apicitis
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Classic triad (Gradenigo’s syndrome)
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Deep ear and retroorbital pain (irritation of
the trigeminal nerve)
Aural discharge
Ipsilateral abducents nerve palsy
Petrous apicitis
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Managements
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Antimicrobials directed
against the most likely
pathogens.
If hearing present in the
affected ear, otic capsule
should be preserved while
effective drainage achieved
retrolabyrinthine,
infralabyrinthine,
infracochlear approachs can
gain access to the petrous
apex
Petrous apicitis
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Managements
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The affected ear is dead
ear, translabyrinthine or
transcochlear approaches
afford greater access to
the petrous apex
Intracranial complications
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Overview
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It is less frequently, due to
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Improved access to medical care
and medication
Broad spectrum antibiotic
Pathways of spread
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Direct extension of infection to
intracranial structure (bone erosion)
Hemogenous routine (microbiologic
an host factors)
Bacteria gain access to intracranial
through unsealed gap, inner ear
Epidural abscess
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Epidual space is a potential space between the
periosteum and outer dural layer, the tough dura
often will limit the spread of infection.
diagnosis
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No specific symptoms and signs to an epidural
abscess,
Pulsative otic discharge
Headache (associated with the size of abscess)
CT reveals bone erosion, abscess
MRI can detect dural thickening and inflammation
Epidural abscess
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Managements
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Surgical exploration and drainage
Bone overlying the temgen tympani, sigmoid sinus,
and posterior fossa dura must be thinned,
 epidural space should be visualized,
 non inflamed dura is encountered.
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Medical treatment
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Antibiotic
Sigmoid sinus thrombosis
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Pathway
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.
Direct extension of mastoid
infection
Retrograde thrombosis
Antergrade thrombosis
Sigmoid sinus thrombosis
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Diagnosis
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Clinical presentation:
high, spiking fevers,
 Headache, Intracraninal high pressure
 active ear disease
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Acute phase of thrombosis, absence of flow
signal in MR venography images
Sigmoid sinus thrombosis
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Managements
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Surgical exploration
Mastoidectomy to expose the sigmoid sinus
 A needle may be used to aspirate the sinus, if freeflowing blood returns, then no additional surgery is
needed. If no blood returns, then open and
draining the sinus are indicated.
 In the face of ongoing septic pulmonary emboli,
internal jugular vein ligation can be performed.
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Sigmoid sinus thrombosis
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Managements
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Medical treatment
Antibiotics
 Anticoagulation (in individual cases, in the face of
propagating thrombosis)
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Meningitis
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Among intracranial complications of
COM, meningitis is one of the most
common, it account for 50% of the
intracranial complications.
In COM, bacterial contamination
may occur via bone erosion with
epidural abscess/granulation
formation or retrograde
thrombophlebitis of emissary veins.
Meningitis
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Diagnosis
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Symptoms of COM
High fever, headache, vomiting
Neck stiffness and altered mental status
CT or MRI will document meningeal enhancement
Lumbar puncture and examination of the CSF is
mandatory (CFS leukocytosis and low glucose,
elevated level of protein and lactate, bacteria culture
present positive)
Meningitis
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Managements
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Urgent antibiotic (culture and sensitivity reports from
the CSF samples can further direct antibiotic therapy
Adjunctive therapy (dexamethasone can reduce the
neurologic and auditory squelae of bacterial
meningitis
Reduce the high intracranial pressure
Mastoidectomy (removal lesion and achievement of
drainage)
Brain abscess
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62% of abscesses were
located in the tempora lobe
and 34% in the cerebellum
Direct extension along
preformed pathways or
perivascular channels is more
likely route of infection.
The thin bone of tegmen may
be more easily violated than
the bone overlying the
posterior fossa dura, given the
increased frequency of
temporal lobe versus
cerebellar abscess.
Brain abscess
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phases
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Initial phase: localized microfoci and cerebritis
or encephalitis
Second phase: expansion and secondary
delineation of the abscess
Final phase: a dense fibroglial scar (capsule)
or rupture.
Brain abscess
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Diagnosis
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Fever, headache and vomiting.
Symptoms and signs are derived from the
location and size of abscess
MRI may be more sensitive in defining area of
cerebritis
Brain abscess
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Temporal abscess
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Contralateral body paralysis
Facial paralysis (central)
Mutism
Cerebellar abscess
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Central nystagmus
Reduction of muscle tension
Ataxia
Dysfunction of distance
perception
Brain abscess
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Treatments
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Antibiotic (penetration of the blood-brain barrier
should be considered)
Steroid is administered to reduce brain swelling,
dehydration agent will reduce intracranial pressure.
Surgical drainage and excision of abscess required
Otologic surgery depends on the patient’s clinical
stability