Download complications of OM - Ain Shams University

Department of Otorhinolaryngology
COMPLICATIONS
of Suppurative Otitis Media
Ossama Mahmoud
Professor of Otorhinolaryngology
Ain Shams University
Complications of Otitis Media
The temporal bone is a complex
anatomic region with close proximity to
a variety of critical structures. These
structures are at risk during both acute
and chronic suppurative otitis media.
Complications of Otitis Media
• Due to antibiotics, the incidence of
complications has greatly declined. (also
treating surgical problems with antibiotics
alone or giving incomplete courses that
mask the infection lead to complications)
• Complications are usually associated with
granulation tissue formation and/or the
presence of a cholesteatoma (bone
erosion).
Complications of Otitis Media
Complications arise mostly due to:
-- Infection spreading by direct extension
from the middle ear or mastoid cavity to
adjacent structures.
- Thrombophlebitis (haematogenous)
Complications of Otitis Media
• Patients appear more ill than expected
– fever, new onset vertigo, sensorineural hearing loss,
fetid drainage, facial nerve weakness, proptotic ear
– lethargy and mental status changes
• CT and MRI are indicated
– CT is superior for evaluating the bony details of the
middle ear and mastoid space
– MRI is more sensitive for diagnosing suspected
intracranial complications.
Complications of Otitis Media
Treatment is:
Parentral Broad Spectrum
Antibiotics and
Surgery are required
Complications of Suppurative O.M.
Cranial (or Temporal bone) complications:
1- Acute Mastoiditis.
2- Acute Petrositis.
3- Otitic Facial paralysis.
4- Acute Labyrinthitis.
Complications of Suppurative O M (cont.)
Intracranial Complications
1- Extra-dural (epidural) abscess.
2- Meningitis.
3- Brain abscess (cerebral or cerebellar).
4- Lateral sinus thrombosis.
Extracranial complications
1- External otitis.
2- Jugular vein thrombophlebitis
3- Bezold’s abscess
4-Retropharyngeal abscess.
Acute Mastoiditis
Acute Mastoiditis
Extension of the suppurative inflammatory
process beyond the mucous membrane lining of
the mastoid air cells leading to osteitis of the
bony septa.
N.B. At this early stage resolution is possible
without surgery, if proper medical treatment is
given.
Acute Mastoiditis (cont.)
The bony inter-cellular
septa will break down
with coalescence of the
infected cells to form one
cavity full of pus leading to
Coalescent Mastoiditis or
Mastoid Abscess.
Acute Mastoiditis (cont.)
In early Coalescent Mastoiditis the outer cortex
of mastoid is intact but with extension of the
disease pus may erode outer cortex of mastoid
leading to Subperiosteal Mastoid Abscess
which can extend by perforating the
periosteium to became Subcutaneous
Mastoid Abscess. If it opens through the skin
Mastoid Fistula will result.
Clinical Picture
Exaggerated symptoms of ASOM (fever, pain and HL)
1- Tenderness over mastoid antrum and
2-External swelling
A- Post-auricular abscess
- Auricle is displaced outwards, forwards and downwards
(erect auricle).
- Post-auricular groove is preserved but if the abscess
ruptures through periosteum and becomes subcutaneous ,
the groove will be obliterated.
- DD. Post auricular lymphadenitis 2ry to Furunculosis of
external auditory meatus.
Clinical Picture
Early stage of Mastoiditis
Mastoid fistula
Mastoid Abscess
Clinical Picture
B- Zygomatic abscess ;
It is due inflammation of the zygomatic air cells. The
swelling is above and in front of the ear.
C- Bezolds abscess;
Pus pierces the tip or inner surface of mastoid and form
abscess in the sternomastoid muscle In the neck.
D- Retropharyngeal abscess;
Pus tracking from the peritubal cells along the
Eustachian tube.
Clinical Picture
3- Internal swelling
Sagging of posterosuperior bony meatal wall, due
to periostitis and edema over the anterior antral
wall.
4- Ear discharge usually profuse , "Mucopurulent
or purulent and may be pulsating with reservoir
sign “ rapid re-accumulation "
5- Drum membrane perforated (small with
pulsating discharge) or intact and bulging.
Investigations
1- C&S of ear discharge
2- CT scan of the
temporal bone to
detect any additional
cranial or
intracranial
complications
Treatment of Acute Mastoiditis
1- Conservative treatment
is to be tried for 48 hours in mild cases without evidences
of abscess formation; parentral broad spectrum
antibiotics.
Myrigotomy if DM found intact and bulging.
2- Cortical Mastoidectomy operation
is the standard treatment if the patient is not responding to
conservative treatment, or if a mastoid abscess is evident
or if other complications are suspected to be present.
Masked Mastoiditis
It Is the result of INCOMPLETE TREATMENT of ASOM with
antibiotics leading to masking of the acute symptoms
while the pathological process is progressing in the
mastoid.
Clinical picture:
- Slight pain and tenderness over the mastoid.
- Intra-cranial complications may occur and may be the
presenting symptom.
Chronic Mastoiditis
• There is thick unhealthy chronically inflamed
mucosa with granulation tissue and osteitis with
sclerosis of mastoid air cells.(sclerosed mastoid
in X-Ray)
• It is condition which may be present in CSOM
(tubo-tympanic type and attico-antral types).
• Persistent ear discharge is the main presenting
symptom
Cortical Mastoidectomy Operation
• It is a drainage operation in which
exentration of the mastoid air cells is
done.
• It is a preliminary step in most of ear
surgeries
INDICATIONS
1- Acute Mastoiditis with failure of
medical treatment (persistent pain,
tenderness and fever , etc ,… for more
than 2 days).
2- Subperiosteal Mastoid abscess.
3- Mastoid fistula.
4- Mastoiditis with complications as
facial paralysis, meningitis or lateral
sinus thrombosis.
INDICATIONS
5- Persistent ear discharge in cases of ASOM
or CSOM (tubo-tympanic) for more than one
month despite proper conservative treatment
6-Resistant cases of OME.
7- Part of ear surgeries (e.g. Sac operations in
Meniere‘s disease ------- etc.).
Petrositis
It is inflammation of the air cells in the
petrous apex of the temporal bone , the 6th
(abducent) and 5th (trigeminal) cranial nerves
are affected as they are closely related to the
petrous apex.
Petrositis (cont.)
Clinical Picture
The condition is called
“GRADINIGO SYNDROME”
Triade of :
1- Diplopia with convergent
squint due to 6th nerve
paralysis.
2- Trigeminal neuralgia
(retro-orbital pain and
headache) due to
irritation of the trigeminal
ganglion.
3- Discharging ear.
Petrositis
(cont.)
Investigations:
1- CT scan of temporal bone
2- C&S of ear discharge
Treatment :
1- Conservative in mild and early cases
2- Mastoidectomy with exentration of
petrous apex air cells or subtotal
petrosectomy
Otitic Labyrinthitis
It is a complication of
ASOM or more
common CSOM.
Types:
1.Circumscribed
Labyrinthitis.
(labyrinthine fistula).
2.Diffuse serous
Labyrinthitis.
3.Diffuse suppurative
Labyrinthitis.
Circumscribed Labyrinthitis
“Labyrinthine Fistula/ Para-labyrinthitis”
It results from erosion of the bony
wall of one of the SSC (usually the
lateral) , or less commonly the
promontory by cholesteatoma.
The inflammatory process is
outside the endosteal lining of the
labyrinth (intact inner ear function).
Labyrinthine Fistula
Clinical Picture
In addition to the clinical picture of OM
new symptoms appear in the form of
• Intermittent attacks of vertigo
• Usually not accompanied by nausea and
vomiting and usually precipitated by
pressure on the tragus or sudden head
movement.
Labyrinthine Fistula
Clinical Picture
Nystagmus accompanies the
vertigo and usually horizontal with
rapid component to the affected
side (irritant lesion).
Labyrinthine Fistula
Clinical Picture
Fistula test is
positive (pressure on
tragus, use of
pneumatic otoscope
or manipulating an
aural
polyp
induces vertigo and
nystagmus).
Diffuse serous Labyrinthitis
“Catarrhal Labyrinthitis”
It is a serous inflammation of the membranous
labyrinth (inflamatory cells in the peri-lymph
without organisms).
Clinical Picture:
1. That of ASOM or CSOM.
2. Vertigo, nausea & vomiting are severe.
3. Nystagmus is usually horizontal with rapid
component to affected side (irritant lesion).
4. Deafness becomes severe and mixed
(Conductive & SNHL).
Diffuse purulent Labyrinthitis
• At first the previous symptoms increase
markedly and HL may be severe or total.
• Nystagmus is beating first towards the
affected side (irritant) but changes to the
other side (dead labyrinth) when destruction
of the labyrinth becomes complete.
Nystagmus will disappear later as it will
be compensated by the healthy side.
Diffuse Purulent Labyrinthitis
Absent or minimal toxic manifestations
as the surface area of the inner ear is
small so there is no or little diffusion of
toxins.
Presence of fever and other toxic
manifestations may suggest
occurrence of
meningitis.
Treatment of Labyrinthitis
Conservative Treatment
- Antibiotics that cross the BBB to guard against
meningitis.
- Labyrinthine sedatives and anti-emetics :
as Dramamine , stugeron, diazepam “valium”
and zofran (4mg) amp. .
Surgical Treatment either;
- Cortical mastoidectomy for control of
suppurative otitis media, or
- Radical mastoidectomy and labyrinthectomy in
cases of supprative labyrinthitis with dead
labyrinth to prevent intracranial extension of
infection
Otitic Facial Nerve Paralysis
As a complication of ASOM facial nerve paralysis
occurs in children if there is congenital
dehiscence in the bony canal of the nerve (20%
of population). Paralysis is usually incomplete and
is due to inflammation of the nerve sheath and
compression by pus.
Treatment:
1. Early myringotomy (usually with Grommet’s tube)
2. Antibiotics (parentral) and steroids.
3. Cortical mastoidectomy if the paralysis persist
in spite of other lines of treatment or if there is
acute mastoiditis.
Facial Nerve Paralysis as a complication of
CSOM
Destruction of the bony
canal and pressure on
the nerve is either by:
1) Cholesteatoma
2) Osteomylitis of the
mastoid.
3) Tuberculous OM.
(Multiple Drum M.
perforations & pale
mucosa).
Facial Nerve Paralysis as a complication of
CSOM
Treatment
1- Mastoidectomy operation with exposure
and decompression of the facial nerve.
2- In case of tuberculous OM Antituberculous ttt usually gives cure of
the paralysis. Surgical ttt is only for
cases showing no recovery after the
disease has been cured.
Post operative Facial Paralysis
(Iatrogenic)
1.Immediate after the operation is due to direct
trauma to the nerve.
Treatment :
• If Partial: corticosteroids & antibiotics.
• If Complete: Immediate exploration of the
nerve and remove any bone specule
compressing the nerve or do nerve suturing
or nerve graft if needed (from Greater
Auricular nerve).
Post-operative facial paralysis
2. Delayed (few hours or days after recovery)
usually due to pressure on the nerve by
edema ,haematoma or tight pack.
Treatment:
1) Removal of the pack.
2) Antibiotics & Cortisone.
Extradural Abscess
It is collection of
pus and /or
granulation
tissue between
skull bone and
dura.
Extradural Abscess
Clinical Picture
The condition is usually symptomless and
accidentally discovered during mastoidectomy.
Presentations :
There may be persistent
1- Earache or headache.
2- Low grade Fever (about 37.5 - 38°C).
3- Pulsating ear discharge.
Extradural Abscess
Treatment
1- Antibiotics (Injection) that cross BBB.
2- Cortical Mastoidectomy operation ,
abscess must be evacuated and bone
must be removed until healthy dura is
reached.
Diffuse Leptomeningitis
It is diffuse inflammation of the arachnoid,
subarachnoid space & pia mater.
Symptoms
1) Symptoms of infection e.g. high fever,
malaise……. etc.
2) Symptoms of increased intracranial
tension:
- Severe headache. - Vomiting.
- Blurring of vision.
3) Symptoms of meningeal irritation Irritability ,
Photophobia , neck rigidity and retraction.
Diffuse Leptomeningitis
Signs
1) High fever (> 39 C) and tachycardia.
2) Neck Rigidity.
3) Signs of meningeal irritation:
a- Kernig’s sign
Flex hip and knee ,then trying to extend the
knee will produce severe pain and will be
resisted by the patients.
b- Brudziniski’s sign
Flex the neck , hip and knee will become flexed.
4- Papilloedema (edema of optic disc) on fundus
examination.
Investigations of Meningitis
A- CT Temporal Bone & Brain (To detect
probable intracranial complication if any).
B- Lumbar Puncture:
1- CSF examination.
2- Culture & Sensitivity.
C.S.F. In meningitis normal CSF
Aspect
Turbid.
Clear.
Pressure
High.
60-180mm Of
CSF.
Cells
Thousands, mainly
polymorphs.
1-5 lymphocytes
per c mm.
Proteins
Increased (due to
the bacteria).
40 mg/100 ml.
Sugar
Decreased
( nutrition
bacteria).
80 mg/100 ml.
of
Chloride
Decreased
(due to vomiting).
750 mg/l00 ml.
Organisms
Can be cultured.
Absent.
Treatment of Meningitis
1- Antibiotics:
i- Intrathecal injection of crystalline penicillin
ii- Intravenous injection of drugs crossing BBB as,
3rd generation cephalosporins & Flagyl for anerobes
2- Measures to reduce the increased intracranial
tension:
i- Repeated lumbar punctures.
ii- Hypertonic glucose solution IV & Diuretics.
iii- Dexamethason injections.
Brain Abscess
It is either Temporal or Cerebellar
Brain Abscess
Clinical Picture
I- Stage of encephalitis:
1- High fever & rapid pulse.
2- Rigors or convulsions specially in
children.
3- Headache.
Brain Abscess
Clinical Picture (cont.)
II- Latent Stage:
(weeks to months)
Due to localization of the abscess with
diminished brain. Most of symptoms
disappear and patient may feel some
headache and lack of concentration.
Brain Abscess
Clinical Picture
III- Manifest Stage:
Due to increase in the size of the abscess.
A- Manifestations of Toxaemia:
i. Anorexia and loss of weight.
ii. Mental dullness , slow cerebration and
delirium.
iii. Leucocytosis which may reach 20.000 or
more.
Brain Abscess
Clinical Picture
B- Manifestations of Increased Intracranial
Tension:
1- Headache which is severe and not relieved by
analgesics.
2- Projectile vomiting (not preceded by nausea
and not related to meals).
3- Blurring of vision due to papilloedema.
Brain Abscess
Clinical Picture
Prolonged increased ICT may lead to
- Slow full pulse(40/min.)
- Subnormal temperature
- Slow cerebration
- Slow deep respiration
Brain Abscess
C- Manifestations of Localization:
Temporal Lobe Abscess
- Nominal Aphasia (inability to name objects due to
pressure on Broca’s area)
- Homonymous hemi-anopia( defect in field of
vision)
- Uncinate fits (epileptic fits preceeded by aura)
- Hemiplegia
- Hemianesthesia
Brain Abscess
Clinical Picture
Cerebellar Abscess:
1. Tremors with muscle weekness (hypotonia).
2. Slurred speech
3. Incoordination of movements (asynergia and
dysmetria) can be shown by finger nose test.
4. Ataxia: unsteadiness of gait with deviation to
the side of lesion.
5. Vertigo and nystagmus.
6. Dysdiadokokinesis: ( patient is unable to do
rapid pronation and supination ).
Brain Abscess
Clinical Picture
IV- Terminal Stage:
Due to rupture of the abscess
resulting in either:
1) Diffuse encephalitis. or
2) Diffuse meningitis.
Coma and death will occur.
Brain Abscess
Investigations
1. CT scan with contrast &/ or MRI show site , size
of abscess and whether acute or chronic
2. Fundus examination show Papilloedema.
3. Field of vision
examination show
homonymmous hemianopia.
4. CBC show marked leucocytosis (20000).
5. C/S from pus from abscess after drainage or
from ear discharge.
N.B. Never do Lumber Puncture as
CONIZATION of medulla may occur due to marked
rise of I.C.T.
Brain
Abscess
Brain Abscess
Treatment
Acute Abscess
1. Antibiotics that cross BBB.
2. Measures to Lower the increased ICT.
3. Repeated Tapping
of abscess through
burr holes by neurosurgery
or
through
mastoidectomy (N.B. Repeated CT must be
done to ensure complete drainage).
4. Mastoidectomy of the affected ear as a
treatment for otitis media when the condition
of the patient allows.
Brain Abscess
Treatment
B. Chronic Abscess
1. Excision
2. Antibiotics (Parentral-crossing BBB) .
3. Mastoidoidectomy for affected ear when
the condition of the patient allows.
Lateral Sinus Thrombophlebitis
It is infective thrombosis of the
lateral (sigmoid) venous sinus.
Lateral Sinus Thrombophlebitis
Pathogenesis
• Peri-sinus abscess (type of extra-dural abscess) is
formed as an extension from infected mastoid
• Infection extends into the sinus wall and lumen
causing thrombophlebitis.
• Infected thrombus may be fragmented with
detachment of septic emboli in blood stream
• Extension of thrombosis to cavernous , supermay
take placeior petrosal, superior sagittal sinus or to
the internal jugular vein may occur
Lateral Sinus Thrombosis
Clinical Picture
1- Pyaemic Type (Malarial like)
- Remittent fever and rigors occurring at
irregular intervals, between them temp.
reach near the base line ( remains above
37°C).
- Multiple pyaemic abscesses in different
parts of the body due to separation of septic
emboli.
Lateral Sinus Thrombosis
Clinical Picture
D.D. from Malaria
a- Fever and rigors in malaria occurs at
regular intervals and between them
temp. can reach 37°C.
b- Leucopenia in malaria instead of
leucocytosis in thrombosis.
c- Blood film will show malaria
parasites. (during the attack)
Lateral Sinus Thrombosis
Clinical Picture (cont.)
2- Septicaemic or Typhoid Type
Continuous fever without remissions or
rigors.
D.D. from Typhoid fever:
a- Widal test Is positive in typhoid.
b- Leucopenia in typhoid.
3- Latent Type
Condition may be asymptomatic and
discovered only during Mastoid
Operation for acute mastoiditis.
Lateral Sinus Thrombosis
Clinical Picture
4- If Septic thrombosis extend to the Jugular
vein in the neck.
a- Cord like mass in the neck.
b- Torticollis.
c- Cervical lymphadenitis may occur.
Lateral Sinus Thrombosis
Treatment
1) Antibiotics (according to blood culture??? )
2) Antipyretic analgesics, light diet, fluids.
3) Anticoagulants as heparin may be given in cases
with extension of the thrombus ????.
4) Mastoidectomy operation and exposure of the
sinus with removal of bone until healthy
dura is reached.
Incision of the sinus and evacuation of the
infected clot is done until unclotted blood is
reached.
Lateral Sinus Thrombosis
Treatment
Ligation of the internal Jugular vein
can be done if we cannot reach
the lower limit of the thrombus
and it must be ligated below the level
of common facial vein which must be
ligated also to avoid cross thrombosis
to the cavernous sinus.
Lateral Sinus Thrombosis
Treatment
N.B. During operation we must
differentiate between thrombosed sinus
and healthy one by the following:
Thrombosed sinus is:
1)Grayish and dull instead of bluish and
glistening.
2)Firm and pulsating instead of soft and not
pulsating.