Transcript PPT 4 - The Medical Post | Trusting Medicine

Complications of
Suppurative Otitis
Media
Dr. Vishal Sharma
Definition
Infection spreads beyond muco-periosteal
lining of middle ear cleft to involve bone &
neighboring structures like facial nerve, inner
ear, dural venous sinuses, meninges, brain
tissue & extra-temporal soft tissue.
Features of Complications
• Severe otalgia, painful swelling around ear
• Vertigo, nausea, vomiting
• Headache + blurred vision + projectile vomiting
• Fever + neck rigidity + irritability / drowsiness
• Facial asymmetry
• Otorrhoea + Retro-orbital pain + diplopia
• Ataxia
Classification
• Intra-cranial
• Extra-cranial, Intra-temporal
• Extra-cranial, Extra-temporal
• Systemic: septicemia, otogenic tetanus
Classification
Intra-cranial Complications
1. Extra-dural abscess
2. Subdural abscess
3. Meningitis
4. Brain abscess
5. Lateral Sinus thrombophlebitis
6. Otitic hydrocephalus
7. Brain fungus (fungus cerebri)
Intra-temporal Complications
• Acute mastoiditis
• Coalescent mastoiditis
• Masked mastoiditis
• Facial nerve palsy
• Labyrinthitis
• Labyrinthine fistula
• Apex Petrositis (Gradenigo syndrome)
Extra-temporal Complications
1. Post-auricular abscess
2. Bezold abscess
3. Citelli abscess
4. Luc abscess
5. Zygomatic abscess
6. Retro-mastoid abscess
Factors Affecting
Pathogen Factors
Patient Factors
 High virulence bacteria
 Young age
 Antimicrobial resistance
 Poor immune status
 Chronic disease (DM, TB)
Physician Factors
 Poor socio-economic status
 Non-availability
 Lack of health awareness
 Injudicious antibiotic use
 Error in recognizing dangerous symptoms & signs
Routes of entry
1. Bony erosion (cholesteatoma destruction, osteitis)
2. Retrograde Thrombophlebitis
3. Anatomical pathway: oval window, round window, internal
auditory canal, suture line, cochlear & vestibular aqueduct
4. Congenital bony defects: facial canal, tegmen plate
5. Acquired bony defects: fracture, neoplasm, stapedectomy
6. Peri-arteriolar space of Virchow-Robin: spread into brain
Erosion of tegmen tympani
Coalescent Mastoiditis
or Surgical Mastoiditis
Pathogenesis
Aditus Blockage
 Failure of drainage
 Stasis of secretions
 Hyperemic decalcification
 Resorption of bony septa of air cells
 Coalescence of small air cells to form cavity
 Empyema of mastoid cavity
Pathogenesis
Clinical Features & Investigation
• Otorrhoea > 2 weeks, otalgia & deafness
• Mastoid reservoir sign: pus fills up on mopping
• Sagging of postero-superior canal wall due to periosteitis of bony wall b/w antrum & posterior E.A.C.
• Ironed out appearance of skin over mastoid due to
thickened periosteum
• Mastoid tenderness present
• Mastoid cavity in X-ray & CT scan
Mastoid reservoir sign
Sagging of posterior wall
Ironed out appearance
Mastoid cavity
Mastoid cavity
Mastoiditis
Furunculosis
H/o otitis media
+
-
Deafness
+
-
Position of pinna
Down + outward
+ forward
Forward
Post-aural groove
Deepened
Obliterated
Ear discharge
Muco-purulent
Serous / purulent
Sagging of EAC wall
+
-
TM congestion
+
-
Tenderness
Mastoid
Tragal
Post-aural lymph node
-
+
X-ray Mastoid
Coalescence of
cells + cavity
Normal
Treatment
• Urgent hospital admission
• Broad spectrum I.V. antibiotics
 No response to medical treatment in 48 hrs
 Development of new complication
 Presence of sub-periosteal abscess
– Myringotomy to drain out painful pus
– Incision drainage of sub-periosteal abscess
– Cortical Mastoidectomy
Sub-periosteal
abscess & fistula
Pathology
Production of pus under tension
 hyperaemic decalcification (halisteresis)
+ osteoclastic resorption of bone
 sub-periosteal abscess
 penetration of periosteum + skin
 fistula formation
Sub-periosteal abscess formation
Sub-periosteal fistula: dry
Sub-periosteal fistula: wet
Types of sub-periosteal abscess
• Post-auricular
• Bezold
• Citelli
• Zygomatic
• Luc
• Retro-mastoid
• Parapharyngeal & Retropharyngeal
Types of sub-periosteal abscess
Post-auricular abscess
Commonest. Present behind the ear.
Pinna pushed forward & downward.
Bezold & Citelli abscesses
Bezold: neck swelling
over sternocleido-
mastoid muscle
Citelli: neck swelling
over posterior belly
of digastric muscle
D/D of Bezold’s abscess
1. Suppurative lymphadenopathy of upper
deep cervical lymph node
2. Para-pharyngeal abscess
3. Parotid tail abscess
4. Infected branchial cyst
5. Internal jugular vein thrombosis
Luc: swelling in external auditory canal
Zygomatic: swelling antero-superior to pinna +
upper eyelid oedema
Retro-mastoid: swelling over occipital bone
(? Citelli’s abscess)
Parapharyngeal & Retropharyngeal: due to spread
of pus along Eustachian tube
Retromastoid abscess
Incision drainage of abscess
Gradenigo syndrome
 Persistent otorrhoea: despite adequate
cortical mastoidectomy
 Retro-orbital pain: Trigeminal nv involvement
 Diplopia: convergent squint due to lateral rectus
palsy by injury to abducent nv in Dorello’s canal under
Gruber’s petro-sphenoid ligament, at petrous apex
Persistent otorrhoea + Retro-orbital pain +
Convergent squint
Right Convergent squint
Right gaze
Central gaze
Left gaze
Etiology: Coalescent mastoiditis involving
petrous apex along postero-superior & anteroinferior tracts in relation to bony labyrinth
Diagnosis: 1. C.T. scan temporal bone for bony
details. 2. M.R.I. to differ b/w bone marrow & pus
Treatment: Modified radical mastoidectomy &
clearance of petrous apex cells
C.T. scan & M.R.I.
Hearing preserving approaches to petrous apex
• Eagleton’s middle cranial fossa approach
• Frenckner’s subarcuate approach
• Thornwaldt’s retro-labyrinthine approach
• Dearmin & Farrior’s infra-labyrinthine approach
• Farrior’s hypotympanic sub-cochlear approach
• Lempert Ramadier’s peri-tubal approach
• Kopetsky Almoor’s peri-tubal approach
Hearing sacrificing approaches to petrous apex
• Trans-cochlear approach
• Trans-labyrinthine approach
Spread of pus
Labyrinthitis
Introduction
Inflammation of endosteal layer of bony labyrinth
Route of infection:
 Round window membrane
 Pre-formed opening (Stapedectomy)
 Retrograde spread of meningitis via IAC / aqueducts
Clinical forms:
1. Circumscribed (labyrinthine fistula)
2. Diffuse serous
3. Diffuse suppurative
• Circumscribed: Fistula commonly involves
lateral SCC. Presents with transient vertigo &
positive fistula test  I/L nystagmus with +ve
pressure; C/L nystagmus with -ve pressure
• Serous: Reversible, non-purulent, mild vertigo,
I/L nystagmus, mild sensori-neural hearing loss
• Purulent: Irreversible, purulent, severe vertigo,
C/L nystagmus, severe / profound hearing loss
Treatment:
Bed rest (affected ear up). Avoid head movement.
Labyrinthine sedative: Prochlorperazine, Cinnarizine
Broad spectrum I.V. antibiotics
Modified Radical Mastoidectomy: removes infection
Open labyrinthine fistula: cover with temporalis fascia
Fistula covered with cholesteatoma matrix
< 2 mm: remove matrix & cover with temporalis fascia
> 2 mm / multiple / over promontory: leave it
Rehabilitation by Cawthorne-Cooksey Exercises
Lateral SSC Fistula
Facial nerve paralysis
• Within 1st wk: due to nerve sheath edema
• After 2 wks: due to bone erosion
• Lower motor neuron palsy
• Common in tubercular otitis media
Treatment:
• Modified Radical Mastoidectomy
• Facial nerve decompression seldom required
Meningitis
• High grade persistent fever with rigors
• Severe headache & neck stiffness
• Irritability  drowsiness  confusion  coma
• Neck rigidity positive
• Kernig sign positive; Brudzinski sign positive
• Papilloedema
• Lumbar Puncture:  cell count,  protein,  sugar
• I.V. Ceftriaxone + Metronidazole + Gentamicin
• Radical Mastoidectomy once patient is stable
Test for neck rigidity
Otogenic brain
abscess
Introduction
50-75 % adult brain abscess & 25% in child = otogenic
Temporal abscess : Cerebellar abscess = 2:1
Route of infection: 1. Direct spread:
 via Tegmen plate: Temporal abscess
 via Trautmann’s triangle: Cerebellar abscess
2. Retrograde thrombophlebitis
Trautmann’s triangle
Superiorly: superior
petrosal sinus
Posteriorly: sigmoid sinus
Anteriorly: solid angle
(semi-circular canals)
Pathway to posterior
cranial fossa from mastoid
cavity
Stages of brain abscess
1. Invasion or Encephalitis (1-10 days)
2. Localization or Latent Abscess (10-14 days)
3. Expansion or Manifest Abscess (> 14 days):
leads to raised intracranial tension & focal signs
4. Termination or Abscess rupture: leads to fatal
meningitis
Stages of brain abscess
Clinical Features of ed I.C.T.
Seen more in cerebellar abscess
• Severe persistent headache, worse in morning
• Projectile vomiting
• Blurring of vision & Papilloedema
• Lethargy  drowsiness  confusion  coma
• Bradycardia
• Subnormal temperature
Focal Clinical Features
Temporal Lobe
Cerebellum
 Nominal aphasia
 I/L nystagmus
 Quadrantic homonymous
 I/L weakness
 I/L hypotonia
hemianopia (C/L)
 Epileptic seizures
 I/L ataxia
 Pupillary dilatation
 Intention tremor
 Hallucination (smell & taste)
 Past-pointing
 C/L hemiplegia
 Dysdiadochokinesia
Bacteriology
• Anaerobic streptococci
• Streptococcus pneumoniae
• Staphylococci
• Proteus
• E. coli
• Pseudomonas
• Bacteroidis fragilis
Investigations
CT scan of brain & temporal bone with contrast
 Site, size & staging of abscess
 Observe progression of brain abscess
 Associated intra-cranial complications
MRI brain
 D/D: pus, abscess capsule, edema & normal brain
 Spread to ventricles & subarachnoid space
Avoid lumbar puncture to prevent coning
Temporal abscess in CT scan
Cerebellar abscess
Medical Treatment
• High dose broad spectrum I.V. antibiotics:
Ceftriaxone + Metronidazole + Gentamicin
• I.V. Dexamethasone 4mg Q6H: es oedema
• I.V. 20% Mannitol (0.5 gm/kg): es I.C.T.
• Anti-epileptics: Phenytoin sodium
• Antibiotic ear drops & aural toilet
Surgical Treatment
• Repeated burr hole aspirations
• Excision of brain abscess with capsule: best Tx
• Open incision & evacuation of pus
• Radical mastoidectomy after pt becomes stable
Lateral sinus
thrombophlebitis
Pathogenesis
Lateral sinus = Sigmoid sinus + Transverse sinus
Erosion of sigmoid sinus plate  peri-sinus
abscess  inflammation of outer wall 
endophlebitis  mural thrombus  occlusion
of sinus lumen  intra-sinus abscess 
propagating infected thrombus
Pathogenesis
Spread of thrombus
Proximal: 1. To superior sagittal sinus via torcula
Hirophili  hydrocephalus
2. To cavernous sinus  proptosis
3. To mastoid emissary vein  Griesinger’s sign
Distal: To internal jugular vein & subclavian vein 
pulmonary thrombo-embolism & septicaemia
Clinical Features
• Remittent high fever with rigors (picket fence)
• Pitting edema over retro-mastoid area & occipital
bone due to mastoid emissary vein thrombosis
(Griesinger’s sign)
• Tenderness along Internal Jugular Vein
• Headache
• Anaemia
Fever charts in C.S.O.M.
Brain
abscess
Meningitis
Lateral Sinus
Thrombophlebitis
Picket fence fever
• High fever, swinging
type
• Chills precedes fever
• Temperature subsides
with sweating
• Each fever spike due
to release of fresh
septic embolus
Special Tests
• Queckenstedt or Tobey-Ayer test: compression
of I.J.V.  rapid rise of C.S.F. pressure (50 – 100
mm water  rapid fall on release of
compression. In L.S.T. no rise / rise by only 10 –
20 mm water.
• Lillie – Crowe - Beck test: pressure on I.J.V. on
normal side  engorgement of retinal veins +
papilloedema seen in fundoscopy due to L.S.T.
on opposite side.
Tobey Ayer Test
Retinal vein dilation &
optic disc edema
Investigations
Lumbar puncture: to rule out meningitis
CT brain with contrast:
MRI brain with contrast:
Delta sign or
Empty triangle sign
MR angiography
Blood culture
Culture & sensitivity of ear discharge
Peripheral blood smear: to rule out malaria
Delta sign
Treatment
1. Radical mastoidectomy: Removal of disease +
needle aspiration to confirm diagnosis. Sinus wall
incised. Infected clots removed & abscess drained.
2. I.V. Ceftriaxone + Metronidazole + Gentamicin
3. Anticoagulants: in cavernous sinus thrombosis
4. Internal jugular vein ligation: for embolism not
responding to antibiotics & surgery
5. Blood transfusion: for anaemia
Extra-dural abscess
Extra-dural abscess
Commonest otogenic intra-cranial complication
Collection of pus b/w skull bone & dura of middle
or posterior cranial fossa
Majority asymptomatic. Suspected in case of:
 Profuse, intermittent, pulsatile, purulent, otorrhoea
 Low grade fever  I/L Persistent headache
 Recurring meningococcal meningitis
CT scan brain shows extra-dural abscess
Tx: I.V. Ceftriaxone + Metronidazole + Gentamicin
Modified Radical mastoidectomy
Drill tegmen or sinus plate  pus drained
Extra-dural abscess
Subdural abscess
Subdural abscess
Collection of pus b/w dura & arachnoid by erosion of
bone & dura mater or by retrograde thrombophlebitis
Due to rapid spread of pus, symptoms of raised intracranial tension & meningeal irritation develop quickly
CT scan brain shows subdural abscess
Tx:
I.V. Ceftriaxone + Metronidazole + Gentamicin
Burr hole evacuation of pus
Radical mastoidectomy after pt becomes stable
Subdural abscess
Otitic
Hydrocephalus
Synonym:  Benign intra-cranial hypertension
 Symond’s syndrome
Etiology: 1. Associated L.S.T.  obstruction of
cerebral venous return.
2. Superior sagittal
sinus thrombosis  ed C.S.F. absorption
Clinical Features: 1. Severe headache, vomiting
2. Blurred vision, papilloedema, optic atrophy
3. Abducens palsy & diplopia due to raised
intra-cranial tension (False localizing sign)
Investigations:
1. Lumbar puncture: ed CSF pressure (> 300 mm
H2O). Biochemistry & bacteriology normal
2. CT scan brain: normal ventricles
Treatment: 1. Tx of L.S.T.: I.V. antibiotics & MRM
2. se CSF pressure (prevents optic atrophy) by:
 I.V. Dexamethasone 4mg Q6H
 I.V. 20% Mannitol 0.5 gm/kg
 Repeated lumbar puncture / lumbar drain
 Ventriculo-peritoneal shunt
Brain Fungus
• Prolapse of brain into middle ear cavity / mastoid
cavity due to erosion of dural plate.
• Common in pre-antibiotic era. Rarely seen now
in resistant infections.
• Diagnosis: C.T. scan temporal bone.
• Treatment: Removal of necrotic tissue,
replacement of healthy prolapsed brain into
cranial cavity & repair of bone defect.
Fungus Cerebri
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