Download presentation
Presentation is loading. Please wait.
1
Complications of Cholesteatoma
4/20/2017 Complications of Cholesteatoma Dr. Supreet Singh Nayyar, AFMC For more presentations, visit 18/07/2012
2
Overview Cholesteatoma –A Historical perspective Cholesteatoma
4/20/2017 Overview Cholesteatoma –A Historical perspective Cholesteatoma Origin of cholesteatoma Pathophysiology of cholesteatoma Intracranial complications of cholesteatoma Conclusion 18/07/2012
3
4/20/2017 Bewildering History 1683- Durverney , first described abscess of bone originating form external auditory canal ,described it as .scales 1892-Cruveilhier described it as avascular tumor arising from subarachnoid space 1838- Muller coined the term cholesteatoma as he demostrated presence of chloestrin and fat in the lesion.(despite this misnomer its still used today.) 18/07/2012
4
4/20/2017 History contd.. 1855 – Virchow classified cholesteatoma among squamous cell carcinoma and atheromas, postulated that cholesteatoma arise from mesenchymal cells 1873- Von Troeltch was first to consider the epidermal origin of the disease, epidermal debri originating in EAC lead to pressure on TM –pressure induced necrosis of bone 1889- Gruber , Wendt & Rokitanski considered that middle ear mucosa undergoes metaplasia in response to chronic inflammation 18/07/2012
5
4/20/2017 Haberman & Bezold (1889)-proved that cholesteatoma arises from from skin of EAC under influence of chronic middle ear inflammation 18/07/2012
6
4/20/2017 Cholesteatoma Cholesteatoma is a three dimensional epidermal and connective tissue structure, usually in the form of a sac and frequently conforming to the architecture of the various spaces of the middle ear, attic, and mastoid. This structure has the capacity for progressive and independent growth at the expense of underlying bone, displacing or replacing the middle ear mucosa, and has a tendency to recur after removal - Abramson (Cholesteatoma – First International Conference, Birmingham, 1977) 18/07/2012
7
Epithelial invagination
4/20/2017 Epithelial invagination 18/07/2012
8
Structure of cholesteatoma
4/20/2017 Perimatrix Matrix Keratin (dry or active bacterial infection 18/07/2012
9
Pathophysiology of cholesteatoma
4/20/2017 Pathophysiology of cholesteatoma Pressure induced bone resorption Enzymatic disollution of bone by cytokine mediated inflammation -Enzyme – matrix metalloproteinases (MMP) - MMP 2,MMP9 cytokines IL-1a .IL-1b,TNF a, TGF a, EGF. 18/07/2012
10
Pathology of complications of cholesteatoma
4/20/2017 Pathology of complications of cholesteatoma Most common pathway by which disease extends beyond middle ear cleft Routes of spread of the disease Direct erosion of the bone Abnormal preformed pathways Vascular channels Natural communications Round window ,oval window Congenital: -aberrant arachnoid granulations -Meningo encephaloceles Progressive thrombophlebitis of small venules Acquired -temporal bone # involving otic capsule -Surgically created defects Along periarteriolar spaces of Virchow- Robin 18/07/2012
11
Relative incidence of Complications in mucosal and squamosal COM*
4/20/2017 Relative incidence of Complications in mucosal and squamosal COM* Extra cranial complications % Intracranial complications % Postauricular abscess Meningitis Facial palsy Brain abscess Bezolds abscess Subdural abscess Petrous apicitis Extra Dural abscess Lateral sinus thrombosis * Scott- Brown’s Otolaryngology ,Head and Neck Surgery : seventh edition. pg 3435 18/07/2012
12
Intracranial complications
4/20/2017 Intracranial complications Meningitis Temporal lobe abscess Brain abscess Cerebellar abscess Lateral sinus thrombophlebitis Extradural abscess Subdural abscess Otitic hydrocephalus 18/07/2012
13
4/20/2017 Although it is thought that majority of intracranial complications are due to squamous disease as compared to mucosal disease it is not the case. Squamous(%) Mucosal(%) Intracranial 59 41 Extra cranial overall 58 42 *Scott- Browns : Otolaryngology, Head & Neck Surgery ; Seventh edition pg3436 18/07/2012
14
Extradural abscess Anatomically Dura is a very tough structure
4/20/2017 Extradural abscess Anatomically Dura is a very tough structure when the disease reaches Dura Pachymeningitis results Dura lightly attached Lateral to arcuate Eminence - large abscess Medial to its attachment - small abscess 18/07/2012
15
4/20/2017 Large abscesses compress squamous part of temporal bone causing ostietic erosion and comes out as sub periosteal abscess – Potts puffy tumour Extra Dural abscess more common in posterior cranial fossa compared to middle fossa 18/07/2012
16
Clinical features Extradural abscess has no specific features Headache
4/20/2017 Clinical features Extradural abscess has no specific features Headache Deep seated boring pain Malaise Tenderness on tapping temporal region Communication with EAC pus discharge –relief following discharge 18/07/2012
17
Investigations Routine hematological profile Pus culture CT scan
4/20/2017 Investigations Routine hematological profile Pus culture CT scan 18/07/2012
18
Treatment Broad spectrum Antibiotics
4/20/2017 Treatment Broad spectrum Antibiotics Surgical evacuation of pus by removing underlying osteitic bone 18/07/2012
19
Lateral Sinus Thrombophlebitis
4/20/2017 Posterior cranial fossa Perisinus abscess Lateral Sinus Thrombophlebitis 18/07/2012
20
Lateral sinus Thrombophlebitis
4/20/2017 Lateral sinus Thrombophlebitis 50% of all the cases have concomitant Conditions like cerebellar abscess or meningitis Internal jugular vein(common) Cavernous sinus (rare) Superior petrosal sinus(rare) Peri sinus abscess Lateral sinus thrombosis Acute mastoiditis Pyaemia Pyaemic abscess lung Subdural abscess Brain abscess 18/07/2012
21
Clinical Features Tenderness along IJV
4/20/2017 Clinical Features Classical presentation “Picket fence fever” Fever- sweating- symptom free period- again fever Chills Rigors (temp reaching up to 40 degree Celsius) Vomiting Dehydration Tenderness along IJV *However in present day and age classical presentation is seldom seen due to advent of broad spectrum antibiotics 18/07/2012
22
4/20/2017 contd… Greisengers sign: pitting edema in post aural region due to thrombosis of mastoid emissary vein Rise in CSF pressure as demonstrated by Queckenstedts test Tobey Ayer test. Lillie Crowe test 18/07/2012
23
Investigations Complete blood count Falling Hb values
4/20/2017 Investigations Complete blood count Falling Hb values Polymorphonuclear leucocytosis HRCT temporal bone CECT – filling defect 18/07/2012
24
Management Medical a) IV Antibiotics
4/20/2017 Management Medical a) IV Antibiotics b) Anticoagulants not recommended routinely coagulation favorable to prevent bacterimia thrombosis generally not too much extensive as anticipated 18/07/2012
25
Surgical Internal jugular vein ligation-Doubtful
4/20/2017 Surgical Undertaken early to expose and treat infected lesion Timing of Mastoidectomy depends on the response to medical treatment Internal jugular vein ligation-Doubtful - thrombosis already spread beyond elective site - vein difficult to expose amidst inflamed surrounding tissues 18/07/2012
26
Brain abscess Commonest intra cranial complication Cerebellar abscess
4/20/2017 Brain abscess Commonest intra cranial complication Cerebellar abscess Temporal lobe abscess Cerebellar abscess is nearly always otogenic Majority of brain abscess are associated with chronic otitis media although acute otitis media also accounts for significant number 18/07/2012
27
Temporal lobe abscess Extra Dural abscess Localized encephalitis
4/20/2017 Temporal lobe abscess Extra Dural abscess Localized encephalitis Septic thrombosis of pial veins (ASOM) Sub cortical white matter Perivascular Liquifactive necrosis 18/07/2012
28
Cerebellar abscess Mastoiditis Peri sinus abscess Cerebellar Abscess
4/20/2017 Cerebellar abscess Mastoiditis Peri sinus abscess Cerebellar Abscess labyrinthitis 18/07/2012
29
Clinical features Increased intracranial tension Focal signs
4/20/2017 Clinical features Increased intracranial tension Focal signs Systemic disturbances 18/07/2012
30
Increased intracranial tension Vomiting Drowsiness Confusion lethargy
4/20/2017 Increased intracranial tension Vomiting Drowsiness Confusion lethargy Papillodema - long standing abscess 18/07/2012
31
Temporal lobe –visual field defect (homonymous hemianopia)
4/20/2017 Focal signs Temporal lobe –visual field defect (homonymous hemianopia) -Aphasia (nominal aphasia) if dominant hemisphere is involved - Seizures 18/07/2012
32
Cerebellar abscess – Truncal and limb ataxia - Cerebellar signs
4/20/2017 Focal signs – Cerebellar abscess – Truncal and limb ataxia - Cerebellar signs -Rhombergs test positive 18/07/2012
33
Systemic features Fever.
4/20/2017 Systemic features Fever. - In cases of Temporal lobe abscess the temperature may remain sub normal - High fever incase abscess raptures into ventricular system Loss of appetite malaise 18/07/2012
34
Pus culture and sensitivity from offending ear
4/20/2017 CT Scan MRI EEG Arteriography Pus culture and sensitivity from offending ear 18/07/2012
35
4/20/2017 Treatment Emergency in case pt deteriorating fast due to raised ICT- inj hydrocortisone 2-4 gms - 20% Mannitol Antibiotics- essential to cross BBB Definitive – Neurosurgical CWD mastoidectomy (COM)/cortical mastoidectomy (AOM) 18/07/2012
36
4/20/2017 D/D Circumscribed serous meningitis may mimic clinical and radiological features of Cerebellar Abscess Formed due to localized meningitis and cyst formation cyst in subarachnoid region 18/07/2012
37
Meningitis Infection reaching pia arachnoid
4/20/2017 Meningitis Infection reaching pia arachnoid by routes already described , commonly Serous meningitis Purulent meningitis 18/07/2012
38
Clinical features Headache Neck Stiffness
4/20/2017 Clinical features Headache Neck Stiffness Fever –initial rigors ,fever settles down to continuous fever of degree Celsius Positive Kernigs sign 18/07/2012
39
Investigations Hematological investigations CSF examination MRI / CECT
4/20/2017 Investigations Hematological investigations CSF examination MRI / CECT 18/07/2012
40
4/20/2017 Treatment Parentral antibiotic therapy- penicillin still drug of choice, 2- 4 megaunits 6 hourly Intrathecal penicillin10,000 units if initial CSF tap is turbid When pt is stabilized can be taken up for Tympano-Mastoid exploration. 18/07/2012
41
Subdural abscess Collection of pus between Dura & Arachnoid
4/20/2017 Subdural abscess Collection of pus between Dura & Arachnoid Manifests as leptomeningitis, effusion or abscess Rate of spread determines the clinical & pathological pattern. Associated with other complications 18/07/2012
42
Clinical presentation
4/20/2017 Clinical presentation Clinical features Headache, fever, drowsiness Focal neurological symptoms a) irritative epilepsy b) hemi paresis Papilloedema and cranial nerve palsies are uncommon 18/07/2012
43
Investigations : CT scan MRI Management.
4/20/2017 Investigations : CT scan MRI Management. Evacuation of abscess by burr hole / craniotomy IV Antibiotics Treatment of ear Antiepileptic medication after recovery 18/07/2012
44
Otitic hydrocephalus Uni/bilateral papillodema
4/20/2017 Otitic hydrocephalus Benign intra cranial hypertension Frequently affects children and adolescents Obscure etiology; possibly sequale to bilateral lateral sinus thrombosis C/F – Intermittant headache Uni/bilateral papillodema CT scan to rule out other more serious complication 18/07/2012
45
Treatment Repeated Lumbar puncture at 48 hr intervals
4/20/2017 Treatment Repeated Lumbar puncture at 48 hr intervals Medical –diuretics / Acetazolamide Long standing cases – surgical ventriculoperitonial shunt/subtemporal decompression 18/07/2012
46
4/20/2017 Conclusion Intracranial complications of COM have drastically reduced however mortality from complication remains significantly high even today (8%). The incidence of complications are nearly as common in mucosal disease as in squamous disease. MRI remains gold standard for most of the intracranial complications Broad spectrum antibiotic cover is to be started immediately as soon as diagnosis is established followed by specific antibiotic cover according to the culture and sensitivity Minimum Ear surgery for a complicated COM AAD remains CWD mastoidectomy 18/07/2012
47
4/20/2017 References Scott- Browns ;Otolaryngology , Head & Neck Surgery; Seventh Edition Scott –Browns ;Diseases of Ear Nose and throat; Fourth Edition Mawson’s; Diseases of the Ear ; Fifth Edition Logan Turners Diseases of the Nose Throat & Ear ;Tenth Edition Otolaryngologic Clinics of North America Volume 39, Issue 6,(December 2006) Various internet searches using Google ,Google images 18/07/2012
48
For more presentations, visit www.nayyarENT.com
4/20/2017 Thank you For more presentations, visit 18/07/2012
Similar presentations
