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 Extra-dural abscess Subdural abscess Meningitis Brain abscess Lateral Sinus thrombophlebitis Otitic hydrocephalus 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 Post-auricular abscess Bezold abscess Citelli abscess Luc abscess Zygomatic abscess 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 peri-osteitis 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 Suppurative lymphadenopathy of upper deep cervical lymph node Para-pharyngeal abscess Parotid tail abscess Infected branchial cyst 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 & antero-inferior 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 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 hemianopia (C/L)  I/L hypotonia  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: Delta sign or MRI brain with contrast: 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 intra-cranial 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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