13 csom-part-4
TRANSCRIPT
Complications of Suppurative Otitis
MediaDr. 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 Complications1. 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 Complications1. Post-auricular abscess
2. Bezold abscess
3. Citelli abscess
4. Luc abscess
5. Zygomatic abscess
6. Retro-mastoid abscess
Factors AffectingPathogen 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 entry1. 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
PathogenesisAditus 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 FurunculosisH/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
PathologyProduction 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 & 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
IntroductionInflammation 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
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
Introduction
Trautmann’s triangleSuperiorly: 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 FeaturesTemporal 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
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
Investigations
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
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
Pathogenesis
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
Spread of thrombus
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.
Meningitis
Lateral Sinus Thrombophlebitis
Brain abscess
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
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
Investigations
Delta sign
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
Treatment
Extra-dural abscess
Extra-dural abscess
Commonest otogenic intra-cranial complicationCollection of pus b/w skull bone & dura of middle
or posterior cranial fossaMajority asymptomatic. Suspected in case of: Profuse, intermittent, pulsatile, purulent, otorrhoea Low grade fever I/L Persistent headache Recurring meningococcal meningitisCT scan brain shows extra-dural abscessTx: 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 ventriclesTreatment: 1. Tx of L.S.T.: I.V. antibiotics & MRM2. 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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