csom revision
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COMPLICATIONS OF CSOM
IntroductionSequelae: The resultant disability caused by the disease and its healing.Complication: When the active disease process spreads or breaks out to involve the surrounding or distant areas or organ systems
Definitions
CSOM involves the Middle Ear CleftMiddle ear cleft consists of 1. E. Tube 2. Middle ear 3. Mastoid air cell system
Definition
In CSOM a complication is said to exist if the disease goes beyond the mucoperiosteum of the middle ear cleft
The Middle Ear RelationsMedial Superior 1. Superiorly: Temporal Lobe
Anterior 2. Posteriorly: Sigmoid Sinus Cerebellum Posterior 3. Anteriorly: Carotid siphon Petrous Apex Inner Ear Jugular Bulb Neck deep spaces Ext Auditory Canal
Lateral
4. Medially: 5. Inferiorly:
Inferior6. Laterally:
Complications
Complications1.Intracranial 1. Intracranial
OR2.Extracranial a)Intratemporal 3. Extratemporal 2. Intratemporal
b)Extratemporal
Routes of Spread1. Direct Routea) b) c) d) Direct extension by spreading osteitis Through an old # line Through pre existing pathways: labyrinth Surgically created pathways
2. Through thrombophlebitis emissary veins & venous drainage 3. Haematogenous spread through the Spaces of Virchow
Intracranial complications
Intracranial Complications1. 2. 3. 4. Meningitis Lateral sinus thrombosis Otitic hydrocephalus Intracranial abscess
a)b) c)
ExtraduralSubdural Parenchymal Cerebral (Temporal lobe) Cerebellum
In GeneralCertain features are common to all: Common Symptoms are because of a) Spread of Infection b) Increased Intracranial pressure
In GeneralSuspicious Symptoms1. 2. 3. 4. 5. 6. Persistent headache Lethargy Irritability Severe otalgia Persistent or intermittent fever Nausea and vomiting
In GeneralDefinitive1. 2. 3. 4. 5. Decreased mental status Stiff neck Ataxia Visual changes Seizures
In GeneralPrinciples of management: 1. Neurological takes priority 2. Investigations & go hand in hand 3. Broad spectrum Abs (blood brain barrier) 4. Supportive measures 5. Neurological Intervention if required
6. Otological intervention later(exception Lat Sin thrombosis)
Meningitis Meningitis - most common IC complication of CSOM Can be due to ASOM or CSOM 12% to 91% of all I/C complications More common in younger age group (12-20 yrs) Commonly associated with other I/C Complications Due to spread by all 3 routes Mortality rate reported a) ASOM 8% b) CSOM - 31%
MeningitisSymptoms & Signs
Severe and generalized headache Headache may radiate to the spine and lower limbs. The patient tends to lie quiet and immobile. Photophobia and general hyperesthesia occur. Vomiting is common. Nuchal rigidity. (most important sign of meningitis). Kernigs sign Brudzinskis sign Late papilloedema
MeningitisInvestigations
Imaging for CSOM (MRI & CT SCAN) LP Fundoscopy prior CSF pressure is elevated. Turbidity +ve The CSF glucose may be low compared with the blood glucose. Microorganisms can be shown on Grams stain and culture.
TLC, DLC Leucocytosis
MeningitisManagement 1) Initial stabilization 2) Radiologic evaluation for other intracranial complications 3) LP to obtain CSF for analysis and culture 4) initiation of broad-spectrum antibiotics.
Lateral Sinus ThrombosisSymptoms 1. Fever - Low grade or intermittent, - Spiking, picket-fence pattern 2. Neck tenderness, particularly over the sternocleidomastoid muscle 3. Torticollis- May mimic nuchal rigidity
4. Otalgia
Lateral Sinus ThrombosisSigns1. 2. 3. 4. 5. 6. Papilledema Greisingers sign: induration over the occiput Jugular foramen syndrome (paralysis of CN IX, X, and XI; CN XII is spared because of its separate hypoglossal canal) Palpable cord in the cervical internal jugular vein Toby-Ayer-Queckenstedt test +ve Elevated cerebrospinal fluid pressure
7.8. 9.
AnemiaLeukocytosis Elevated erythrocyte sedimentation rate
ManagementPrompt surgical intervention: - Cortical Mastoidectomy (? MRM) - Complete exposure of sigmoid sinus - Aspiration of sinus till blood comes - If pus aspirated, evacuate & obliterate sinus
Brain AbscessA brain abscess progresses through three clinical stages: 1. Initial encephalitis, 2. Latent or quiescent stage, 3. Manifest or expanding abscess.Symptoms & Signs varies as the stages
Stage 1:Initial encephalitisIt is the inflammation and edema in the white matter around an infected vein. Occurs in a few days - Chills with moderate rise in temperature - Headache - Nausea - Vomiting Depressed mental status (apathy, irritability, drowsiness) Seizure (in children) Slight neck stiffness CSF: elevated protein, no bacteria, normal cell count and glucose Vigorous antimicrobial therapy may arrest the infection in this stage, and brain abscess may not develop.
Stage 2: Latent or quiescent stage- Occurs over several days to several weeks or even months. - Signs and symptoms are very subtle or may be absent. - The body tries to localize the infection. Malaise & Poor appetite Intermittent headache
Slight temperature elevationListlessness, irritability Slowed cerebration No focal neurologic signs CSF: normal composition
Stage 3: Expanding abscessA fibrous capsule forms around the abscess. The surrounding brain tissue becomes involved with an advancing encephalitis. Severe and continuous headache Projectile vomiting Intermittent slowing of the pulse
Elevated, normal, or decreased temperatureApathy, drowsiness, or disorientation Paralysis of extraocular muscles Papilledema Cerebrospinal fluid: increased cells, elevated protein Focal Neurological signs develop
Focal signs : Temporal Lobe Aphasia Contralateral facial or upper extremity paresis
Visual field defect (upper quadrant homonymous hemianopsia)Oculomotor nerve paresis Visual hallucinations
Temporal Lobe Abscess
MRI
Focal Neurological signs : Cerebellum
Suboccipital headache Vomiting Ataxia Spontaneous and gaze nystagmus Past pointing Intention tremor
DysdiadochokinesisWeakness and incoordination of ipsilateral muscles
Brain Abscess: Management1.Multidrug I/V ABs (blood brain barrier) 2. Supportive measures for ICT 3. Anticonvulsive therapy 4. Neurological Intervention by drainage / excision of fibrous capsule 5. Otological intervention later: - Mastoid exploration
EXTRAcranial complications
Intratemporal Complications1.Mastoiditis 2. Petrous apicitis 3. Labyrinthitis a. Serous b. Suppurative 4. Labyrinthine fistula 5. Facial paralysis
Petrositis-Petrositis is an extension of the inflammation of the middle ear or mastoid cavity into the pneumatized cells of the petrous apex. -The petrous apex has no drainage system and spontaneous drainage of an abscess cannot occur -Petrositis has a greater tendency toward intracranial extension - Near petrous apex are 3, 5, & 6 CN
Petrositis
CT Scan
PetrositisGradenigo first described the triad of symptoms Classically, these are - Retro-orbital pain (from CN V irritation) - Otorrhea - Diplopia (CN VI paralysis). Others: - Fever - Sensorineural hearing loss, - Transient facial paresis, - Vertigo
Petrositis
Management: 1. ABs 2. Cortical Mastoidectomy along with petrous apex clearance 3. Adequate drainage of the petrous cells are to be ensured
AC COALESCENT MASTOIDITIS Mastoid Air cells are a part of the middle ear cleft Invariably involved in all cases of ASOM/CSOM However, Coalescent mastoiditis occurs in only few
AC COALESCENT MASTOIDITIS Blockage of Aditus due to inflammed mucosa Drainage blocked Pressure erosion of the bony septae One large pus filled cavity
AC COALESCENT MASTOIDITISSuggestive -Otorrhea persisting more than 2 weeks -Persistent otalgia -Edema over the mastoid tip
Definitive - Presence of a postauricular abscess - Mastoid tenderness Over mastoid tip Over root of Zygoma Through the concha
- Sagging of the posterosuperior external auditory canal wall - Loss of bony air cell septations on computed tomography
AC COALESCENT MASTOIDITIS
AC COALESCENT MASTOIDITIS Management: 1. ABs 2. Myringotomy for initial drainage 3. Cortical Mastoidectomy & drainage if:Pus discharge persists more than 2 wks pain, edema over the mastoid tip Sagging of posterior canal wall partitions Signs or symptoms of threatened or definite complication
Extratemporal complicationsSubperiosteal abscesses a. Mastoid (postauricular) b. Zygomatic c. Bezolds
Post auricular abscess When the infection erodes the outer cortex of the mastoid tip, a subperiosteal abscess results. Most common 1. The auricle is displaced anteriorly and inferiorly 2. The postauricular crease is obliterated 3. Skin over the mastoid process is fluctuant and erythematous.
Post auricular abscess
CT Scan
Post auricular abscess
Management: 1. ABs 2. Immediate drainage of postauricular abscess with drain left for 48 hrs 3. Cortical Mastoidectomy subsequently
Bezolds Abscess
Perforation on the medial aspect of the mastoid tip into the digastric groove produces a deep abscess of the neck known as Bezolds abscess
Bezolds Abscess Presents as a soft fluctuant swelling at the ant. edge of Sternocleidomastoid
CT Scan
Zygomatic Abscess Subperiosteal abscess at the root of the zygoma. It presents as a swelling above and in front of the ear Upper half of the auricle is displaced laterally At times there can be extension into the mandibular fossa displacing the mandible towards the normal side. Trismus is present has been and teeth no longer meet in occlusion.33
Zygomatic Abscess
Zygomatic Abscess
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