INTRACRANIAL COMPLICATIONS INTRACRANIAL COMPLICATIONS

Chronic Suppurative Otitis Chronic Suppurative Otitis MediaMedia

Prof. Oleksandr I. Yashan MD, PhDProf. Oleksandr I. Yashan MD, PhD

Anatomy of the Anatomy of the earear

Anatomy

Site of Ext Canal

Mastoid

ME

Eust tube Petous apex

Carotid A. IAM

Lateral sinus

Cochlear aquiduct

Endolymphatic sac & duct

Cranial Complications

Ext. A. M.

M.E.

Mastoiditis

Petrositis

Facial palsy

Labyrinthitis

Mastoiditis

Acute Mastoiditis, Sagging, Bulging

TM

Mastoid Subcutaneous

abcess & Mastoid Fistula

Pertrositis

Ext. A. M.

Mastoid

M.E.

Gradinigo Syndrome:

Face pain (trigiminal neuralgia)

Diplopia (VIth N)

Increasing ear discharge

Trigiminal gang

Abducent VI th N

Abducent (VI th N) Palsy

NormalAbducent paralysis

Facial ParalysisInability to raise eye brow (frontalis m.)

Inability to close eye lids (orbicularis occuli)

Deviation of the mouth angle to opposite side (orbicularis oris)

Failure to blow the mouth or build intra-oral pressure on the

affected side (buccinator m.)

Partial and Complete Facial N. Palsy

OTOGENIC INTRACRANIAL OTOGENIC INTRACRANIAL COMPLICATIONSCOMPLICATIONS

The extension of an infection from The extension of an infection from the ear to intracranial spaces of a the ear to intracranial spaces of a

skull.skull.

In such cases the severe, In such cases the severe, sometimes fatal, diseases can sometimes fatal, diseases can

develop.develop.

OTOGENIC INTRACRANIAL OTOGENIC INTRACRANIAL COMPLICATIONSCOMPLICATIONS

Meningitis;Meningitis; Abscess of a brain or cerebella;Abscess of a brain or cerebella; Sigmoid sinus thrombosis (and Sigmoid sinus thrombosis (and

otogenic sepsis);otogenic sepsis); Subdural abscess;Subdural abscess; Extradural abscess;Extradural abscess; Arachnoiditis of posterior cranial fossaArachnoiditis of posterior cranial fossa

THE REASONS of OTOGENIC THE REASONS of OTOGENIC INTRACRANIAL INTRACRANIAL

COMPLICATIONSCOMPLICATIONS

Acute suporative (purulent) otitis Acute suporative (purulent) otitis media;media;

Chronic otitis media;Chronic otitis media; Mastoiditis;Mastoiditis; Labyrinthitis.Labyrinthitis.

AGENTS of OTOGENIC AGENTS of OTOGENIC INTRACRANIAL COMPLICATIONSINTRACRANIAL COMPLICATIONS

– Viruses;Viruses;– Staphylococcus;Staphylococcus;– Streptococcus;Streptococcus;– Pneumococcus - and dyplococcus;Pneumococcus - and dyplococcus;– Protey;Protey;– Pseudomonas aerogenoza;Pseudomonas aerogenoza;– Funguses;Funguses;– Combination of microorganisms.Combination of microorganisms.

Paths of penetration of an Paths of penetration of an infection to the intracranial infection to the intracranial

spacesspaces ContactContact (or on a prolongation), through the holes in (or on a prolongation), through the holes in the bony walls of middle and inner ear (due to the bony walls of middle and inner ear (due to destructions) or through dehiscence in walls of destructions) or through dehiscence in walls of temporal bone arises immediate contact temporal bone arises immediate contact inflammatory of the center with brain shells.inflammatory of the center with brain shells.

Haemotogenic or lymphogenicHaemotogenic or lymphogenic, when the infection , when the infection penetrates intracranial space from a blood or lymph.penetrates intracranial space from a blood or lymph.

Through the prephormed pathsThrough the prephormed paths – peryneural or – peryneural or peri vascular when inflammatory the process is peri vascular when inflammatory the process is spreaded to intracranial space through channels, spreaded to intracranial space through channels, that naturally exist in temporal bone (where nerves, that naturally exist in temporal bone (where nerves, vessel pass) and dehiscence in walls of middle ear.vessel pass) and dehiscence in walls of middle ear.

LabyrinthogenicLabyrinthogenic - through aqueducts of the inner - through aqueducts of the inner ear.ear.

Pathogenesis of OICCPathogenesis of OICC

Impairment of exudates drainage from Impairment of exudates drainage from middle or inner ear;middle or inner ear;

Eustachian tube not capable to take out the Eustachian tube not capable to take out the exudates from the ear to nasopharynx, and exudates from the ear to nasopharynx, and outflow it through a tympanic membrane is outflow it through a tympanic membrane is hampered.hampered.

Exudates or cholesteatoma are Exudates or cholesteatoma are accumulated in a tympanic cavity or mastoid accumulated in a tympanic cavity or mastoid process’s cells, where the process’s cells, where the pressure is pressure is increasedincreased. That promotes a penetration of . That promotes a penetration of infection by different ways into intracranial infection by different ways into intracranial space.space.

Pathogenesis of OICCPathogenesis of OICC Due to contact mode of a Due to contact mode of a

penetration the infection to the penetration the infection to the intracranial space, the accumulation intracranial space, the accumulation of pus or cholesteatoma in attic or of pus or cholesteatoma in attic or antrum results in destruction of the antrum results in destruction of the upper wall of a tympanic cavity or upper wall of a tympanic cavity or antrum. Contaminated exudate antrum. Contaminated exudate spreads under a dura mater of spreads under a dura mater of middle cranial fossa, where middle cranial fossa, where extradural abscessextradural abscess is created. is created.

In a place of abscess dura mater In a place of abscess dura mater varies, becomes penetrable for varies, becomes penetrable for toxins and bacterias, which hitting in toxins and bacterias, which hitting in space between dura mater and space between dura mater and arachnoidea, forms arachnoidea, forms subdural subdural abscessabscess. The more deep . The more deep penetration of infection in brain penetration of infection in brain substance finishes in creation of substance finishes in creation of brain abscessbrain abscess

Extra-dural Abscess

Brain

Dura Tegmen

Attic

Antrum

Tymp. Memb. (TM)

Lateral sinus

Mastoid

Cholesteatoma& Attic perf or Central Perf

Erosion of tegmen, extension of infection

below dura

MeningitisErosion of tegmen,

extension of infection below dura=

Extradural Abscess

Erosion of the dura and extension to lepto-meningies (Pia & Arachenoid mater = meningitis

Brain Dura Tegmen

Attic Cholesteatoma

Lateral sinus

Sinus plate

Erosion of sinus plate and extension of infection above sinus dura = Peri-sinus Abscess

Perisinus abscessLateral Sinus Thrombosis

Extension of infection inside the sinus cause first partially occluding infected thrombus

The thrombus occludes the sinus and extends up &

down

Lat. Sinus thrombosis

Mast. Emissary V. & Griesinger sign

Int. Jugular. V.

Super. & inf. Petrosal sinuses

Cavernous S.

Extension of thrombus

Brain AbscessDirect extension of infection

through meningiesIndirect vascular extension

Temporal Lobe

Cereb- ellum

Temporal Lobe

Cereb- ellum

مناطق ( التوافقية المناطق( والفقه البيان

: البيان بروكاس منطقةالكالمى

الكتابى البيان منطقة

الفقه ( الكالم فقه منطقةالسمعى)

فقه منطقةالفقه ( القراءة

البصرى)

Motor area

Sensory area

Temporal Lobe

Abscess

Pathogenesis of OICCPathogenesis of OICC If inflammatory process penetrates If inflammatory process penetrates

in the skull: either through a in the skull: either through a posterior-internal wall of mastoid posterior-internal wall of mastoid process, or through internal process, or through internal auditory canal, or through the auditory canal, or through the aqueducts of inner ear. The aqueducts of inner ear. The inflammation process progresses in inflammation process progresses in posterior cranial fossa with posterior cranial fossa with formation of formation of perysinuses perysinuses abscess or cerebella abscessabscess or cerebella abscess..

The generalization of process, due The generalization of process, due to reduced resistance of to reduced resistance of macroorganism and high macroorganism and high resistance of micro flora, develops resistance of micro flora, develops meningitis, meningoencephalitis meningitis, meningoencephalitis or sepsis. All intracranial or sepsis. All intracranial complications can be mortal.complications can be mortal.

The doctors, which have taken The doctors, which have taken part in diagnosis and in part in diagnosis and in

treatment of the patient with treatment of the patient with ICC:ICC: ENT- physician;ENT- physician;

Reanimation physician;Reanimation physician; Neuropathology physician;Neuropathology physician; Neurosurgery physician;Neurosurgery physician; Therapy - physician;Therapy - physician; Ophthalmology physician;Ophthalmology physician; Infection physician;Infection physician; Phtysiatry - physician;Phtysiatry - physician; X-ray physician.X-ray physician.

OTOGENIC MENINGITISOTOGENIC MENINGITIS

Inflammation of all brain shells otologyc Inflammation of all brain shells otologyc origin origin . .

Can be serous or purulent Can be serous or purulent

OTOGENIC MENINGITIS OTOGENIC MENINGITIS Meningeal symptomsMeningeal symptoms

Appears due to tension of spinal nerve roots to the dura Appears due to tension of spinal nerve roots to the dura mater. They are:mater. They are:

Rigidity of neck musclesRigidity of neck muscles - impossibility to get by a - impossibility to get by a patient’s chin to physician’s thumb located on jugular patient’s chin to physician’s thumb located on jugular fossa;fossa;

KerningKerning - impossibility to unbend a leg in a knee joint - impossibility to unbend a leg in a knee joint after simultaneous bending of knee and coccyx joints;after simultaneous bending of knee and coccyx joints;

Brudzinsky upperBrudzinsky upper – when patient try to get by the chin – when patient try to get by the chin to jugular fossa the patient’s knees are reduced to a to jugular fossa the patient’s knees are reduced to a stomach;stomach;

Brudzinsky middleBrudzinsky middle – during pressing by physician’s – during pressing by physician’s fists on patient’s symphis the knees are reduced to the fists on patient’s symphis the knees are reduced to the stomach; stomach;

Brudzinsky lowerBrudzinsky lower - during checking Kerning symptom - - during checking Kerning symptom - other leg are reduced to the stomach.other leg are reduced to the stomach.

OTOGENIC MENINGITISOTOGENIC MENINGITIS

Appears due to raising of spinal liquor Appears due to raising of spinal liquor pressure:pressure:

Deterioration of consciousness (sopor, stupor Deterioration of consciousness (sopor, stupor or coma).or coma).

Severe headache,Severe headache, Nausea, vomiting,Nausea, vomiting, hyper aesthesia (light phobia, noise phobia, hyper aesthesia (light phobia, noise phobia,

raising of tactile and temperature sensitivity).raising of tactile and temperature sensitivity). Forced position of the patient: „ Raising cock” Forced position of the patient: „ Raising cock”

pose;pose;

ІІ. ІІ. Brain symptomsBrain symptoms

OTOGENIC MENINGITISOTOGENIC MENINGITIS

The common – intoxication The common – intoxication symptomssymptoms

Fever, temperature curve - constant;Fever, temperature curve - constant; Tachycardia;Tachycardia; Tachypnoe;Tachypnoe; Blood hypertension Blood hypertension Hypo or anuria.Hypo or anuria.

Additional methods of Additional methods of inspectioninspection

Blood analysisBlood analysis: neutrophillic leycocytosis, accelerated : neutrophillic leycocytosis, accelerated SОЕ is expressed;SОЕ is expressed;

Spinal punctionSpinal punction - liquid implies under the increased - liquid implies under the increased pressure, it is muddy, and also contains to much cells pressure, it is muddy, and also contains to much cells elements, protein, sometimes - bacteria, contents of elements, protein, sometimes - bacteria, contents of sugar and chlorides are reduced.sugar and chlorides are reduced.

Bacteriological research of ear pus and spinal Bacteriological research of ear pus and spinal canal liquidcanal liquid shows the agent and its antibiotics shows the agent and its antibiotics resistance (to choice the adequate antibiotic therapy).resistance (to choice the adequate antibiotic therapy).

X-ray of temporal boneX-ray of temporal bone.. Computer tomography and magnet -nuclear Computer tomography and magnet -nuclear

resonance researchresonance research - detection of cavities, filled with - detection of cavities, filled with exudates in temporal bone.exudates in temporal bone.

TreatmentTreatment Urgent hospitalization in ЕNT -department, where Urgent hospitalization in ЕNT -department, where

urgent surgical procedure will performed urgent surgical procedure will performed ((extended radical mastoidectomyextended radical mastoidectomy). From usual ). From usual mastoidectomy it differs by maximum wide mastoidectomy it differs by maximum wide disclosure of a dura mater of middle and posterior disclosure of a dura mater of middle and posterior cranial fosses, and available mastoid cells. cranial fosses, and available mastoid cells. Postauricular wound is not closed to give possibility Postauricular wound is not closed to give possibility of cleaning of operational cavity and introduction of cleaning of operational cavity and introduction medicines in operational wound.medicines in operational wound.

The intensive conservative therapy includes: The intensive conservative therapy includes: treatment by antibiotics in maximum dozes, that treatment by antibiotics in maximum dozes, that penetrate through blood-brain barrier (including in penetrate through blood-brain barrier (including in spinal canal), massive des intoxication, de spinal canal), massive des intoxication, de hydratation, hormones.hydratation, hormones.

ABSCESS of temporal ABSCESS of temporal lobe or CEREBELLAlobe or CEREBELLA

Suppurative inflammation of brain Suppurative inflammation of brain substance, which localized mainly in substance, which localized mainly in cerebellum or in temporal lobe.cerebellum or in temporal lobe.

Can be multiple abscesses.Can be multiple abscesses. Quite often caused by anaerobic Quite often caused by anaerobic

infectioninfection

STAGES of ABSCESS of STAGES of ABSCESS of the BRAIN and the BRAIN and

CEREBELLACEREBELLA 1. 1. The initial stageThe initial stage (2 weeks) is (2 weeks) is characterized by insignificant changing of the characterized by insignificant changing of the general patient’s, subfebrile temperature, general patient’s, subfebrile temperature, increasing of headache on pathologic side, increasing of headache on pathologic side, possible nausea and vomiting. The clinical possible nausea and vomiting. The clinical patient’s state is like accution of chronic patient’s state is like accution of chronic suppurative otitis media.suppurative otitis media.

2. In2. In latent stage latent stage (2 weeks) the general (2 weeks) the general state is changes unsignificantly. Depression, state is changes unsignificantly. Depression, occasionally - diffuse or local headache. occasionally - diffuse or local headache. Tiredness, sleepiness, lack of appetite. Tiredness, sleepiness, lack of appetite. Temperature may be normal.Temperature may be normal.

STAGES of ABSCESS of STAGES of ABSCESS of the BRAIN and the BRAIN and

CEREBELLACEREBELLA 3. The transformation in3. The transformation in manifest stage manifest stage happens gradually happens gradually or suddenly. Presentation of arising of mental changing: or suddenly. Presentation of arising of mental changing: depression, apathy, dormancy, slow silent language, attack depression, apathy, dormancy, slow silent language, attack of sleepiness at preservation of consciousness. Also: of sleepiness at preservation of consciousness. Also: diminution of a patient’s mass, vomiting, local painfulness diminution of a patient’s mass, vomiting, local painfulness during percussion on skull, lack of appetite, smell from a during percussion on skull, lack of appetite, smell from a mouth. Temperature can be normal or subfebrile, mouth. Temperature can be normal or subfebrile, deceleration of a rhythm of intimate reductions deceleration of a rhythm of intimate reductions (bradycardia), leukocytosis. Neurological manifestation of (bradycardia), leukocytosis. Neurological manifestation of the brain abscess is a paralysis of arm or leg on opposite the brain abscess is a paralysis of arm or leg on opposite side. In this stage in majorities of cases it is possible to do side. In this stage in majorities of cases it is possible to do the previous diagnosis.the previous diagnosis.

4. 4. The terminal stageThe terminal stage is characterized by coma, which is characterized by coma, which develops due to progressing encephalitis, brain edema, develops due to progressing encephalitis, brain edema, diffuse meningitis or breaking of abscess in the cerebrum diffuse meningitis or breaking of abscess in the cerebrum ventricles.ventricles.

LOCAL sings of temporal LOCAL sings of temporal lobe abscesslobe abscess

Amnesty aphasiaAmnesty aphasia (Right hand patients with (Right hand patients with abscess, located in the left brain lobe, can abscess, located in the left brain lobe, can not term noun),not term noun),

Motor aphasiaMotor aphasia (the patients can (the patients can understand the language, but can not speak) understand the language, but can not speak)

Sensory aphasiaSensory aphasia (the patients lose a (the patients lose a possibility to understand the people’s possibility to understand the people’s language and himself language).language and himself language).

Abscess in the not conducting brain lobe is Abscess in the not conducting brain lobe is exhibited by mental disorders – lose of exhibited by mental disorders – lose of criticism, euphoria or depression. That can criticism, euphoria or depression. That can be imperceptible.be imperceptible.

LOCAL sings of LOCAL sings of CEREBELLA ABSCESSCEREBELLA ABSCESS

General patient’s state is more severe, than in patient with General patient’s state is more severe, than in patient with temporal lobe abscess. Rough rotatoric nistagmus directed temporal lobe abscess. Rough rotatoric nistagmus directed to a pathologic side.to a pathologic side.

Significant deterioration of an equilibrium and coordination.Significant deterioration of an equilibrium and coordination. For diagnostics of cerebella abscess is necessary to fulfill a For diagnostics of cerebella abscess is necessary to fulfill a

finger – nose, finger-finger, or tests, the patient misses out finger – nose, finger-finger, or tests, the patient misses out only by the hand on a side of abscess disposition.only by the hand on a side of abscess disposition.

In tests on an equilibrium: Romberg pose - direction of a In tests on an equilibrium: Romberg pose - direction of a falling does not vary at position of the head; at a straight falling does not vary at position of the head; at a straight gate patient with the closed eyes the course deviates in the gate patient with the closed eyes the course deviates in the abscess side. Besides the sign cerebella abscess is positive abscess side. Besides the sign cerebella abscess is positive test on adiadochokinetic (hand on pathologic side defeats) test on adiadochokinetic (hand on pathologic side defeats) and muscles hypotonia on abscess side.and muscles hypotonia on abscess side.

Additional inspection Additional inspection methodmethod

Common blood analysisCommon blood analysis: possible leukocyteosis, : possible leukocyteosis, accelerated SОЕ;accelerated SОЕ;

Spinal punctionSpinal punction - liquid implies under the raised - liquid implies under the raised pressure, transparent, increased contents of proteins pressure, transparent, increased contents of proteins and insignificant pleocytosis.and insignificant pleocytosis.

Computer tomography imaging and magnet -Computer tomography imaging and magnet -nuclear resonance researchnuclear resonance research - allows to reveal the - allows to reveal the abscess in the substance of brain, and to estimate it abscess in the substance of brain, and to estimate it size and localization.size and localization.

Bacteriological research of ear pus and spinal Bacteriological research of ear pus and spinal canal liquidcanal liquid shows the agent and its antibiotics shows the agent and its antibiotics resistance (to choice the adequate antibiotic therapy).resistance (to choice the adequate antibiotic therapy).

Echoencephalographia - dislocation of brain structuresEchoencephalographia - dislocation of brain structures

TreatmentTreatment Surgical disclosure of the purulent center in temporal Surgical disclosure of the purulent center in temporal

bone together with wide disclosure of a dura mater of bone together with wide disclosure of a dura mater of middle or posterior cranial fossa (extended middle or posterior cranial fossa (extended mastiodectomy or extended radical operation on the ear).mastiodectomy or extended radical operation on the ear).

Through an operational wound make a injection of brain Through an operational wound make a injection of brain substance on depth in 4 cm with the purpose of searching substance on depth in 4 cm with the purpose of searching abscess. Its uncovering and drainage to maintain abscess. Its uncovering and drainage to maintain constant outflow and washing of the abscess cavity until constant outflow and washing of the abscess cavity until it full obliteration.it full obliteration.

After operation the patient translate in reanimation After operation the patient translate in reanimation department, where continue intensive conservative department, where continue intensive conservative therapy: treatment by antibiotics, that penetrate through therapy: treatment by antibiotics, that penetrate through hematological-encephalitic barrier, in maximum dozes hematological-encephalitic barrier, in maximum dozes (including in spinal canal), massive des intoxication, de (including in spinal canal), massive des intoxication, de hydratation, hormones.hydratation, hormones.

SINUS THROMBOSIS And SINUS THROMBOSIS And OTOGENIC SEPSISOTOGENIC SEPSIS

Sinus thrombosis arises mainly due to at mastoiditis and Sinus thrombosis arises mainly due to at mastoiditis and epitympanitis. The accumulation of pus in air cells epitympanitis. The accumulation of pus in air cells located near sigmoid sinus, reduces in destruction inner located near sigmoid sinus, reduces in destruction inner bony of a wall mastois and creation pery sinus abscess.bony of a wall mastois and creation pery sinus abscess.

In a place abscess the sigmoid sinus wall inflammated - In a place abscess the sigmoid sinus wall inflammated - develops develops peryphlebitisperyphlebitis. Afterwards inflammatory the . Afterwards inflammatory the process passes on inner surface of sinus process passes on inner surface of sinus ((endophlebitisendophlebitis). In a sinus lumen wall thromb is ). In a sinus lumen wall thromb is created, it gradually increases in sizes and obstructs the created, it gradually increases in sizes and obstructs the sinus. Due to inflammation thromb purulently fuses, and sinus. Due to inflammation thromb purulently fuses, and it contaminated parts by the blood current are delivered it contaminated parts by the blood current are delivered on all organism (septicopiemia or septicehaemy), on all organism (septicopiemia or septicehaemy), creating the lesions of remote metastases (in the lungs, creating the lesions of remote metastases (in the lungs, muscles, joints, interior organs and so on).muscles, joints, interior organs and so on).

CLINIC of SINUS CLINIC of SINUS THROMBOSIS THROMBOSIS

Sever common condition of the patient, is Sever common condition of the patient, is exhibited first of all by deterioration of central exhibited first of all by deterioration of central nervous system functions (stupor, coma), septic nervous system functions (stupor, coma), septic body temperature (more then 1 day differential), body temperature (more then 1 day differential), ague, dense sweat, tachycardia, painfulness of ague, dense sweat, tachycardia, painfulness of mastoid process, magnification and painfulness mastoid process, magnification and painfulness of neck lymphatic nods, accelerated SОЕ.of neck lymphatic nods, accelerated SОЕ.

Sometimes on the foreground appear septic Sometimes on the foreground appear septic lesions of interior organs: lungs, heart, kidneys, lesions of interior organs: lungs, heart, kidneys, liver, digestive tract and so on. Hemorrhages in liver, digestive tract and so on. Hemorrhages in interior organs sometime happen, also under the interior organs sometime happen, also under the skin and mucous lining. The skin quite often skin and mucous lining. The skin quite often gains yellow coloringgains yellow coloring

Additional inspection Additional inspection methodsmethods Common blood analysis: possible leukocyteosis, Common blood analysis: possible leukocyteosis,

accelerated SОЕ;accelerated SОЕ; Spinal punction - liquid implies under the raised Spinal punction - liquid implies under the raised

pressure, transparent, increased contents of proteins pressure, transparent, increased contents of proteins and insignificant pleocytosis.and insignificant pleocytosis.

Computer tomography imaging and magnet -nuclear Computer tomography imaging and magnet -nuclear resonance research - allows to reveal the inflammatory resonance research - allows to reveal the inflammatory lesion near or in the sigmoid sinus, and presence of lesion near or in the sigmoid sinus, and presence of thromb in it lumen.thromb in it lumen.

Bacteriological research of ear pus and spinal canal Bacteriological research of ear pus and spinal canal liquid shows the agent and its antibiotics resistance (to liquid shows the agent and its antibiotics resistance (to choice the adequate antibiotic therapy).choice the adequate antibiotic therapy).

Echoencephalographia- dislocation of brain structures.Echoencephalographia- dislocation of brain structures.

TreatmentTreatment In suspicion of sinus thrombosis the patient must be In suspicion of sinus thrombosis the patient must be

urgently transported to ЕNТ-department. After installation urgently transported to ЕNТ-department. After installation of the diagnosis it is necessary to perform immediately of the diagnosis it is necessary to perform immediately operation. In patient with acute otitis media the extended operation. In patient with acute otitis media the extended mastoidectomy is necessary, in patient with chronic mastoidectomy is necessary, in patient with chronic suppurative otitis media - extended radical mastoidectomy suppurative otitis media - extended radical mastoidectomy operation on ear. The aim of surgical interference is to operation on ear. The aim of surgical interference is to remove inflammatory lesions in temporal bone, to disclose remove inflammatory lesions in temporal bone, to disclose the sigmoid sinus, and to remove obliterative thromb (if the sigmoid sinus, and to remove obliterative thromb (if persist).persist).

Intensive conservative therapy: treatment by antibiotics, Intensive conservative therapy: treatment by antibiotics, that penetrate through hematological-encephalitic barrier, that penetrate through hematological-encephalitic barrier, in maximum dozes (including in spinal canal), massive des in maximum dozes (including in spinal canal), massive des intoxication, de hydratation, hormones and anticoagulants.intoxication, de hydratation, hormones and anticoagulants.

Prognosis favorable at opportune and combined (surgical Prognosis favorable at opportune and combined (surgical and conservative) treatment.and conservative) treatment.

After-care on the patients After-care on the patients with intracranial with intracranial

complicationscomplications After-care on the patients with intracranial complications has After-care on the patients with intracranial complications has especially important value. The general state of the patient especially important value. The general state of the patient is commonly very severe and requires singular attention of is commonly very severe and requires singular attention of medical staff. A right after-care has not smaller value, than medical staff. A right after-care has not smaller value, than surgical treatment, in preservation of patient’s life.surgical treatment, in preservation of patient’s life.

Such the patient is necessary to put in separate small Such the patient is necessary to put in separate small chambers with the blacked out windows (light phobia), to chambers with the blacked out windows (light phobia), to ensure full silence (noise phobia), comfortable temperature ensure full silence (noise phobia), comfortable temperature and strict bed condition.and strict bed condition.

Is necessary to ensure constant supervision of the general Is necessary to ensure constant supervision of the general patient’s state, his consciousness, temperature, palpitation, patient’s state, his consciousness, temperature, palpitation, and these data in an hour are spelled in the temperature and these data in an hour are spelled in the temperature leaf. Transport such patients (on bandagings) only on leaf. Transport such patients (on bandagings) only on wheeled bed.wheeled bed.

Prophylaxis of Prophylaxis of intracranial intracranial

complicationscomplications Consists in opportune detection both Consists in opportune detection both

right treatment of acute and chronic right treatment of acute and chronic suppurative otitis media.suppurative otitis media.

Mandatory operating treatment in Mandatory operating treatment in cholesteatoma;cholesteatoma;

Early paracentesis of a tympanic Early paracentesis of a tympanic membrane in patient with acute membrane in patient with acute purulent otitis mediapurulent otitis media