intracranial complications of suppurative otitis media and ... lectures/ent/csom compli.pdf ·...
TRANSCRIPT
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Intracranial Complications of Suppurative
Otitis Media and management
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• Intra-cranial complications
• • Extradural abscess.• • Subdural abscess.• • Meningitis.• • Brain abscess:(Temporal lobe abscess,Cerebellar abscess)• • Lateral sinus thrombosis.
• • Otitic hydrocephalus.
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Predisposing factors:• • Virulent organisms.
• • Cholesteatoma and bone erosion.
• • Presence of a congenital dehiscence (e.g.dehiscent facial canal) or a preformed pathway (e.g. skull base fracture).
• • Obstruction of drainage e.g. by a polyp.
• • Low resistance of the patient.
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Pathways of spread
• 1.Direct bone erosion– Hyperaemic decalcification– Cholesteatoma or granulation tissue.
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2.Venous thrombophlebitis
Thrombophlebitis of venous sinuses or cortical vein thrombosis
Dural venous sinuses & superficial veins of brain
Dural veins
Veins of haversian canals
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Pre-formed pathways
• 1.Congenital dehiscences• 2.Patent sutures• 3.Previous skull fractures• 4.Surgical defects• 5.Oval and round windows• 6.Along IAM, aqueducts of vestibule and that of cochlea to the
meninges.
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Extradural Abscess• – Collection of pus against the dura of the middle or
posterior cranial fossa.• Pathology-
– Acute otitis media-hyperaemic decalcification– CSOM-cholesteatoma
• Granulations along dura is seen more commonly than actual abscess
• Usually precedes sinus thrombophlebitis and brain abscess.• When pus collects against the walls of the lateral sinus, it is
called perisinus abscess.
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Extradural Abscess• ��Clinical Picture:• – Asymptomatic (discovered during surgery)• – Persistent headache on the side of otitis media.• – Pulsating ear discharge.• –Pain in the ear, Fever.• ��Diagnosis:• – CT scans reveal the abscess as well as the middle ear
pathology.
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Extradural Abscess
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TREATMENT:Granulation tissue penetrating bone or along sigmoid sinus should be explored.Surrounding bone removed& abscess drained.Granulations gently trimmed .Antibiotic coverage.
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Subdural Abscess• ��Definition:• Collection of pus between the dura and the arachnoid.• rare pathology • ��Clinical picture:• Signs of meningeal irritation: Headache(abrupt onset & unusually
severe), Fever & vomiting, neck rigidity, kernig”s sign.• Cortical vein thrombophlebitis: aphasia, hemiplegia
hemianopia,epileptic fits.• Raised ICT: papilloedema, ptosis, mydriasis
•
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Subdural Abscess• ��Investigations:• MRI
– Detecting presence and extensions of the infection– Distinguish b/w epidural and subdural infection– Absence of bone artifact, heightened contrast b/w bone ,CSF,brain– Multiplanar imaging capability
• ��Treatment:• – Drainage• – Systemic antibiotics• – Mastoidectomy
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Leptomeningitis
• ��Definition:• – Inflammation of leptomeninges (pia & arachinoid)• – Two forms:• • Circumscribed meningitis: no bacteria in CSF.• • Generalized meningitis: bacteria are present in CSF
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pathophysiology• Pathogens: H.influenzae,S.pneumoniae• Results from:
– Retrograde thrombophlebitis, bone erosion, preformed pathways.– Through oval and round windows.– Via perineural spaces to int. auditory canal or via endolymphatic ducts.– Fracture, dural tear, CSF leak
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Leptomeningitis
• ��Pathological stages of generalized meningitis :• • Serous stage: characterized by outpouring of fluid and
increased CSF pressure.• • Cellular stage: characterized by increase number of cells
especially lymphocytes.• • Bacterial stage: bacteria and polymorphonuclear leucocytes
are present in large numbers
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Leptomeningitis• Clinical picture:• – General symptoms and signs:• • headache,high fever, vomiting,restlessness, irritability,photophobia, and
delirium.• – Signs of meningeal irritation:• • Neck rigidity.• • Positive Kernig’s sign: difficulty to straighten the knee while the hip is
flexed• • Positive Brudzinski’s sign:• – passive flexion of one leg results in a similar movement on the opposite side or
if the neck is passively flexed, flexion occurs in the hips and knees.
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Leptomeningitis
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Leptomeningitis
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• Clinical picture:• – Signs of increased intracranial pressure:• • severe headache, vomiting and papilledema.• – Terminal stage:• • the delirium progresses to coma,• • the reflexes become weak or absent,• • cranial nerve palsies occur.
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Leptomeningitis• Diagnosis:• HRCT Temporal bone• MRI• Fundoscopy• – Lumbar puncture is diagnostic:• • CSF is cloudy and• • CSF pressure is increased.• • Contains bacteria and many polymorphs.• • Protein concentration is raised but• • Glucose and chlorides are decreased.
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• ��Treatment:• Treatment of the complication itself and control of ear infection.• Specific antibiotics, Antipyretics and supportive measures• Steroids
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Lateral Sinus Thrombosis
• ��Definition:• Thrombophlebitis of the lateral venous sinus.• ��Etiology:• It usually develops secondary to direct extension from a
perisinus abscess due to unsafe otitis media with cholesteatoma.
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Lateral Sinus Thrombosis• Pathology:• ��Inflammation of the walls of the sinus causes the formation of a
mural thrombus which obstructs the lumen of the sinus. »»• ��Then become infected intra-sinus abscess.• ��Infected emboli are shed from the infected thrombus causing
pyemia.• ��When the organisms reach the blood stream septicemia
develops.• ��Progression of infection may lead to• – cavernous sinus thrombosis or• – cerebellar brain abscess.
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Pathogenesis
Mural thrombus propagates,obliterating lumen
MURAL THROMBUS
Inflammation of intima (inner wall of sinus)
Inflammation of outer wall (dura) of sinus
Perisinus abscess/inflammation
Erosion of bone covering sigmoid sinus
AOM & COM
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Lateral Sinus Thrombosis
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Lateral Sinus Thrombosis• Clinical picture:• – Signs of blood invasion:• • hectic (spiking) fever with rigors and chills due to the
showers of septic emboli. D.D: malaria.• • persistent fever (septicemia).• – Positive Greissinger’s sign which is edema and
tenderness over the area of the mastoid emissary vein.• – Signs of increased intracranial pressure:• headache, vomiting, and papilledema.• – When the clot extends to the jugular vein, the vein will
be felt in the neck as a tender cord.
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DiagnosisCTscan—”delta” sign
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• – Tobey-Ayer test: {Queckentedt´s test}• • Pressure on the internal jugular vein on the healthy side causes
elevation of CSF pressure• • pressure on the vein on the diseased side has not effect on
CSF pressure.• – Blood cultures is positive during the febrile phase.• Crowe-Beck test—Engorgement of retinal veins and supraorbital
veins
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Lateral Sinus Thrombosis
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Lateral Sinus Thrombosis
• ��Treatment:• – Medical:• • Antibiotics and supportive treatment.• • Anticoagulants• – Surgical:• •Mastoidectomy with exposure of the affected sinus and the
intra-sinus abscess is drained.• • Ligation of the internal jugular vein distal to the facial vein is
indicated in recurrent embolism.
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Brain Abscess• Focal suppurative process.• Bimodal age distribution---paediatric age and 4th decade• M:F----3:1• Cerebrum(temporal lobe)> cerebellum• Mortality –25%
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PATHOPHYSIOLOGY• MICROBIOLOGY: Anaerobes, gram+ ,gram- organisms• Result from:
– Contiguous focus eg. O.media– Hematogenous spread from distant focus– Head injury/cranial surgery
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Within 2wks abcess capsule surrounding by granulation tissue
Necrosis and liquefaction of brain tissue with surrounding edema
encephalitis
Retrograde thrombophlebitis of dural vessels
Osteitis or granulation tissue
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Brain Abscess• Pathology:• – Site:• • Temporal lobe or• • Less frequently, in the cerebellum. (more dangerous)• – 4 stages:• • Stage of encephalitis: brain tissue inflammation• • Stage of localization (latent stage): small cavities filled• with pus• • Stage of acute abscess (Manifest stage)• – Rupture spontaneously• – Compress other brain centers
• • Stage of chronic abscess:• – Stationary, low virulent organism, thick wall
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• Clinical picture:• 1. Stage of invasion (encephalitis):• • fever, headache, delirium, and• • Signs of meningeal irritation.• 2. Latent stage (stage of localization):• • Minimum symptoms ,mild headache• • The patient may be lethargic & irritable.
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• 3. Manifest stage (acute abscess):• • Symptoms and signs of increased intracranial pressure:• – Severe headache.• – Projectile vomiting (no nausea).• – Papilledema.• • Characteristic signs and symptoms of brain abscess:• – Marked toxemia and loss of appetite.• – Slow pulse.• – Subnormal temperature.• – Delirium and lethargy.
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• 3. Manifest stage (acute abscess):• • Localizing signs:• – Temporal lobe abscess:• • Aphasia (left-sided lesions of Brochas area)• • Hemianopia (optic radiation).• • Hemiplegia or hemiparesis. (motor area)• • Uncinate: olfactory hallucinations.• – Cerebellar abscess:• • Homolateral hypotonia.• • Ataxia• • Intention tremors (finger-to-nose test).• • Dysdiadochokinesis.• • Positive Romberg’s sign.
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• 4. Terminal stage:• • Brain abscess unless treated usually ends by death either due to:
– Coning of the brain stem into foramen magnum,– Rupture of the abscess.
• 5. Chronic abscess:• • Headache• • Mental changes
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��Diagnosis:
CT scan–Ring signFollow the effects of treatmentTiming of surgical intervention
MRI—Detecting subtle changes in brain parenchyma and spread.
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Treatment:
• – Medical:• • Systemic antibiotics.• • Measure to decrease intracranial pressure.• – Surgical:• • Neurosurgical drainage of the abscess or excision.• • Appropriate mastoidectomy operation after subsidence of
the acute stage.
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Otitic Hydrocephalus
• Syndrome assoc.with otitis media– Increased ICT– Normal CSF findings– Spontaneous recovery– No abscess
• No ventricular dilatation• Commonly assoc. with sigmoid sinus thrombosis
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PATHOPHYSIOLOGY
Raised CSF pressure
CSF decreased absorption/increased secretion
Blockage of arachnoid villi
Retrograde extention of thrombophlebitis from sigmoid sinus to sup saggitalsinus
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Diagnosis:
• Headache, projectile vomiting, and papilledema.• Diplopia due to VI nerve,blurring• Optic atrophy• Increased CSF pressure, otherwise CSF is normal.
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Treatment
• Eradication of ear disease• Lowering of raised ICT• Decompression of sigmoid sinus• Shunts• Optic sheath decompression• Medical therapy –corticosteroids ,mannitol,
diuretics,acetazolamide.
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Medical Care
• IV antibiotics.• third-generation cephalosporin.
Complications of chronic disease . Furosemide and mannitol
• Monitoring of visual acuity and visual fields
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Surgical Care
• Myringotomy with removal and culture of middle ear fluid/granulation tissue.
• Mastoidectomy with exposure of diseased dura is imperative in cases of extradural abscess or granulation tissue, sigmoid sinus thrombophlebitis, and otitic hydrocephalus.
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