Chronic otitis and Chronic otitis and its management its management

Otitis media chronica Otitis media chronica (OMCH)(OMCH) Chronic inflamatory changes on the eardrum, middle ear Chronic inflamatory changes on the eardrum, middle ear

mucosa, ossicles, bone of the intercellular septs in the mucosa, ossicles, bone of the intercellular septs in the mastoid system, sometimes with the extension to the inner mastoid system, sometimes with the extension to the inner ear, facial nerve, middle andosterior fossa, sigmoid sinus ear, facial nerve, middle andosterior fossa, sigmoid sinus etc.- complicationsetc.- complications

Classifications according toClassifications according to Course – constantly, intermitently discharging ear, residua Course – constantly, intermitently discharging ear, residua

post otitidempost otitidem Localisation - epitympanic, mesotympanic, Localisation - epitympanic, mesotympanic,

epimesotympanic OMCHepimesotympanic OMCH Extension of the pathologic changes – OMCH simplex Extension of the pathologic changes – OMCH simplex

( changes on the middle ear and mastoid mucosa ), cum ( changes on the middle ear and mastoid mucosa ), cum ostitide ( changes on the mucosa and ossicles, temporal ostitide ( changes on the mucosa and ossicles, temporal bone event. ), cum cholesteatomate ( changes on the bone event. ), cum cholesteatomate ( changes on the mucosa, bones and ossicles cause dby cholesteatoma )mucosa, bones and ossicles cause dby cholesteatoma )

Type of the discharge – serous, purulent, Otitis media with Type of the discharge – serous, purulent, Otitis media with effusion (OME)effusion (OME)

Otitis media with Otitis media with effusion (OME), Glue effusion (OME), Glue ear…ear… Chronic secretory otitisChronic secretory otitis – OME - first staduim of the pathology continuing – OME - first staduim of the pathology continuing

by adhesive – retraction process (retraction pockets) than by adhesive – retraction process (retraction pockets) than cholesteatoma and or tympanosclerosischolesteatoma and or tympanosclerosis

Eustachian tube dysfunction followed by decreasement of the middle ear Eustachian tube dysfunction followed by decreasement of the middle ear air pressure (resorbtion by the mucosa overweights the aeration via air pressure (resorbtion by the mucosa overweights the aeration via Eustachian tube that irritates the mucosa to produce the exsudate or Eustachian tube that irritates the mucosa to produce the exsudate or transudate transudate

Increasement of the resistence of the ossicular chain – conductive Increasement of the resistence of the ossicular chain – conductive hearing loss.hearing loss.

Chronic changes in longer duration – mucosal metaplasia – cubic and Chronic changes in longer duration – mucosal metaplasia – cubic and spinocelular epithelium changes in cylindric with goblet cells that spinocelular epithelium changes in cylindric with goblet cells that produce more viscous secretion creation of the cholesterin granulomas, produce more viscous secretion creation of the cholesterin granulomas, hypertophia of the connective tissue in submucosal layers and finally hypertophia of the connective tissue in submucosal layers and finally complete transformation of the middle ear mucoperiost in the complete transformation of the middle ear mucoperiost in the hyperplastic respiration type mucosa (with polyps in extreme cases) with hyperplastic respiration type mucosa (with polyps in extreme cases) with Ig production enzymatic activity etc. This further accelerates the vitious Ig production enzymatic activity etc. This further accelerates the vitious circle of the deficit middle ear aeration circle of the deficit middle ear aeration

Time factor - If lasting longer than 3months – significantly increased the Time factor - If lasting longer than 3months – significantly increased the risk of the progressive adhesive – retraction process with retraction risk of the progressive adhesive – retraction process with retraction pockets and cholesteatoma creationpockets and cholesteatoma creation

GER as one of the causes esp. In cleft palate populationGER as one of the causes esp. In cleft palate population

OME, tympanostomyOME, tympanostomy

OMCH without OMCH without cholesteatomacholesteatoma

Chronic suppurative (purulent) otitis Chronic suppurative (purulent) otitis (Constantly + Intermitently discharging ear)(Constantly + Intermitently discharging ear)

Residua post otitidem (Constantly dry ear with Residua post otitidem (Constantly dry ear with perforation)perforation)

Symptoms:Symptoms: SecretionSecretion Conductive or combined hearing lossConductive or combined hearing loss Pain, ear fulness or pressurePain, ear fulness or pressure VertigoVertigo TinnitusTinnitus

OMCH without OMCH without cholesteatoma - cholesteatoma - perforationperforation

OMCH without OMCH without cholesteatomacholesteatoma PathogenesisPathogenesis Infection via Eustachian tube or eardrum perforation Infection via Eustachian tube or eardrum perforation Mucosal inflammatory changes, ostitis, aseptic Mucosal inflammatory changes, ostitis, aseptic

necrosis – vascular obliteration subepitelially – necrosis – vascular obliteration subepitelially – predilection - long process of incus anastomosis of r. predilection - long process of incus anastomosis of r. stpadius stpadius

Important factors – tubal function, type and extension Important factors – tubal function, type and extension of the pneumatisation, communication between of the pneumatisation, communication between spaces – Prussak ś space, aditus ad antrum..(ahesive spaces – Prussak ś space, aditus ad antrum..(ahesive changes). Type and virulence of the pathogens, type changes). Type and virulence of the pathogens, type and thickness of the mucosa. Imunology + general and thickness of the mucosa. Imunology + general conditions – allergy, diabetes,cachexia…conditions – allergy, diabetes,cachexia…

OMCH without OMCH without cholesteatomacholesteatoma DiagnosticsDiagnostics History – secretion, hypacusis, History – secretion, hypacusis,

tinnitus,vertigo.. tinnitus,vertigo.. otomicroscopy central perforation, scarrs, otomicroscopy central perforation, scarrs,

incrustations (esp. p. tensa), mucosal incrustations (esp. p. tensa), mucosal changeschanges

Imaging methods – X-ray Schueller , HRCT Imaging methods – X-ray Schueller , HRCT decreased pneumatisation, bone decreased pneumatisation, bone sclerotisationsclerotisation

Audiometry – conductive or combined heaing Audiometry – conductive or combined heaing loss various gradeloss various grade

OMCH without OMCH without cholesteatomacholesteatoma Treatment – goal – to dry the mucosa Treatment – goal – to dry the mucosa Conservative – evacuation of the secretion-suction the most Conservative – evacuation of the secretion-suction the most

important medicamentous – local – ATB drops important medicamentous – local – ATB drops (ciprofloxacine, gentamycine…) sometimes + corticosteroids (ciprofloxacine, gentamycine…) sometimes + corticosteroids

- decreasment of pH – Boric Acid in - decreasment of pH – Boric Acid in powder powder

Surgical – sanation and reconstruction phase if possible in Surgical – sanation and reconstruction phase if possible in one sessionone session

Extension of the sanation according to the extension of the Extension of the sanation according to the extension of the pathology – tympanotomy, atticotomy, atticoantrotomy, pathology – tympanotomy, atticotomy, atticoantrotomy, atticoantromastoidectomy, petrosectomy atticoantromastoidectomy, petrosectomy

Reconstruction – tympanoplasty + reconstruction of the Reconstruction – tympanoplasty + reconstruction of the posterior canal wallposterior canal wall

Course and prognosis : Attacks of secretion, minimal Course and prognosis : Attacks of secretion, minimal ostelysis – coomplications intracranial rare local unusual, ostelysis – coomplications intracranial rare local unusual, good timing of surgery helps to avoid progression of good timing of surgery helps to avoid progression of destruction i.e. surdity and secretiondestruction i.e. surdity and secretion

OMCH without OMCH without cholesteatomacholesteatoma Diff. Dg. Diff. Dg. Cholesteatoma – marginal eardrum Cholesteatoma – marginal eardrum

perforation typical otomicroscopy, HRCT perforation typical otomicroscopy, HRCT findingfinding

TBC – multiple eardrum perforation, more TBC – multiple eardrum perforation, more sever hypacusis including sensorineural sever hypacusis including sensorineural

Tumours esp. Ca – marginal perforation Tumours esp. Ca – marginal perforation accentation of pain, in initial stages accentation of pain, in initial stages difficultdifficult

OMCH with OMCH with cholesteatomacholesteatoma Symptoms Symptoms PainPain Putrid secretion Putrid secretion Progressive hypacusis , tinnitus vertigoProgressive hypacusis , tinnitus vertigo PathogenesisPathogenesis Differs according to the type of cholesteatoma (usually Differs according to the type of cholesteatoma (usually

retraction – invagination of the thinned part of the eardrum retraction – invagination of the thinned part of the eardrum and dislocation of the epidermal tissue to the middle ear + and dislocation of the epidermal tissue to the middle ear + presence of the pathologic secretion) common features – presence of the pathologic secretion) common features – proliferation activity of epidermal tissue accelerated by proliferation activity of epidermal tissue accelerated by cytokins, progressive osteolysis caused by enzymatic cytokins, progressive osteolysis caused by enzymatic activity (Collagenase, alc.phosphatase) in perimatrix and by activity (Collagenase, alc.phosphatase) in perimatrix and by activation and transformation of osteoclasts activation and transformation of osteoclasts

Several types of cholesteatoma classification according to Several types of cholesteatoma classification according to various criteria - primary, secondary (acquired), localisation various criteria - primary, secondary (acquired), localisation ……

Conditions for the Conditions for the cholesteatoma cholesteatoma creationcreation Middle ear ventilation and Middle ear ventilation and

drainage disturbancedrainage disturbance Dislocated epidermal cells in Dislocated epidermal cells in

middle ear in contact with middle ear in contact with mucosamucosa

Increased proliferation tendency Increased proliferation tendency because of purulent inflammationbecause of purulent inflammation

CHolesteatoma typesCHolesteatoma types

1.1. Flaccida cholesteatoma (Epitympanic cholesteatoma attiku) retraction of Flaccida cholesteatoma (Epitympanic cholesteatoma attiku) retraction of Shrapnells membrane - attikus, event. aditus ad antrum, Shrapnells membrane - attikus, event. aditus ad antrum, antrummastoideum, intersinofacial tract, processus mastoideus middle antrummastoideum, intersinofacial tract, processus mastoideus middle earear

2.2. Sinus cholesteatoma retraction of the eardrum superior posterior Sinus cholesteatoma retraction of the eardrum superior posterior quadrant reaching sinus tympani, medially from the ossiclesin quadrant reaching sinus tympani, medially from the ossiclesin atticus,aditus ad antrum antrum,no anterior part of middle earatticus,aditus ad antrum antrum,no anterior part of middle ear

3.3. Tensa cholesteatom retraction of pars tensa, reaching the supraubar Tensa cholesteatom retraction of pars tensa, reaching the supraubar recess anterior epitympanum and tubal ostiumrecess anterior epitympanum and tubal ostium

4.4. Cholesteatoma of the external auditory canal dislocation of the epidermal Cholesteatoma of the external auditory canal dislocation of the epidermal tissue under the skin of the ext. Auditory canal – trauma, cleaning..tissue under the skin of the ext. Auditory canal – trauma, cleaning..

5.5. Posttraumatic cholesteatoma – epidermal tissue dislocated to the middle Posttraumatic cholesteatoma – epidermal tissue dislocated to the middle ear by trauma(often explosionear by trauma(often explosion

6.6. Congenital cholesteatoma (primary, occult, behind the intact eardrum…) Congenital cholesteatoma (primary, occult, behind the intact eardrum…) from epidermoid tissue closed to the tubal ostium that survives from from epidermoid tissue closed to the tubal ostium that survives from prenatal timesprenatal times

7.7. Residual cholesteatoma – after cholesteatoma surgery behind the Residual cholesteatoma – after cholesteatoma surgery behind the reconstructed eardrumreconstructed eardrum

8.8. Recurrent cholesteatoma – cholesteatoma after previous cholesteatoma Recurrent cholesteatoma – cholesteatoma after previous cholesteatoma surgery surgery

9.9. Iatrogenic cholesteatoma – dislocation of the epidermal tissue behind the Iatrogenic cholesteatoma – dislocation of the epidermal tissue behind the eardrum after previous non cholesteatoma surgeryeardrum after previous non cholesteatoma surgery

CholesteatomasCholesteatomas

CholesteatomaCholesteatoma

DiagnosticsDiagnostics Otomicroscopy Otomicroscopy – charakteristic pearl appearance (if not covered by crust or – charakteristic pearl appearance (if not covered by crust or

polyp), marginal eardrum perforation, purulent secretion event. polyp), marginal eardrum perforation, purulent secretion event. Imaging methodsImaging methods –HRCT osteolysis, destruction of tegmen tympani, tegmen –HRCT osteolysis, destruction of tegmen tympani, tegmen

antri, lateral semicircular canal or Fallopian canal wallantri, lateral semicircular canal or Fallopian canal wall AudiometryAudiometry – conductive or combined hearing loss, . – conductive or combined hearing loss, . VestibulometryVestibulometry – asymetric finding +fistula sign can indicate destruction of – asymetric finding +fistula sign can indicate destruction of

the labyrinth – labyrinthine fistulathe labyrinth – labyrinthine fistula

TreatmentTreatment Conservative treatment can calm the mucosa, suction can reduce the mass of Conservative treatment can calm the mucosa, suction can reduce the mass of

cholesteatoma, but treatment of coice is surgical sanationcholesteatoma, but treatment of coice is surgical sanation Course and prognosisCourse and prognosis Non treated cholesteatoma can whenever cause the intracanial ol local life Non treated cholesteatoma can whenever cause the intracanial ol local life

threatening complication threatening complication Specialcourse in children – the younger is the child the more rare nad Specialcourse in children – the younger is the child the more rare nad

agressive is the cholesteatoma. In elderly is higher tendency to asymptomatic agressive is the cholesteatoma. In elderly is higher tendency to asymptomatic and complicated course.and complicated course.

Diff dg. Diff dg. OMCH without cholesteatoma, Tumour, TBC, WG otomicrosckopy, HRCT, OMCH without cholesteatoma, Tumour, TBC, WG otomicrosckopy, HRCT,

sometimes surgerysometimes surgery

HRCT – cholesteatoma HRCT – cholesteatoma of the pyramid apexof the pyramid apex

Approaches to the Approaches to the middle earmiddle ear EndauralEndaural Endomeatal Endomeatal RetroauricularRetroauricular

Retraction pocketRetraction pocket

Retraction Retraction classificationclassification Tensa retractions (Sadé) Tensa retractions (Sadé) 1. Mild retraction without contact if the eardrum and IS joint1. Mild retraction without contact if the eardrum and IS joint 2. Eardrum in contact with IS joint2. Eardrum in contact with IS joint 3. Eardrum in contactwith promontory without fixation3. Eardrum in contactwith promontory without fixation 4. Eardrum in contact with promontorywith fixation4. Eardrum in contact with promontorywith fixation Bordered retractions - retraction pockets (Charachon )Bordered retractions - retraction pockets (Charachon ) 1. Controlled pocket without fixation1. Controlled pocket without fixation 2. Controlled pocket with fixation2. Controlled pocket with fixation 3. Non controlled pocket with fixation3. Non controlled pocket with fixation Flaccida retractions (Tos)Flaccida retractions (Tos) 1.Mild retraction without contact to the malleus neck1.Mild retraction without contact to the malleus neck 2. Retraction in contact with malleus neck without bony erosion2. Retraction in contact with malleus neck without bony erosion 3. Retraction in contact with malleus neck with erosion of 3. Retraction in contact with malleus neck with erosion of

scutumscutum 4. Retraction in the contactwith the malleus neck and head and 4. Retraction in the contactwith the malleus neck and head and

erosionof the scutumerosionof the scutum

Retraction pocket Retraction pocket surgerysurgery

Goal –to resect or elevate non Goal –to resect or elevate non controlled or otherwise controlled or otherwise problematic retraction pockets problematic retraction pockets

via tympanotomy, atticotomy or via tympanotomy, atticotomy or atticoantrotomy to prevent the atticoantrotomy to prevent the creation of cholesteatoma in creation of cholesteatoma in retraction pocket retraction pocket

Preventive surgeryPreventive surgery

Surgical anatomy of Surgical anatomy of the middle earthe middle ear

Surgical anatomy of Surgical anatomy of the middle earthe middle ear

Surgical anatomy of the Surgical anatomy of the middle ear – sinus middle ear – sinus tympanitympani

SurgicaSurgical l anatomanatomy of the y of the facial facial nervenerve

Surgical sanationSurgical sanation

Lege artis always using microscope (rarely endoscope)Lege artis always using microscope (rarely endoscope) Extention according to the pathology of the finding.,the goal is to Extention according to the pathology of the finding.,the goal is to

remove the cholesteatoma completely in totoremove the cholesteatoma completely in toto Principles of minimum invasive surgery former Principles of minimum invasive surgery former

tympanomastoidectomies and radical operations are very rare, tympanomastoidectomies and radical operations are very rare, nearly abandonded nearly abandonded

Restitution of „normal“ anatomic conditions if possible - trepanation Restitution of „normal“ anatomic conditions if possible - trepanation cavity is divided from external auditory canal by its posterior wall – cavity is divided from external auditory canal by its posterior wall – closed technique closed technique

Either the posterior canal wall is left intact - canal wall up (CWU) Either the posterior canal wall is left intact - canal wall up (CWU) surgery – worse view –primary closed techniquesurgery – worse view –primary closed technique

Or the posterior wall is drilled out – better view and in the end of Or the posterior wall is drilled out – better view and in the end of surgery reconstructed (cartilage, bone usually autologous or surgery reconstructed (cartilage, bone usually autologous or ionomer cement) – secondary closed technique ionomer cement) – secondary closed technique

Closed technique enables better postoperation comfort of the Closed technique enables better postoperation comfort of the patient (swimming, diving,no infection from outwards to the patient (swimming, diving,no infection from outwards to the trepanation cavity) and better hearing results. trepanation cavity) and better hearing results.

Surgical sanationSurgical sanation

Alternative solution not very suitable in cholesteatoma Alternative solution not very suitable in cholesteatoma because of bad control and ossiblemuscle atrophy for because of bad control and ossiblemuscle atrophy for opened cavities is obliteration by muscle flaps – Palvaopened cavities is obliteration by muscle flaps – Palva´s,m. temporalis flap, cartilage, bony or ionomer cement ´s,m. temporalis flap, cartilage, bony or ionomer cement particles particles

Second – look – in closed technique surgery (especially Second – look – in closed technique surgery (especially secondary) in cases of large or problematically localized secondary) in cases of large or problematically localized cholesteatomas is second surgery check up after 12 cholesteatomas is second surgery check up after 12 months indicated. The aim is to remove event. persistent months indicated. The aim is to remove event. persistent cholestatomaby minimum invasive means until.it makes cholestatomaby minimum invasive means until.it makes a large destruction. Sometimes endoscopically, indication a large destruction. Sometimes endoscopically, indication as a matterof discussionV as a matterof discussionV

If no security of sanation is reached, in extreme If no security of sanation is reached, in extreme cholesteatomas andin complications trepanation cavity is cholesteatomas andin complications trepanation cavity is left open to to the external auditory canal – opened left open to to the external auditory canal – opened technique - more secure, worse hearing results, technique - more secure, worse hearing results, discomfort for patientdiscomfort for patient

Extension of the surgery Extension of the surgery --Atticotomy Atticotomy AtticoantrotomyAtticoantrotomy

Extension of the surgery Extension of the surgery --AtticoantromastoidectomAtticoantromastoidectomyy CWU CWD CWU CWD

CWU left CWD CWU left CWD rightright

St.p. AAME CWD + St.p. AAME CWD + Reconstruction of the Reconstruction of the posterior canal wall by posterior canal wall by cartilage CT scanscartilage CT scans

Secondary closed Secondary closed technique ( CW technique ( CW reconstructed by reconstructed by cartilage) healedcartilage) healed

Inflammatory Inflammatory Complications of OMCH - Complications of OMCH - locallocal MastoiditisMastoiditis Extension of the inflammation from the mucosa to the bone of the mastoid cell septsExtension of the inflammation from the mucosa to the bone of the mastoid cell septs PathogenesisPathogenesis The further inflammatory changes extension from mucosa to the bone depends on :The further inflammatory changes extension from mucosa to the bone depends on : – –anatomical conditions – narrow aditus ad antrum – wrong aeration of the antrumanatomical conditions – narrow aditus ad antrum – wrong aeration of the antrum – – patient ´s health (diabetes, renál, hepatal pathology, immunity etc.)patient ´s health (diabetes, renál, hepatal pathology, immunity etc.) DiagnosticsDiagnostics symptomatic trias – ear discharge, painful palpation of mastoid process and planum, oedema of the symptomatic trias – ear discharge, painful palpation of mastoid process and planum, oedema of the

retroauricular fold sometimes modified by ATB therapyretroauricular fold sometimes modified by ATB therapy Otomicroscopy vidíme perforation of eardrum or posterior wall of the canalpurulent scretion, descensus of Otomicroscopy vidíme perforation of eardrum or posterior wall of the canalpurulent scretion, descensus of

the wallthe wall Otapostasis or Oedemas of the zygomatic, or lateral collar triangle in abscesses – subperiostal, rare cases -. Otapostasis or Oedemas of the zygomatic, or lateral collar triangle in abscesses – subperiostal, rare cases -.

Bezold, Mouret, Moure´sBezold, Mouret, Moure´s Blood count Leukocytosis, elevated sedimentation + CRPBlood count Leukocytosis, elevated sedimentation + CRP Imaging methods X ray Schuller or Stenvers projection, HRCT osteolysis of mastoid cellar septa, obstruction Imaging methods X ray Schuller or Stenvers projection, HRCT osteolysis of mastoid cellar septa, obstruction

of the mastoid cells of the mastoid cells měkkotkáňových hmot, tekutiny a osteolýzy sept sklípků je nejspolehlivějším zobrazenímměkkotkáňových hmot, tekutiny a osteolýzy sept sklípků je nejspolehlivějším zobrazením TreatmentTreatment Cortical mastoidectomy AAME resp., ATB general and local administration.Cortical mastoidectomy AAME resp., ATB general and local administration. Course and prognosisCourse and prognosis Sometimes very rapid in hours, sometimes weeks, prognosis in adequate surgical treatment good, if non Sometimes very rapid in hours, sometimes weeks, prognosis in adequate surgical treatment good, if non

treated - high risk of complicationstreated - high risk of complications Diff dg.Diff dg. Mastoidismus in external otitis (no elevation of the lab. Values, no finding on imaging methods)Mastoidismus in external otitis (no elevation of the lab. Values, no finding on imaging methods)

LabyrinthitisLabyrinthitis

SymptomsSymptoms Peripheral vertigo, tinnitus, sensorineural or mixed hypacusisPeripheral vertigo, tinnitus, sensorineural or mixed hypacusis PathogenesisPathogenesis Toxin or pus diffusion via oval or round window membrane or Toxin or pus diffusion via oval or round window membrane or

perilyphatic fistula (cholesteatoma, fractures of temporal bone, perilyphatic fistula (cholesteatoma, fractures of temporal bone, iatrogenic trauma). iatrogenic trauma).

DiagnosisDiagnosis Otomicrscopic finding of discharge, cholesteatoma, fracture resp. Otomicrscopic finding of discharge, cholesteatoma, fracture resp.

together with typical cochleovestibular symptoms together with typical cochleovestibular symptoms Treatment Treatment Medicamentous -Antibiotics, vazodilatators, corticosteroids i.v., middle Medicamentous -Antibiotics, vazodilatators, corticosteroids i.v., middle

ear drainage via paracentesis (in serous labyrintitis) ear drainage via paracentesis (in serous labyrintitis) Surgery – mastoidectomy in facial nerve palsy, intracranial Surgery – mastoidectomy in facial nerve palsy, intracranial

complication, perilymphatic or liquor fistula, cholesteatoma, complication, perilymphatic or liquor fistula, cholesteatoma, Mastoidectomy + labyrinthectomy in purulent labyrinthitis Mastoidectomy + labyrinthectomy in purulent labyrinthitis Course and Course and prognosisprognosis

Differs according to the form, extension and complications Differs according to the form, extension and complications Diferenciální Diferenciální diagnostikadiagnostika

M. Menière attack, SHL , Acute vertigo – normal otomicroscopy finding, M. Menière attack, SHL , Acute vertigo – normal otomicroscopy finding, no otitisno otitis

Complications - Complications - intracranialintracranial Epidural empyema – non specific sympotms, Epidural empyema – non specific sympotms, Otogenic meningitis Cefalea, nuchal stiffening, lost of the Otogenic meningitis Cefalea, nuchal stiffening, lost of the

consciousness,. Restlessness, tonic- clonic spasms.consciousness,. Restlessness, tonic- clonic spasms. spread of the infection through lytic bone of tegmen antri or spread of the infection through lytic bone of tegmen antri or

tympani or via perforator canals, through labyrinth (in tympani or via perforator canals, through labyrinth (in labyrintitis, internal auditory canal, vv. Diploicae (in labyrintitis, internal auditory canal, vv. Diploicae (in tromboflebitis) - meningitistromboflebitis) - meningitis

Diagnosis - HRCT, neurologic investigation, liquor analysis – Diagnosis - HRCT, neurologic investigation, liquor analysis – increased proteins, decreased glucosa, chlorid ions- increased proteins, decreased glucosa, chlorid ions- meningitis.meningitis.

Every unclear meningitis is potentially otogenic – i.e. Every unclear meningitis is potentially otogenic – i.e. otogenic (and sinogenic) origin must be excluded!otogenic (and sinogenic) origin must be excluded!

TreatmentTreatment Mastoidectomy, exposition of the dura, drainage , I.v. ATB Mastoidectomy, exposition of the dura, drainage , I.v. ATB Course and prognosisCourse and prognosis Good in case of adequate and in time surgical treatment .Good in case of adequate and in time surgical treatment .

Complications - Complications - intracranialintracranial Otogenous sigmoid sinus thrombosis Otogenous sigmoid sinus thrombosis Septicaemia + non specific symptoms (headache, septic T Septicaemia + non specific symptoms (headache, septic T

curve, nuchal stifness..)curve, nuchal stifness..) Infection spreads in the dissolved bone to the sinus, there Infection spreads in the dissolved bone to the sinus, there

perisinous absces, phlebitis, creation of thrombs that perisinous absces, phlebitis, creation of thrombs that growtowards sinus transversus and sagittalis, and to jugular growtowards sinus transversus and sagittalis, and to jugular vein bulb , emissaria mastoidea (Griesinger ´s sign)vein bulb , emissaria mastoidea (Griesinger ´s sign)

Diagnosis septicaemia in chronic otitis , painful induration of Diagnosis septicaemia in chronic otitis , painful induration of VJI, splenomegaly, HRCTVJI, splenomegaly, HRCT

Every unclear septicaemia is potentially otogenous(or Every unclear septicaemia is potentially otogenous(or tonsillogenous) – must be excluded!!! tonsillogenous) – must be excluded!!!

Treatment – mastoidectomy + exposition of the sigmoid Treatment – mastoidectomy + exposition of the sigmoid sinus , iv. ATB, heparin sinus , iv. ATB, heparin

Course and prognosisCourse and prognosis 80 % cured in adequate in time treatment80 % cured in adequate in time treatment

Complications - Complications - intracranialintracranial Otogenous brain abscessOtogenous brain abscess Symptoms – meningism, cefalea, nausea, febrilities – first stage, Symptoms – meningism, cefalea, nausea, febrilities – first stage,

second stage – non specific, third stage psychiatric changes + second stage – non specific, third stage psychiatric changes + topical changes - aphasia, ataxia alexia, agraphia , nystagmus , III.-topical changes - aphasia, ataxia alexia, agraphia , nystagmus , III.-VIII n. palsy etc. VIII n. palsy etc.

PathogenesisPathogenesis – – direct infection spread in lytic bone through tegmen tympani, direct infection spread in lytic bone through tegmen tympani,

antri..antri.. – – preformed spaces – int. auditory canal, vv. diploicaepreformed spaces – int. auditory canal, vv. diploicae DiagnosisDiagnosis Neurootology, neuroophtalmology, neurology incl. EEG + liquor Neurootology, neuroophtalmology, neurology incl. EEG + liquor

analysis, HRCT, MRI analysis, HRCT, MRI Treatment - Treatment - Surgery AAME + neurosurgery – exstirpation of the Surgery AAME + neurosurgery – exstirpation of the

abces or evacuation of pus + ATB, corticosteroidsabces or evacuation of pus + ATB, corticosteroids Course and prognosis - Course and prognosis - rare complication with 20% mortality even rare complication with 20% mortality even

though adequately treated, frequent residual neurological disordesthough adequately treated, frequent residual neurological disordes Diff. Dg. - Diff. Dg. - Intracranial Tu, Multiple sclerosis, in cerebellar a. Intracranial Tu, Multiple sclerosis, in cerebellar a.

labyrintitis, vestibulopathylabyrintitis, vestibulopathy

Complications - Complications - intracranialintracranial PetrositisPetrositis Symptoms - Symptoms - Otorrhea, trigeminal neuralgy, abducens palsy+ Otorrhea, trigeminal neuralgy, abducens palsy+

diplopia – Gradenigo ´s sy, vertigo, surdity pain „deep in head“diplopia – Gradenigo ´s sy, vertigo, surdity pain „deep in head“ Pathogenesis – Pathogenesis – spread of infection medially to the spread of infection medially to the

hyperpneumatised pyramid to the supra, perilabyrinthine and hyperpneumatised pyramid to the supra, perilabyrinthine and apical tract (that are not in normal pneumatisation fully apical tract (that are not in normal pneumatisation fully developed) osteomyelitis of the pyramid apex, lesions of the V developed) osteomyelitis of the pyramid apex, lesions of the V and VI. Th cranial nerve and VII., IX., and X. event. + labyrintitis and VI. Th cranial nerve and VII., IX., and X. event. + labyrintitis event. event.

Diagnosis - Diagnosis - Gradenigo trias + Imaging methods - Schueller, Gradenigo trias + Imaging methods - Schueller, Stenvers projection, HRCT.Stenvers projection, HRCT.

Neurology, OphtalmologyNeurology, Ophtalmology Treatment – Treatment – Surgery – mastoidectomy, labyrinthectomy, Surgery – mastoidectomy, labyrinthectomy,

drianage of the apical cells + ATB, corticosteroids drianage of the apical cells + ATB, corticosteroids Course and prognosis - Course and prognosis - rare complication with quite good rare complication with quite good

prognosis quoad vitam in early dg. and adequate treatment prognosis quoad vitam in early dg. and adequate treatment frequent neurology deficits after healing – localised meningitis in frequent neurology deficits after healing – localised meningitis in pontocerebellar anglepontocerebellar angle