Subtitle

Complications Of CSOM

Define complication with reference to CSOM

Enumerate the complications of CSOM

Identify a case of CSOM with complications based on clinical features

Evaluation & management of CSOM with complications

OBJECTIVES

Spread of infection beyond the confines of the mucosal spaces of middle ear cleft

Definition

Complications of csom

Meningitis

Sigmoid sinus thrombosis

Brain abscess

Extradural abscess

Subdural abscess

Otitic hydrocephalus

Intra cranial complications

Mastoiditis

Petrositis

Labyrinthitis

Facial paralysis

Extracranial ( Intratemporal ) complications

Sub periosteal abscess

Bezold’s abscess

Zygomatic ( Luc’s abscess/ Meatal )

Digastric ( Cittelli’s abscess)

Extracranial ( Extratemporal ) complications

Attico antral disease ( cholesteatoma )

Highly virulent organism

Poor host immune response

Presence of preformed pathways for spread

Extremes of age

poor socioeconomic status

Predisposing factors

Bone erosion

Suppurative retrograde thrombophlebitis

Preformed pathways

Routes of spread

In ASOM-Hyperemic decalcification

In CSOM-Cholesteatoma or granulation tissue.

Direct bone erosion

Suppurative retrograde thrombophlebitis

Congenital dehiscence: Dehiscence in facial canal and over the jugular bulb

Patent sutures: Petro squamous suture

Temporal bone fractures: The fibrous scar permits infection

Surgical defects: Stapedectomy, fenestration and exposure of dura

Perilymphatic fistula: Congenital or acquired

Normal anatomical openings: Infection of labyrinth and from labyrinth to the meninges

Oval and round windows Internal acoustic meatus enlarged Cochlear aqueduct( Mondini’s anomaly )

Endolymphatic duct and sac

Preformed pathways

Ear pain

Fever

Severe headache

Projectile vomiting

Neck stiffness

Photophobia

Irritability / altered consciousness.

Features of impending complications

when infection spreads from the mucosa lining the mastoid air cells to involve bony walls of the mastoid air cell system

Mastoiditis

Acute coalescent mastoiditis

Clinical Features of acute mastoiditisSymptoms

Earache Fever Ear discharge-profuse & purulent

Signs Mastoid tenderness Sagging of postero-superior meatal wall Eardrum perforation Swelling, redness and bulging over the mastoid ( ironed out mastoid )

Hearing loss (conductive)

The persistence of otorrhea beyond 3 weeks in a case of AOM indicates mastoiditis

HRCT Temporal Bone Aural swab for culture & sensitivity

Investigations

Hospitalization

I.V antibiotics

Myringotomy

Cortical mastoidectomy

TREATMENT

Subperiosteal abscess

Bezold’s abscess

Cittelli's abscess

Luc’s abscess

Petrositis

Labyrinthitis

Facial paralysis

Meningitis, brain abscess , sigmoid sinus thrombosis

Sequelae of acute coalescent mastoiditis

Luc’s abscess

Subperiosteal

abscess

Bezold’s abscess

Bezold’s abscess

slow destruction of mastoid air cells

acute sign and symptoms of acute mastoiditis are absent

Inadequate antibiotic therapy - Dose, frequency ,duration

pain, discharge, fever , mastoid swelling - Absent

mastoidectomy -extensive destruction of the air cells with granulation tissue and dark gelatinous material filling the mastoid

Masked mastoiditis

Petrous bone - pneumatized in about 30% individuals

Two groups of air cells’ tracts -communicate mastoid and middle ear to the petrous apex

Postero superior tract: From the attic and antrum the tract passes around semicircular canals to petrous apex

Antero inferior tract: From the hypotympanum the tract passes around the ET and cochlea to the petrous apex

Infection may pass through these cell tracts and reach petrous apex

Petrositis

Cranial nerve VI palsy

Deep seated ear or retro-orbital pain

Persistent ear discharge

Persistent ear discharge in cases of cortical or modified radical mastoidectomy may be due to Petrositis.

Gradenigo’s syndrome or triad

Management HRCT

I.V antibiotics

Surgical exploration

complication of both acute and chronic otitis media

Due to dehiscent facial canal-ASOM

Destruction of facial canal- CSOM-AAD

Treatment- in ASOM- myringotomy - in CSOM- Cortical Mastoidectomy

Facial nerve paralysis

Acute inflammation of the labyrinth

Diffusion of toxins via the round window from the middle ear –Serous Labyrinthitis

Labyrinthine fistula caused by hyperemic decalcification-Circumscribed Labyrinthitis

Pyogenic infection of the labyrinth- suppurative Labyrinthitis

Retrospective diagnosis –with treatment improves in serous labyrinthitis

LABYRINTHITIS

inflammation of leptomeninges (pia-arachnoid)and CSF of subarachnoid space

most common intracranial complication

One third cases of meningitis are otogenic in origin

Otogenic meningitis

Circumscribed meningitis: no bacteria in CSF.

Generalized meningitis: bacteria are present in CSF

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

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 polymorph nuclear leucocytes are present in large numbers

stages of generalized meningitis

Rise in temperature (102–104°F) often with chills and rigors

Headache

Neck rigidity

Photophobia and mental irritability

Nausea and vomiting (sometimes projectile)

Cranial nerve palsies and hemiplegia

Symptoms

neck rigidity

positive Kernig’s sign

positive Brudzinski’s sign

tendon reflexes are exaggerated initially but later become sluggish or absent

papilloedema (usually seen in late stages).

Signs

HRCT Temporal boneMRIFunduscopicLumbar 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.

Investigations

Thrombophlebitis of the lateral venous sinus

usually develops secondary to direct extension from a perisinus abscess due to an advanced otitis media

Acute otitis media: Hemolytic streptococcus, Pneumococci

Cholesteatoma: Bacillus proteus, Pseudomonas pyocynea, Escherichia coli and Staphylococci

Lateral sinus thrombosis

Pathogenesis

Intracranial Complications: Lateral Sinus Thrombosis-clinicalSigns of blood invasion:

-Fever (spiking) with rigors and chills or persistent fever(septicemia)

Positive Greisinger’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 might be felt in the neck as a tender cord.

Intracranial Complications: Lateral Sinus Thrombosis-diagnosis

CT scan with contrast, “delta” sign

MRI, Angiography, Venography

Angiography, venography

Blood cultures is positive during the febrile phase.

MR venography showing obstructedsigmoid sinus on the right side and good venous filling on the left

clinical featuresSigns of blood invasion:-Fever (spiking) with rigors and chills or persistent fever(septicemia)

– Positive Greisinger’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 might be felt in the neck as a tender cord.

Treatment

Medical:• High dose IV antibiotics and supportive treatment

• Anticoagulants

Surgical:• Mastoidectomy with exposure of the affected sinus and the intra-sinus abscess is drained.

Localized suppuration in the brain substance

Most lethal complication of suppurative otitis media

Otogenic brain abscess

Pathogenesis

Intracranial Complications: Brain Abscess-treatment Medical:• Broad-spectrum antibiotics.• Measures to decrease intracranial pressure.

Surgical:• Neurosurgical drainage or excision of the abscess .

• Mastoidectomy operation after subsidence of the acute stage.

Increased intracranial pressure with normal CSF

Severe headache

Diplopia due to paralysis of VIth cranial nerve

Blurring of vision due to papilledema

Otitic hydrocephalus

Otitic hydrocephalus

HRCT Temporal bone

Lumbar puncture-elevated CSF pressure

Treatment - acetazolamide corticosteroids

Lumbo peritoneal shunt

Treatment of the underlying cause

Evaluation & management

Collection of pus against the Dura of the middle or posterior cranial fossa

EXTRADURAL ABSCESS

Extradural abscess – clinical & treatmentClinical Picture– Persistent headache on the side of otitis media– Pulsating discharge– Fever– May be asymptomatic (discovered during surgery)

Diagnosis:– CT scans reveal the abscess as well as the middleear pathology.- MRI reveals associated dural inflammation.

Treatment:

– Mastoidectomy and drainage of the abscess.

subdural empyema

Lumbar puncture contra indicated

HRCT temporal bone and brain

Craniotomy and evacuation of pus

Management