1. Complications of Suppurative Otitis Media
Dr. Vishal Sharma

2. Definition
Infection spreads beyond muco-periosteal lining of middle ear cleft to involve bone & neighboring structures like facial nerve, inner ear, dural venous sinuses, meninges, brain tissue & extra-temporal soft tissue.

3. Features of Complications
Severe otalgia, painful swelling around ear
Vertigo, nausea, vomiting
Headache + blurred vision + projectile vomiting
Fever + neck rigidity + irritability / drowsiness
Facial asymmetry
Otorrhoea + Retro-orbital pain + diplopia
Ataxia

4. Classification Intra-cranial Extra-cranial, Intra-temporal
Extra-cranial, Extra-temporal
Systemic: septicemia, otogenic tetanus

5. Classification

6. Intra-cranial Complications
Extra-dural abscess
Subdural abscess
Meningitis
Brain abscess
Lateral Sinus thrombophlebitis
Otitic hydrocephalus
Brain fungus (fungus cerebri)

7. Intra-temporal Complications
Acute mastoiditis
Coalescent mastoiditis
Masked mastoiditis
Facial nerve palsy
Labyrinthitis
Labyrinthine fistula
Apex Petrositis (Gradenigo syndrome)

8. Extra-temporal Complications
Post-auricular abscess
Bezold abscess
Citelli abscess
Luc abscess
Zygomatic abscess
Retro-mastoid abscess

9. Factors Affecting Pathogen Factors Patient Factors
 High virulence bacteria  Young age
 Antimicrobial resistance  Poor immune status
 Chronic disease (DM, TB)
Physician Factors  Poor socio-economic status
 Non-availability  Lack of health awareness
 Injudicious antibiotic use
 Error in recognizing dangerous symptoms & signs

10. Routes of entry 1. Bony erosion (cholesteatoma destruction, osteitis)
2. Retrograde Thrombophlebitis
3. Anatomical pathway: oval window, round window, internal auditory canal, suture line, cochlear & vestibular aqueduct
4. Congenital bony defects: facial canal, tegmen plate
5. Acquired bony defects: fracture, neoplasm, stapedectomy
6. Peri-arteriolar space of Virchow-Robin: spread into brain

11. Erosion of tegmen tympani

12. Coalescent Mastoiditis or Surgical Mastoiditis

13. Pathogenesis Aditus Blockage  Failure of drainage
 Stasis of secretions
 Hyperemic decalcification
 Resorption of bony septa of air cells
 Coalescence of small air cells to form cavity
 Empyema of mastoid cavity

14. Pathogenesis

15. Clinical Features & Investigation
Otorrhoea > 2 weeks, otalgia & deafness
Mastoid reservoir sign: pus fills up on mopping
Sagging of postero-superior canal wall due to peri-osteitis of bony wall b/w antrum & posterior E.A.C.
Ironed out appearance of skin over mastoid due to thickened periosteum
Mastoid tenderness present
Mastoid cavity in X-ray & CT scan

16. Mastoid reservoir sign

17. Sagging of posterior wall

18. Ironed out appearance

19. Mastoid cavity

20. Mastoid cavity

21. Mastoiditis Furunculosis
H/o otitis media + -
Deafness
Position of pinna
Down + outward + forward
Forward
Post-aural groove
Deepened
Obliterated
Ear discharge
Muco-purulent
Serous / purulent
Sagging of EAC wall
TM congestion
Tenderness
Mastoid
Tragal
Post-aural lymph node
X-ray Mastoid
Coalescence of cells + cavity
Normal

22. Treatment Urgent hospital admission Broad spectrum I.V. antibiotics
 No response to medical treatment in 48 hrs
 Development of new complication
 Presence of sub-periosteal abscess
Myringotomy to drain out painful pus
Incision drainage of sub-periosteal abscess
Cortical Mastoidectomy

23. Sub-periosteal abscess & fistula

24. Pathology Production of pus under tension
 hyperaemic decalcification (halisteresis)
+ osteoclastic resorption of bone
 sub-periosteal abscess
 penetration of periosteum + skin
 fistula formation

25. Sub-periosteal abscess formation

26. Sub-periosteal fistula: dry

27. Sub-periosteal fistula: wet

28. Types of sub-periosteal abscess
Post-auricular
Bezold
Citelli
Zygomatic
Luc
Retro-mastoid
Parapharyngeal & Retropharyngeal

29. Types of sub-periosteal abscess

30. Post-auricular abscess
Commonest. Present behind the ear.
Pinna pushed forward & downward.

31. Bezold & Citelli abscesses
Bezold: neck swelling
over sternocleido-
mastoid muscle
Citelli: neck swelling
over posterior belly
of digastric muscle

32. D/D of Bezold’s abscess
Suppurative lymphadenopathy of upper deep cervical lymph node
Para-pharyngeal abscess
Parotid tail abscess
Infected branchial cyst
Internal jugular vein thrombosis

33. Luc: swelling in external auditory canal
Zygomatic: swelling antero-superior to pinna +
upper eyelid oedema
Retro-mastoid: swelling over occipital bone
(? Citelli’s abscess)
Parapharyngeal & Retropharyngeal: due to spread
of pus along Eustachian tube

34. Retromastoid abscess

35. Incision drainage of abscess

36. Gradenigo syndrome  Persistent otorrhoea: despite adequate
cortical mastoidectomy
 Retro-orbital pain: Trigeminal nv involvement
 Diplopia: convergent squint due to lateral rectus
palsy by injury to abducent nv in Dorello’s canal under
Gruber’s petro-sphenoid ligament, at petrous apex

37. Persistent otorrhoea + Retro-orbital pain +
Convergent squint

38. Right Convergent squint
Right gaze
Central gaze
Left gaze

39. Etiology: Coalescent mastoiditis involving petrous apex along postero-superior & antero-inferior tracts in relation to bony labyrinth
Diagnosis: 1. C.T. scan temporal bone for bony
details. 2. M.R.I. to differ b/w bone marrow & pus
Treatment: Modified radical mastoidectomy & clearance of petrous apex cells

40. C.T. scan & M.R.I.

41. Hearing preserving approaches to petrous apex
Eagleton’s middle cranial fossa approach
Frenckner’s subarcuate approach
Thornwaldt’s retro-labyrinthine approach
Dearmin & Farrior’s infra-labyrinthine approach
Farrior’s hypotympanic sub-cochlear approach
Lempert Ramadier’s peri-tubal approach
Kopetsky Almoor’s peri-tubal approach

43. Hearing sacrificing approaches to petrous apex
Trans-cochlear approach
Trans-labyrinthine approach

44. Spread of pus

45. Labyrinthitis

46. Introduction Inflammation of endosteal layer of bony labyrinth
Route of infection:
 Round window membrane
 Pre-formed opening (Stapedectomy)
 Retrograde spread of meningitis via IAC / aqueducts
Clinical forms:
1. Circumscribed (labyrinthine fistula)
2. Diffuse serous 3. Diffuse suppurative

47. Circumscribed: Fistula commonly involves lateral SCC
Circumscribed: Fistula commonly involves lateral SCC. Presents with transient vertigo & positive fistula test  I/L nystagmus with +ve pressure; C/L nystagmus with -ve pressure
Serous: Reversible, non-purulent, mild vertigo, I/L nystagmus, mild sensori-neural hearing loss
Purulent: Irreversible, purulent, severe vertigo, C/L nystagmus, severe / profound hearing loss

48. Treatment: Bed rest (affected ear up). Avoid head movement.
Labyrinthine sedative: Prochlorperazine, Cinnarizine
Broad spectrum I.V. antibiotics
Modified Radical Mastoidectomy: removes infection
Open labyrinthine fistula: cover with temporalis fascia
Fistula covered with cholesteatoma matrix
< 2 mm: remove matrix & cover with temporalis fascia
> 2 mm / multiple / over promontory: leave it
Rehabilitation by Cawthorne-Cooksey Exercises

49. Lateral SSC Fistula

51. Facial nerve paralysis
Within 1st wk: due to nerve sheath edema
After 2 wks: due to bone erosion
Lower motor neuron palsy
Common in tubercular otitis media
Treatment:
Modified Radical Mastoidectomy
Facial nerve decompression seldom required

52. Meningitis

53. High grade persistent fever with rigors
Severe headache & neck stiffness
Irritability  drowsiness  confusion  coma
Neck rigidity positive
Kernig sign positive; Brudzinski sign positive
Papilloedema
Lumbar Puncture:  cell count,  protein,  sugar
I.V. Ceftriaxone + Metronidazole + Gentamicin
Radical Mastoidectomy once patient is stable

54. Test for neck rigidity

55. Otogenic brain abscess

56. Introduction 50-75 % adult brain abscess & 25% in child = otogenic
Temporal abscess : Cerebellar abscess = 2:1
Route of infection: 1. Direct spread:
 via Tegmen plate: Temporal abscess
 via Trautmann’s triangle: Cerebellar abscess
2. Retrograde thrombophlebitis

57. Trautmann’s triangle Superiorly: superior petrosal sinus
Posteriorly: sigmoid sinus
Anteriorly: solid angle
(semi-circular canals)
Pathway to posterior
cranial fossa from mastoid
cavity

58. Stages of brain abscess
1. Invasion or Encephalitis (1-10 days)
2. Localization or Latent Abscess (10-14 days)
3. Expansion or Manifest Abscess (> 14 days): leads to raised intracranial tension & focal signs
4. Termination or Abscess rupture: leads to fatal meningitis

59. Stages of brain abscess

60. Clinical Features of ed I.C.T.
Seen more in cerebellar abscess
Severe persistent headache, worse in morning
Projectile vomiting
Blurring of vision & Papilloedema
Lethargy  drowsiness  confusion  coma
Bradycardia
Subnormal temperature

61. Focal Clinical Features
Temporal Lobe Cerebellum
 Nominal aphasia  I/L nystagmus
 Quadrantic homonymous  I/L weakness
hemianopia (C/L)  I/L hypotonia
 Epileptic seizures  I/L ataxia
 Pupillary dilatation  Intention tremor
 Hallucination (smell & taste)  Past-pointing
 C/L hemiplegia  Dysdiadochokinesia

62. Bacteriology Anaerobic streptococci Streptococcus pneumoniae
Staphylococci
Proteus
E. coli
Pseudomonas
Bacteroidis fragilis

63. Investigations CT scan of brain & temporal bone with contrast
 Site, size & staging of abscess
 Observe progression of brain abscess
 Associated intra-cranial complications
MRI brain
 D/D: pus, abscess capsule, edema & normal brain
 Spread to ventricles & subarachnoid space
Avoid lumbar puncture to prevent coning

64. Temporal abscess in CT scan

65. Cerebellar abscess

66. Medical Treatment
High dose broad spectrum I.V. antibiotics: Ceftriaxone + Metronidazole + Gentamicin
I.V. Dexamethasone 4mg Q6H: es oedema
I.V. 20% Mannitol (0.5 gm/kg): es I.C.T.
Anti-epileptics: Phenytoin sodium
Antibiotic ear drops & aural toilet

67. Surgical Treatment Repeated burr hole aspirations
Excision of brain abscess with capsule: best Tx
Open incision & evacuation of pus
Radical mastoidectomy after pt becomes stable

68. Lateral sinus thrombophlebitis

69. Pathogenesis Lateral sinus = Sigmoid sinus + Transverse sinus
Erosion of sigmoid sinus plate  peri-sinus abscess  inflammation of outer wall  endophlebitis  mural thrombus  occlusion of sinus lumen  intra-sinus abscess  propagating infected thrombus

71. Pathogenesis

72. Spread of thrombus
Proximal: 1. To superior sagittal sinus via torcula Hirophili  hydrocephalus
2. To cavernous sinus  proptosis
3. To mastoid emissary vein  Griesinger’s sign
Distal: To internal jugular vein & subclavian vein  pulmonary thrombo-embolism & septicaemia

73. Clinical Features Remittent high fever with rigors (picket fence)
Pitting edema over retro-mastoid area & occipital bone due to mastoid emissary vein thrombosis (Griesinger’s sign)
Tenderness along Internal Jugular Vein
Headache
Anaemia

74. Fever charts in C.S.O.M. Brain abscess Meningitis
Lateral Sinus Thrombophlebitis

75. Picket fence fever High fever, swinging type Chills precedes fever
Temperature subsides with sweating
Each fever spike due to release of fresh septic embolus

76. Special Tests
Queckenstedt or Tobey-Ayer test: compression of I.J.V.  rapid rise of C.S.F. pressure (50 – 100 mm water  rapid fall on release of compression. In L.S.T. no rise / rise by only 10 – 20 mm water.
Lillie – Crowe - Beck test: pressure on I.J.V. on normal side  engorgement of retinal veins + papilloedema seen in fundoscopy due to L.S.T. on opposite side.

77. Tobey Ayer Test

78. Retinal vein dilation & optic disc edema

79. Investigations Lumbar puncture: to rule out meningitis
CT brain with contrast: Delta sign or
MRI brain with contrast: Empty triangle sign
MR angiography
Blood culture
Culture & sensitivity of ear discharge
Peripheral blood smear: to rule out malaria

80. Delta sign

81. Treatment
1. Radical mastoidectomy: Removal of disease + needle aspiration to confirm diagnosis. Sinus wall incised. Infected clots removed & abscess drained.
2. I.V. Ceftriaxone + Metronidazole + Gentamicin
3. Anticoagulants: in cavernous sinus thrombosis
4. Internal jugular vein ligation: for embolism not responding to antibiotics & surgery
5. Blood transfusion: for anaemia

82. Extra-dural abscess

83. Extra-dural abscess

84. Commonest otogenic intra-cranial complication
Collection of pus b/w skull bone & dura of middle or posterior cranial fossa
Majority asymptomatic. Suspected in case of:
 Profuse, intermittent, pulsatile, purulent, otorrhoea
 Low grade fever  I/L Persistent headache
 Recurring meningococcal meningitis
CT scan brain shows extra-dural abscess
Tx: I.V. Ceftriaxone + Metronidazole + Gentamicin
Modified Radical mastoidectomy Drill tegmen or sinus plate  pus drained

85. Extra-dural abscess

86. Subdural abscess

87. Subdural abscess

88. Collection of pus b/w dura & arachnoid by erosion of bone & dura mater or by retrograde thrombophlebitis
Due to rapid spread of pus, symptoms of raised intra-cranial tension & meningeal irritation develop quickly
CT scan brain shows subdural abscess
Tx: I.V. Ceftriaxone + Metronidazole + Gentamicin Burr hole evacuation of pus Radical mastoidectomy after pt becomes stable

89. Subdural abscess

90. Otitic Hydrocephalus

91. Synonym:  Benign intra-cranial hypertension  Symond’s syndrome
Etiology: 1. Associated L.S.T.  obstruction of cerebral venous return Superior sagittal sinus thrombosis  ed C.S.F. absorption
Clinical Features: 1. Severe headache, vomiting
2. Blurred vision, papilloedema, optic atrophy
3. Abducens palsy & diplopia due to raised intra-cranial tension (False localizing sign)

92. Investigations:
1. Lumbar puncture: ed CSF pressure (> 300 mm H2O). Biochemistry & bacteriology normal
2. CT scan brain: normal ventricles
Treatment: 1. Tx of L.S.T.: I.V. antibiotics & MRM
2. se CSF pressure (prevents optic atrophy) by:
 I.V. Dexamethasone 4mg Q6H
 I.V. 20% Mannitol 0.5 gm/kg
 Repeated lumbar puncture / lumbar drain
 Ventriculo-peritoneal shunt

93. Brain Fungus
Prolapse of brain into middle ear cavity / mastoid cavity due to erosion of dural plate.
Common in pre-antibiotic era. Rarely seen now in resistant infections.
Diagnosis: C.T. scan temporal bone.
Treatment: Removal of necrotic tissue, replacement of healthy prolapsed brain into cranial cavity & repair of bone defect.

94. Fungus Cerebri

95. Thank You