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Department of Otorhinolaryngology

Department of Otorhinolaryngology. COMPLICATIONS of Suppurative Otitis Media. Ossama Mahmoud Professor of Otorhinolaryngology Ain Shams University. Complications of Otitis Media.

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Department of Otorhinolaryngology

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  1. Department of Otorhinolaryngology

  2. COMPLICATIONS of Suppurative Otitis Media Ossama Mahmoud Professor of Otorhinolaryngology Ain Shams University

  3. Complications of Otitis Media The temporal bone is a complex anatomic region with close proximity to a variety of critical structures. These structures are at risk during both acute and chronic suppurative otitis media.

  4. Complications of Otitis Media • Due to antibiotics, the incidence of complications has greatly declined. (also treating surgical problems with antibiotics alone or giving incomplete courses that mask the infection lead to complications) • Complications are usually associated with granulationtissue formation and/or the presence of a cholesteatoma(bone erosion).

  5. Complications of Otitis Media Complications arise mostly due to: -- Infection spreading by direct extensionfrom the middle ear or mastoid cavity to adjacent structures. - Thrombophlebitis (haematogenous)

  6. Complications of OtitisMedia • Patients appear more ill than expected • fever, new onset vertigo, sensorineural hearing loss, fetid drainage, facial nerve weakness, proptotic ear • lethargy and mental status changes • CT and MRI are indicated • CT is superior for evaluating the bony details of the middle ear and mastoid space • MRI is more sensitive for diagnosing suspected intracranial complications.

  7. Complications of Otitis Media Treatment is: Parentral Broad Spectrum Antibiotics and Surgery are required

  8. Complications of Suppurative O.M. Cranial (or Temporal bone) complications: 1- Acute Mastoiditis. 2- Acute Petrositis. 3- Otitic Facial paralysis. 4- Acute Labyrinthitis.

  9. Complications of Suppurative O M(cont.) Intracranial Complications 1- Extra-dural (epidural) abscess. 2- Meningitis. 3- Brain abscess (cerebral or cerebellar). 4- Lateral sinus thrombosis. Extracranial complications 1- External otitis. 2- Jugular vein thrombophlebitis 3- Bezold’s abscess 4-Retropharyngeal abscess.

  10. Acute Mastoiditis

  11. Acute Mastoiditis Extension of the suppurative inflammatory process beyond the mucous membrane lining of the mastoid air cells leading to osteitis ofthe bony septa. N.B.At this early stage resolution is possible without surgery, if proper medical treatment is given.

  12. Acute Mastoiditis (cont.) The bony inter-cellular septa will break down with coalescence of the infected cells to form one cavity full of pus leading to Coalescent Mastoiditis or Mastoid Abscess.

  13. Acute Mastoiditis (cont.) In early Coalescent Mastoiditis the outer cortex of mastoid is intact but with extension of the disease pus may erode outer cortex of mastoid leading to SubperiostealMastoid Abscess which can extend by perforating the periosteium to became Subcutaneous Mastoid Abscess. If it opens through the skin Mastoid Fistula will result.

  14. Clinical Picture Exaggerated symptoms of ASOM (fever, pain and HL) 1- Tendernessover mastoid antrum and 2-External swelling A- Post-auricular abscess - Auricle is displaced outwards, forwards and downwards (erect auricle). - Post-auricular groove is preserved but if the abscess ruptures through periosteum and becomes subcutaneous , the groove will be obliterated. - DD. Post auricular lymphadenitis 2ry to Furunculosis of external auditory meatus.

  15. Clinical Picture Early stage of Mastoiditis Mastoid fistula

  16. Mastoid Abscess

  17. Clinical Picture B- Zygomatic abscess ; It is due inflammation of the zygomatic air cells. The swelling is above and in front of the ear. C- Bezolds abscess; Pus pierces the tip or inner surface of mastoid and form abscess in the sternomastoid muscle In the neck. D- Retropharyngeal abscess; Pus tracking from the peritubal cells along the Eustachian tube.

  18. Clinical Picture 3- Internal swelling Sagging of posterosuperior bony meatal wall, due to periostitis and edema over the anterior antral wall. 4- Ear discharge usually profuse , "Mucopurulent or purulent and may be pulsating with reservoir sign “ rapid re-accumulation " 5- Drum membrane perforated (small with pulsating discharge) or intact and bulging.

  19. Investigations 1- C&S of ear discharge 2- CT scan of the temporal bone to detect any additional cranial or intracranial complications

  20. Treatment of Acute Mastoiditis 1- Conservative treatment is to be tried for 48 hours in mild cases without evidences of abscess formation; parentral broad spectrum antibiotics. Myrigotomy if DM found intact and bulging. 2- Cortical Mastoidectomy operation is the standard treatment if the patient is not responding to conservative treatment, or if a mastoid abscess is evident or if other complications are suspected to be present.

  21. Masked Mastoiditis It Is the result of INCOMPLETE TREATMENT of ASOM with antibiotics leading to masking of the acute symptoms while the pathological process is progressing in the mastoid. Clinical picture: - Slight pain and tenderness over the mastoid. - Intra-cranial complications may occur and may be the presenting symptom.

  22. Chronic Mastoiditis • There is thick unhealthy chronically inflamed mucosa with granulation tissue and osteitis with sclerosis of mastoid air cells.(sclerosed mastoid in X-Ray) • It is condition which may be present in CSOM (tubo-tympanic type and attico-antral types). • Persistent ear discharge is the main presenting symptom

  23. Cortical Mastoidectomy Operation • It is a drainage operation in which exentration of the mastoid air cells is done. • It is a preliminary step in most of ear surgeries

  24. INDICATIONS 1-Acute Mastoiditis with failure of medical treatment (persistent pain, tenderness and fever , etc ,… for more than 2 days). 2- Subperiosteal Mastoid abscess. 3- Mastoid fistula. 4- Mastoiditis with complications as facial paralysis, meningitis or lateral sinus thrombosis.

  25. INDICATIONS 5-Persistent ear discharge in cases of ASOM or CSOM (tubo-tympanic) for more than one month despite proper conservative treatment 6-Resistant cases of OME. 7- Part of ear surgeries (e.g. Sac operations in Meniere‘s disease ------- etc.).

  26. Petrositis It is inflammation of the air cells in the petrous apex of the temporal bone , the 6th (abducent) and 5th (trigeminal) cranial nerves are affected as they are closely related to the petrous apex.

  27. Petrositis(cont.) Clinical Picture The condition is called “GRADINIGO SYNDROME” Triade of : 1- Diplopia with convergent squint due to 6th nerve paralysis. 2- Trigeminal neuralgia (retro-orbital pain and headache) due to irritation of the trigeminal ganglion. 3- Discharging ear.

  28. Petrositis (cont.) Investigations: 1- CT scan of temporal bone 2- C&S of ear discharge Treatment : 1- Conservative in mild and early cases 2- Mastoidectomy with exentration of petrous apex air cells or subtotal petrosectomy

  29. Otitic Labyrinthitis It is a complication of ASOM or more common CSOM. Types: 1.Circumscribed Labyrinthitis. (labyrinthine fistula). 2.Diffuse serous Labyrinthitis. 3.Diffuse suppurative Labyrinthitis.

  30. Circumscribed Labyrinthitis “Labyrinthine Fistula/ Para-labyrinthitis” It results from erosion of the bony wall of one of the SSC (usually the lateral) , or less commonly the promontory by cholesteatoma. The inflammatory process is outside the endosteal lining of the labyrinth (intact inner ear function).

  31. Labyrinthine FistulaClinical Picture In addition to the clinical picture of OM new symptoms appear in the form of • Intermittent attacks of vertigo • Usually not accompanied by nausea and vomiting and usually precipitated by pressure on the tragus or sudden head movement.

  32. Labyrinthine FistulaClinical Picture Nystagmus accompanies the vertigo and usually horizontal with rapid component to the affected side (irritant lesion).

  33. Fistula testis positive (pressure on tragus, use of pneumatic otoscope or manipulating an aural polyp induces vertigo and nystagmus). Labyrinthine FistulaClinical Picture

  34. Diffuse serous Labyrinthitis“Catarrhal Labyrinthitis” It is a serous inflammation of the membranous labyrinth (inflamatory cells in the peri-lymph without organisms). Clinical Picture: 1. That of ASOM or CSOM. 2. Vertigo, nausea & vomiting are severe. 3. Nystagmusis usually horizontal with rapid component to affected side (irritant lesion). 4. Deafness becomes severe and mixed (Conductive & SNHL).

  35. Diffuse purulent Labyrinthitis • At first the previous symptoms increase markedly and HL may be severe or total. • Nystagmus is beating first towards the affected side (irritant) but changes to the other side (dead labyrinth) when destruction of the labyrinth becomes complete. Nystagmus will disappear later as it will be compensated by the healthy side.

  36. Diffuse Purulent Labyrinthitis Absent or minimal toxic manifestations as the surface area of the inner ear is small so there is no or little diffusion of toxins. Presence of fever and other toxic manifestations may suggest occurrence of meningitis.

  37. Treatment of Labyrinthitis Conservative Treatment - Antibiotics that cross the BBB to guard against meningitis. - Labyrinthine sedatives and anti-emetics : as Dramamine , stugeron, diazepam “valium” and zofran (4mg) amp. . Surgical Treatment either; • Cortical mastoidectomy for control of suppurativeotitis media, or • Radical mastoidectomy and labyrinthectomy in cases of supprativelabyrinthitis with dead labyrinth to prevent intracranial extension of infection

  38. Otitic Facial Nerve Paralysis As a complication of ASOM facial nerve paralysis occurs in children if there is congenital dehiscence in the bony canal of the nerve (20% of population). Paralysis is usually incomplete and is due to inflammation of the nerve sheath and compression by pus. Treatment: • Early myringotomy(usually with Grommet’s tube) • Antibiotics (parentral) and steroids. • Cortical mastoidectomy if the paralysis persist in spite of other lines of treatment or if there is acute mastoiditis.

  39. Facial Nerve Paralysis as a complication of CSOM Destruction of the bony canal and pressure on the nerve is either by: 1) Cholesteatoma 2) Osteomylitis of the mastoid. 3) Tuberculous OM. (Multiple Drum M. perforations & pale mucosa).

  40. Facial Nerve Paralysis as a complication of CSOM Treatment 1- Mastoidectomy operation with exposure and decompression of the facial nerve. 2- In case of tuberculous OM Anti-tuberculous ttt usually gives cure of the paralysis. Surgical ttt is only for cases showing no recovery after the disease has been cured.

  41. Post operative Facial Paralysis(Iatrogenic) 1.Immediate after the operation is due to direct trauma to the nerve. Treatment : • If Partial: corticosteroids & antibiotics. • If Complete: Immediate exploration of the nerve and remove any bone specule compressing the nerve or do nerve suturing or nerve graft if needed (from Greater Auricular nerve).

  42. Post-operative facial paralysis 2. Delayed (few hours or days after recovery) usually due to pressure on the nerve by edema ,haematoma or tight pack. Treatment: 1) Removal of the pack. 2) Antibiotics & Cortisone.

  43. Extradural Abscess It is collection of pus and /or granulation tissue between skull bone and dura.

  44. Extradural Abscess Clinical Picture The condition is usually symptomless and accidentally discovered during mastoidectomy. Presentations : There may be persistent 1- Earache or headache. 2- Low grade Fever (about 37.5 - 38°C). 3- Pulsating ear discharge.

  45. Extradural Abscess Treatment 1- Antibiotics (Injection) that cross BBB. 2- Cortical Mastoidectomy operation , abscess must be evacuated and bone must be removed until healthy dura is reached.

  46. Diffuse Leptomeningitis It is diffuse inflammation of the arachnoid, subarachnoid space & pia mater. Symptoms 1) Symptoms of infection e.g. high fever, malaise……. etc. 2) Symptoms of increased intracranial tension: - Severe headache. - Vomiting. - Blurring of vision. 3) Symptoms of meningeal irritation Irritability , Photophobia , neck rigidity and retraction.

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