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Extracranial Complications of Otitis Media

Extracranial Complications of Otitis Media. Dr. Mubeena. Factors. Age Poor socio economic group High virulence of organisms Poor nutrition and immunosuppression Inadequate course and dose of antibiotic therapy. Pathway of spread. Extension by bone erosion

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Extracranial Complications of Otitis Media

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  1. ExtracranialComplications of Otitis Media Dr. Mubeena

  2. Factors • Age • Poor socio economic group • High virulence of organisms • Poor nutrition and immunosuppression • Inadequate course and dose of antibiotic therapy

  3. Pathway of spread • Extension by bone erosion • Extension by thrombophlebitis • Extension by preformed pathways 1. Congenital dehiscence of facial canal 2. Patent petrosquamous suture 3. Temporal bone fractures 4. Surgical defects- Stapedectomy, fenestration 5. Normal anatomical openings

  4. Intracranial complications • EXTRADURAL ABSCESS • SUBDURAL ABSCESS • MENINGITIS • BRAIN ABSCESS • LATERAL SINUS THROMBOPHLEBITIS • OTITIC HYDROCEPHALUS

  5. Acute mastoiditis

  6. Acute Mastoiditis • Infection spreads from the mucosa lining the mastoid air cells, to involve the bony walls of the mastoid air cell system • Follows ASOM

  7. Organisms • Beta- hemolytic organisms • Staphylococcus • Anaerobic organisms Susceptible individuals • Children • Immunocompromised (DM, Measles, etc)

  8. Pathogenesis

  9. Hyperemic decalcification and osteoclasticresorption of bone walls - Hyperemia and engorgement of mucosa causes dissolution of calcium from the bony walls of the mastoid air cells • Abscess coalesce and gradual destruction of bone converting into an irregular cavity with pus – Empyema of mastoid

  10. Signs • Mastoid tenderness • Ear discharge (purulent and pulsatile- lighthouse effect), mastoid reservoir sign positive • Sagging of posterosuperiormeatal wall • Perforation of TM • Swelling over the mastoid • Conductive hearing loss

  11. Differential Diagnosis • Furunculosis of meatus • Suppuration of mastoid lymph nodes- No h/o of any preceding otitis media or ear discharge • Infected sebaceous cyst

  12. Investigations • Blood counts- Polymorphonuclearleucocytosis and raised ESR • X- Ray Mastoid- Clouding of air cells • CT temporal bone- loss of bony trabeculae • C/S of ear swab

  13. Treatment • Antibiotics: Amoxycillin or Ampicillin given IV till culture reports come • Chloramphenicol or Metronidazole for anaerobic organisms • Myringotomy facilitates pus drainage • Cortical Mastoidectomy:

  14. Complications of acute mastoiditis • Subperiosteal abscess • Facial paralysis • Petrositis • Extradural abscess • Subdural abscess • Meningitis • Brain abscess • Lateral sinus thrombophlebitis • Otitichydrocephalus

  15. Abscesses in relation to the mastoid

  16. POST AURICULAR abscess : pus beneath periosteum. Pinna pushed forwards and outwards, fluctuant mass behind the ear

  17. ZYGOMATIC abscess : pus extends anteriorly to zygomatic process – facial and eyelid swelling

  18. BEZOLD’S ABSCESS • Necrosis of mastoid tip – • Sternocleidomastoid muscle • Posterior triangle • Parapharyngeal space • Carotid vessels

  19. CITELLI’S abscess : when pus extends along digastric into submandibular triangle • LUCS / MEATAL abscess : seen in the deep EAC as a result of pus breaking through bony canal wall • PARAPHARYNGEAL / RETROPHARYNGEAL abscess : infection of peritubal cells

  20. Masked mastoiditis

  21. It consists of slow destruction of mastoid cells without acute signs of mastoiditis such as pain, ear discharge and mastoid swelling.

  22. Etiology • Inadequate dose • Inadequate frequency • Inadequate duration of antibiotic therapy

  23. Pathology • Mastoidectomy in latent mastoiditis reveals extensive destruction of air cells with granulation tissue and dark gelatinous material filling the mastoid. • Erosion of the tegmen tympani and sinus plate can result in extradural and perisinus abscess

  24. CLINICAL FEATURES • SYMPTOMS • Mild pain behind ear, persitant hearing loss • SIGNS • TM – Thick with loss of translucency, slight tenderness over mastoid • PTA – Conductive hearing loss • X Ray – Clouding of air cells with loss of cell outline

  25. Treatment • Cortical mastoidectomy: Complete exenteration of all accessible mastoid air cells and converting them into a single cavity. • Antibiotic therapy

  26. PETROSITIS

  27. Petrositis • Spread of infection from middle ear and mastoid to petrous part of temporal bone. • Associated with acute coalescent mastoiditis, latent mastoiditis and chronic middle ear infections. • Abducent nerve and trigeminal ganglion are closely related to the petrous apex

  28. Pathology • 2 groups of cells’ tract • Posterosuperior tract: From attic and antrum, the tract passes around semicircular canals to petrous apex • Anteroinferiortract: From hypotympanum , it passes around the ET and cochlea to petrous apex

  29. Gradenigo’s syndrome • Retro-orbital pain, due to trigeminal nerve involvement. • Lateral rectus palsy (squint), due to Abducens nerve palsy. • Discharge. Otitis media (persistent otorrhea). • Sometimes, fever , headache, vomiting and neck rigidity also seen

  30. Investigations • HRCT Temporal bone

  31. Broad spectrum antibiotics. • Surgical drainage • If antibiotics fail, complete mastoidectomy must be done to remove the infection from the ME and petrous part of temporal bone

  32. FACIAL PARALYSIS

  33. Facial paralysis

  34. Facial Paralysis in AOM • Facial nerve is normally dehiscent in 20% of the population. • Mostly due to pressure on a dehiscent nerve by inflammatory products, or spread of infection to the nerve, by destroying the bone, leading to paralysis. • Systemic antibiotics, myringotomy or cortical mastoidectomy

  35. Facial paralysis in CSOM • Usually is due to pressure by cholesteatoma or granulation tissue. • Cholesteatomaforms a mass, destroying the bone. • Exerts pressure on the nerve, causing facial palsy. • Urgent exploration of mastoid

  36. Facial nerve paralysis

  37. Clinical Features • Insidious and slowly progressive • Unable to close the eyes • Bell’s phenomena is positive • Face is asymmetrical • Epiphora • Noise intolerance due to stapedial palsy • Loss of taste sensation

  38. Labyrinthitis

  39. Types • 1. Circumscribed • 2.Diffuse serous • 3. Diffuse suppurative

  40. Circumscribed labyrinthitis • It is a localized perilabyrinthitis following inflammatory condition where the pathological fistula formation occur mainly in LSCC. • Pathology : erosion of bony labyrinth with fistula formation

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