Complications of Chronic Otitis Media

Complications of Chronic Otitis Media

1. Complications Of CSOM 1 DR.PRASANNA DATTA

2. Classif ication 2 Intra cranial Extra-cranial, Intra-temporal

3. Factors affecting 3 Pathogen Factors High virulence bacteria Antimicrobial resistance Patient Factors Young age/Elderly Poor immune status Chronic disease(DM,TB) Poor socio-economic status

4. Routes of entry 4 Bony erosion (cholesteatoma,osteitis) Anatomical pathway: oval window, round window, internal auditory canal, suture line, cochlear & vestibular aqueduct Retrograde Thrombophlebitis Congenital bony defects: facial canal, tegmen plate Acquired bony defects: fracture, neoplasm, stapedectomy

5. Extra-Cranial 5

6. Mastoiditis 6 It is the inflammation of mucosal lining of mastoid antrum and air cells system. Pathology Production of pus under tension Hyperaemic decalcification Osteoclastic resorption of bony walls

7. Clinical Features Otorrhoea > 2 weeks, otalgia & deafness Mastoid reservoir sign: pus fills up on mopping Sagging of postero-superior canal wall Ironed out appearance of skin over mastoid due to thickened periosteum Mastoid tenderness Investigation X-ray & CT scan 7

8. 8

9. Mastoid reservoir sign Sagging of posterior wall 9

10. Ironed out appearance Mastoid cavity 10

11. Treatment 11 Urgent hospital admission Broad spectrum I.V. antibiotics No response to medical treatment in 48 hrs Cortical Mastoidectomy

12. Facial Nerve Paralysis 12

13. Seen in AOM,COM(both mucosal and squamosal variety) Predisposing factors: 1.congenital dehescence of FC 2.canal erosion by cholesteatoma/granulation 13

14. AOM: sudden onset, full recovery COM: gradual onset, paralysis persist(erosion) 14 Treatment: Medical(Corticosteroids) Modified Radical Mastoidectomy(Sq CSOM) Facial nerve decompression if required Physioyheraphy

15. Labrynthit i s 15

16. Inflammation of bony labyrinth Route of infection: Round window membrane Pre-formed opening (Stapedectomy) Retrograde spread of meningitis types: Serous labyrinthitis Otogenic suppurative labyrinthitis Meningitic suppurative labyrinthitis 16

17. Serous labyrinthitis occurs during acute or chronic otitis media. It is presumed that bacterial exotoxins enter the inner ear via the oval or round window or a labyrinthine fistula. there is no clinical method for differentiating serous from suppurative labyrinthitis. If vestibular and auditory functions are partially or completely retained, it can be assumed that the infection was serous. 17

18. Treatment 18 Bed rest (affected ear up). Avoid head movement. Labyrinthine sedative: Prochlorperazine, Cinnarizine Broad spectrum I.V. antibiotics Modified Radical Mastoidectomy: removes infection

19. PETROSITIS 19

20. Spread of infection from middle ear and mastoid to the (peumatised) petrous part of temporal bone. Petrous bone are of three types; 1.Well peumatised(25-30%) Diploic Sclerotic(Most common) 20

21. Gradenigo syndrome 21 It is triad of, Persistent otorrhoea Retro-orbital pain : Trigeminal nerve involvement Dip l op i a : C o nvergent squ i nt due to l ateral rect us palsy by injury to abducent nerve

22. Etiology: 22 mastoiditis involving petrous apex along postero- superior & anteroinferior tracts in relation to bony labyrinth Anteroinferior tract : starts at the hypotympanum near the eustachian tube runs around the cochlea to reach the petrous . Posterosuperior tract : starts in the mastoid and runs behind or above the bony labyrinth to the petrous apex.

23. Diagnosis : 23 C.T. scan temporal bone M.R.I. to differ b/w bone marrow & pus Treatment: Modified radical mastoidectomy & clearance of petrous apex cells

24. Sub-Periosteal abscess & Fistula 24

25. Pathology Production of pus under tension hyperaemic decalcification (halisteresis) osteoclastic resorption of bone sub-periosteal abscess penetration of periosteum + skin fistula formation 25

26. Sub-periosteal fistula: dry Sub-periosteal fistula: wet 26

27. Types of sub-periosteal abscess 27 Post-auricular Bezold Citelli Zygomatic Luc

28. Post-auricular Abscess Commonest. Present behind the ear. Pin n a pushed forward & downward. 28

29. Luc: swelling in external auditory canal Bezold absceses-swelling over sternocleidomastoid muscle Citelli absceses-swelling over posterior belly of digastric muscle Parapharyngeal & Retropharyngeal: due to spread of pus along Eustachian tube 29

30. Intra Cranial 30

31. Meningit i s 31 It defined as inflammation of leptomeninges (Pia & Arachnoid) with bacterial invasion of CSF in subarachnoid space.

32. Mode of invasion 32 Preformed pathway (patent petro squamus suture or labyrinth) Venous thrombophlebitis Direct erosion of bone by cholesteatoma

33. Clinical features Fever with chills and rigor Headache Neck rigidity Photophobia, irritability Nausea, Vomiting 33

34. On examination Kernig’s sign– Extension of leg with thigh flexed causes pain Brudzinski’s sign– Flexion of neck causes flexion of hip and knee. Exaggerated tendon reflex Papilloedema 34

35. Otogenic brain abscess 35 50-70 % adult & 25% in child abscess are otogenic Route of infection: 1. Direct spread: via Tegmen plate: Temporal abscess via Trautmann’s triangle: Cerebellar abscess 2. Retrograde thrombophlebitis

36. Trautmann’s Triangle Superiorly: superior petrosal sinus Posteriorly: sigmoid sinus Anteriorly: semi-circular canals) Pathway to posterior cranial fossa from mastoid cavity 36

37. Stages of Brain Abscess 37 Early cerebritis(invasion)- 1-3 days Late cerebritis(Localization)-4-10days Early capsule formation(Enlargement)-10-13 days Late capsule formation(termination)-14 days.

38. Investigations 38 CT scan of brain MRI brain Avoid lumbar puncture to prevent coning

39. Medical Treatment 39 High dose broad spectrum I.V. antibiotics: Ceftriaxone + Metronidazole + Gentamicin I.V. Dexamethasone : reduce oedema I.V. Mannitol : reduce I.C.T. Anti-epileptics: Phenytoin sodium Antibiotic ear drops & aural toilet

40. Surgical Treatment 40 Repeated burr hole aspirations Excision of brain abscess with capsule Open incision & evacuation of pus Radical mastoidectomy after pt becomes stable

41. Otitic Hydrocephalus 41 Defined as raised intracranial pressure with normal CSF finding Seen in children and adolescent with acute and chronic middle ear infection

42. Mechanism Retrograde extension of thrombophibittis from sigmoid sinus to superior sagittal sinus Blockage of arachnoid villi Dec CSF absorption/Inc Secretions Raised CSF pressure 42

43. Symptoms 43 Severe headache, Drowsines Vomiting Blurring of vision,Diplopia Signs Papilloedema Nystagmus CSF pressure > 300 mm of water.

44. Treatment 44 I.V. antibiotics & MRM Reducing CSF pressure (prevents optic atrophy) by: I.V. Dexamethasone I.V. Mannitol Repeated lumbar puncture / lumbar drain Ventriculo-peritoneal shunt

45. Extradural Abscess 45 It is collection of pus between dura matter and the bone of the IC Pathology Bone over the dura destroyed by decalcification (Acute) or cholesteatoma (Chronic) Spread of infection by venous thrombophlebitis Clinical features Persistent headache Severe pain in the ear Low grade fever and malaise.

46. Subdural abscess 46 Collection of pus between dura and arachnoid Erosion of bone and dura by thrombophlebitic process Pus may get loculated at various places in subdural space Clinical features – Due to meningeal irritation – Fever, malaise, headache, neck rigidity, positive kernig’s sign Due to raised intra cranial tension – papilloedema, ptosis.

47. Lateral sinus thrombosis 47 Syn – Sigmoid sinus thrombosis Definition – It is an inflammation of inner wall of lateral venous sinus with thrombus formation. Aetiology –CSOM with cholesteatoma.

48. Pathology Formation of perisinus abscess(outer wall sinus) Endophlebitis and mural thrombus formation(inner Wall) Thrombus enlarges to Obliterate the sinus lumen and leads to intrasinus abscess Extension of the thrombus-Septicemia. 48

49. Clinical features Rise of temperature Headache, neck pain Papilloedema Tenderness along jugular vein Investigation – CSF examination X-ray mastoid CECT scan, MRI Culture and sensitivity of ear swab 49

50. THANK Y O U 50