Complications of csom

COMPLICATIONS OF EAR INFECTION

1. COMPLICATIONS OF COM Dr. AJAY MANICKAM JUNIOR RESIDENT, DEPT OF ENT RG KAR MEDICAL COLLEGE

2. Introduction 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 Mortality due to intracranial complication is still high

3. Complications Extracranial Intracranial Meningitis Extradural abscess Subdural empyema Lateral sinus thrombophlebitis Brain abscess Otitic hydrocephalus CSF otorrhoea Extratemporal Subperiosteal abscesses Intratemporal Mastoiditis Labyrinth involvement Petrous apicitis Facial nerve paralysis Sensorineural hearing loss

4. Routes of access Bony defects anatomical dehiscences (jugular bulb, dural plate, Fallopian canal) erosion ( cholesteatoma , granulation tissue) trauma (accidental, dural plate breach during mastoidectomy ) Normal anatomical pathways oval window round window aqueducts Haematogenous infected thrombus venous spread (sinus, emissary veins, systemic ) Periarteriolar spread (of Virchow-Robin) seeding in the white matter of brain

5. Spread of Infection

6. FACTORS Pathogen Factors Patient Factors  High virulence bacteria  Young age Antimicrobial resistance  Poor immune status  Chronic disease (DM, TB)  Poor socio-economic status  Lack of health awareness

7. EXTRADURAL ABSCESS

8. Extra Dural abscess 2 nd Most common otogenic intracranial complication Acute infection by demineralization and chronic by erosion

9. MIDDLE CRANIAL FOSSA Tegmen tympani (lateral to the arcuate eminence) Petrous apicitis (medial to the arcuate eminence ) POSTERIOR CRANIAL FOSSA Sinus plate ( perisinus abscess, lateral sinus thrombophlebitis ) Trautmann’s triangle ANTERIOR CRANIAL FOSSA Pott’s puffy tumour

10. 2 nd most common intracranial complication Coalescence, cholesteatoma , granulation Non-specific symptoms (unilateral headache, fever, otorrhoea ) Often diagnosed peroperatively (silent abscess) MRI (Gadolinium-enhanced) > CT scan Systemic antibiotics + surgery ( mastiodectomy + removal of necrosed bone and non- adherant granulation tissue over dura )

11. SUBDURAL EMPYEMA

12. Subdural Empyema Least common complication Non hemolytic streptococci Inflammatory reaction underneath dura - granulation- fibrosis-necrosis of bone Seropurulent – purulent collection Subdural space, along tentorium cerebelli and interhemispheric spaces

13. CLINICAL FEATURES Dramatic presentation , rapid detioration Severe headache, fever, drowsiness, follwed by focal neurological symptoms Much more rapid than brain abscess Jacksonian fits Hemianopia , hemianaesthesia , aphasia Mortality 15%

14. along the falx loculated hypodense ring enhancement contrast imaging mass effect blunted sulci Gd-DTPA enhanced T1 weighted MRI CECT

15. Diagnosis and management CT scan CSF culture sterile With neurosurgeons Systemic antibiotics + removal of subdural fluid (burr hole) + ear infections acute by myringotomy and cortical mastiodectomy Now craniotomy abscess excision Radical mastoidectomy after patient is stable

16. MENINGITIS

17. Meningitis Most common intracranial complication In children following acute and adults following chronic infection Mortality 5-30 % Otogenic meningitis is most serious than meningococcal meningitis Hemophilus influenzae , streptococcus pneumonia type iii – acute Chronic – proteus and pseudomonas Anaerobic – bacteroid

18. Routes of entry into the meninges – haematogenous (MC) direct extension by bone erosion ( cholesteatoma , encephalocoel ) preformed channels ( Hyrtl’s fissures) labyrinth, aqueduct ( suppurative labyrinthitis , Mondini malformation) Suspicious signs – persistent/intermittent fever lethargy nausea and vomiting persistent headache irritability Ominous signs – visual changes ataxia new onset seizures altered sensorium nuchal rigidity Associted intracranial complications in 50% of cases Meningitis

19. Diagnosis and treatment CSF study by LP (cytology, chemistry, smear, culture) Broad spectrum IV antibiotics, steroids (to prevent subsequent hearingloss ) Myringotomy Mastoidectomy ( cholesteatoma , coalescent mastoiditis , extension through bone erosion, failure of maximal medical therapy)

20. LATERAL SINUS THROMBOPHLEBITIS

21. Lateral sinus thrombophlebitis Lateral sinus = Sigmoid sinus + Transverse sinus sinus plate  peri-sinus abscess  inflammation of Erosion of sigmoid outer wall  endophlebitis  m ural thrombus  occlusion of sinus lumen  intra-sinus abscess  propagating infected thrombus

22. Pathogenesis

23. Lateral sinus thrombophlebitis Sagittal sinus ( papilloedema , visual loss ) Petrosal and cavernous sinus ( proptosis , chemosis ) Mastoid emissary vein ( Griesinger’s sign) Internal jugular vein Subclavian vein Systemic spread (bacteraemia, septicaemia, septic embolisation) Torcula

24. Lateral sinus thrombophlebitis Proximal: 1. To superior sagittal sinus via torcula Herophili  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

25. 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

26. Symptoms & signs High fever, swinging type Chills precedes fever Temperature subsides with sweating Each fever spike due to release of fresh septic embolus

27. Investigations 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. Low sensitivity and specificity

28. investigations Lumbar puncture: to rule out meningitis CT brain with contrast: Delta sign or Empty triangle sign MRI brain with contrast MR angiography Blood culture Culture & sensitivity of ear discharge

29. Intravenous antibiotics Surgery Anticoagulants Ligation of internal jugular vein Treatment

30. Algorithm for Surgery Mastoidectomy Inspection of the sinus wall NORMAL (compressible, healthy-looking) DISEASED (inflammed, immobile, pale, opaque) Wide bore needle aspiration Free flow blood No blood, pus Conservative Thrombectomy, drainage (healthy thrombus, free flow blood) Dry tap

31. Otogenic brain abscess

32. OTOGENIC BRAIN ABSCESS 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 and 3. virchow robin space

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

34. 4 stages (Neely, Mawson ) 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

35. RAISED ICT Seen more in cerebellar abscess Severe persistent headache, worse in morning Projectile vomiting Blurring of vision & Papilloedema Lethargy  drowsiness  confusion  coma Bradycardia Subnormal temperature

36. Different findings Temporal Lobe Cerebellum  Nominal aphasia  I/L n ystagmus  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

37. 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

38. DIFFERENTIAL DIAGNOSIS Meningitis- high fever, neck stiffness , CSF findings Subdural abscess – the progression Lateral sinus thrombosis – precursor of cerebellar abscess Otitic hydrocephalous absence of focal neurological sign , CT scan findings and CSF features

39. Management 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

40. Surgical management Repeated burr hole aspirations – safer for ill patients Excision of brain abscess with capsule: best Tx – extensive damage to cerebral tissue , residual neurological deficit Open incision & evacuation of pus Radical mastoidectomy after pt becomes stable

41. OTITIC HYDROCEPHALUS

42. syn . Benign intracranial hypertension Symptomatic ↑ in ICT (>240 mm H 2 o in LP) , papilloedema , normal CSF studies, in absence of brain abscess or meningitis A misnomer Lateral sinus thrombophlebitis → torcula → sagittal sinus thrombosis → inhibition of CSF resorption through arachnoid villi → ↑ ICT [Symonds] Otitic hydrocephalus

43. Otitic hydrocephalus Clinical Features: 1. Severe headache, vomiting 2. Blurred vision, papilloedema , optic atrophy 3. Abducens palsy & diplopia due to raised intra-cranial tension ( Falselocalizing sign) Conservative (acetazolamide, fluid restriction, diuretics,mannitol , serial LP, ± systemic anticoagulants in case of sagittal sinus thrombosis) Mastoidectomy ± thrombectomy (in COM with cholesteatoma )

44. management Investigations: 1. Lumbar puncture:  ed CSF pressure (> 300 mm H 2 O). 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 , acetazolamide , diuretics  Repeated lumbar puncture / lumbar drain  Ventriculo -peritoneal shunt

45. CSF OTORRHOEA

46. More common with COM Cholesteatoma → tegmen dehiscence → middle or posterior cranial fossa dural tear → CSF leak/ encephalocoel Iatrogenic Presentations clear, colourless , watery fluid from mastoid cavity or external auditory canal through nose, in intact TM middle ear/ myringotomy fluid rich in glucose Proper exposure → temporalis muscle/fascia graft with gelfoam compression Sinodural angle tear most difficult to control Repair via intracranial route ( extradural / intradural )

47. 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.

48. SUBPERIOSTEAL ABSCESS

49. Extension of mastoid infection through the cortex and air cells into the subperiosteal region Types – Mastoid abscess ( subperiosteal abscess “proper”) [MC] von Bezold’s abscess Luc’s ( meatal ) abscess Zygomatic abscess Citelli’s abscess Para-/retropharyngeal abscess Haematogenous spread (perforators, especially in children) Differential diagnosis – Mastoiditis without abscess Suppurative lymphadenopathy Superficial abscess Infected sebaceous cyst

50. pathogenesis Production of pus under tension  hyperaemic decalcification + osteoclastic resorption of bone  sub- periosteal abscess  penetration of periosteum + skin  fistula formation

51. Subperiosteal fistula

52. Subperiosteal abscess (lateral wall) Bezold’s abscess (tip cells) Zygomatic abscess (zygomatic cells) Luc’s (meatal) abscess Parapharyngeal/retropharyngeal abscess (peritubal cells)

53. Postauricular abscess Commonest. Present behind the ear. Pinna pushed forward & downward

54. Bezold & citelli’s abscess Bezold : neck swelling over sternocleido - mastoid muscle Citelli : neck swelling over posterior belly of digastric muscle

55. 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

56. Luc’s abscess Luc: swelling in external auditory canal Zygomatic : swelling antero -superior to pinna + upper eyelid oedema Parapharyngeal & Retropharyngeal: due to spread of pus along Eustachian tube

57. Clinical features & treatment Late feature of neglected COM CT scan (extent of the lesion, intracranial and intratemporal complications) Subperiosteal abscess + cholesteatoma Drainage + cortical mastoidectomy + IV antibiotics Subperiosteal abscess – cholesteatoma Drainage + cortical mastoidectomy + IV antibiotics Drainage + myringotomy + IV antibiotics Aspiration + myringotomy + IV antibiotics

58. MASTOIDITIS

59. Mastoiditis = mucositis of mastoid cavity and air cells + effusion part of the spectrum of uncomplicated otitis media per se , not a complication Acute (clinical) mastoiditis red, oedematous soft tissue over mastoid antrum painful/tender pinna directed laterally, downward and forward loss of post-auricular crease otorrhoea localised reactive lymphadenopathy pain the only presentation in adults (thicker cortex)

60. 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

61. Disease of childhood (>2 years, peak at 6 years) Mostly a sequelae of ASOM ( Pneumococcus , Haemophilus ) 25% of coalescent mastoiditis seen in sclerotic temporal bone with COM and cholesteatoma

62. Fate of an inflammed mastoid cavity Acute mastoiditis Spontaneous resolution, perforation of tympanic membrane Persists Blockage of aditus by granulation/ cholesteatoma Mastoid empyema Acute coalescent mastoiditis Acidosis Osteoclast activity Pressure of pent-up pus DEMINERALISATION Subperiosteal abscess Petrositis Intratemporal & intracranial complications

63. Symptoms & signs Otorrhoea > 3 weeks, pain behind the ear & fever 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 Blood counts , ESR raised , Mastoid cavity in X-ray & CT scan , ear swab culture & sensitivity

64. Mastoid reservoir sign

65. Posterior sagging of posterior canal wall

66. mastoiditis

67. Coalescence of cells

68. Mastoiditis Furunculosis H/o otitis media + - Deafness + - Position of pinna Down + outward + forward Forward 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

69. management Urgent hospital admission Broad spectrum I.V. antibiotics Cortical mastoidectomy  No response to medical treatment in 48 hrs , sagging of post meatal wall  Development of new complication  Presence of sub- periosteal abscess Myringotomy to drain out painful pus Incision drainage of sub- periosteal abscess

70. Masked mastoiditis Natural progress of acute mastoiditis halted by antibiotics Middle ear apparently free from infection Persistence of symptoms of mastoiditis TM fails to return to normalcy Blockage of aditus by granulation/ cholesteatoma

71. PETROSITIS

72. Pneumatisation of the petrous pyramid 30% (anterior petrous apex), 10% (posterior petrous apex) after 3 years of age continuous with the middle ear cleft POSTEROSUPERIOR/INFRALABYRINTHINE CHAIN (attic, antrum → semicircular canal → apex) ANTEROINFERIOR/PERITUBAL CHAIN ( hypotympanum , PT tube → cochlea → apex)

73. ACUTE PETROSITIS Gradenigo’s syndrome deep-seated retro-orbital/aural pain (50%) diplopia (lateral rectus palsy) (25%) otorrhoea TYPICAL GRADENIGO’S SYNDROME IS RARE NOT PATHOGNOMONIC OF APICITIS SIMILAR PRESENTATIONS WITH EXTRADURAL ABSCESS AT THE APEX Cochleo -vestibular symptoms, facial weakness, constitutional symptoms

74. Petrositis Pneumatisation of petrous apex not a prerequisite ALTERNATIVE ROUTES OF SPREAD Thrombophlebitis Osteitis Long standing persistent otorrhoea (discharging petrous tract) , with indolent symptoms

75. Long term, high dose systemic antibiotics Myringotomy (± grommet), corticosteroids (neuropathy) Surgery – petrous abscess, necrosis, failure of medical traetment Simple mastoidectomy Surgery in a hearing ear – approaches following the infected air-cells Surgery in a non-hearing ear – translabyrinthine & transcochlear approaches

76. INVOLVEMENT OF THE LABYRINTH (Otitis interna)

77. Most common complication of COM with cholesteatoma Arch of the horizontal semicircular canal most commonly affected (~90%) [nearest to the antrum Breach of the otic capsule Resorptive osteitis (inflammatory mediators in COM with cholesteatoma /granulation tissue) Pressure necrosis ( cholesteatoma mass) Cholesteatoma and/or granulation

78. Presentations of labyrinthine fistula sensorineural hearing loss subjective episodic vertigo positive fistula test Tullio phenomenon Preoperative CT scan (30° tilted) (57-60% sensitivity, even with 1mm cuts) Intraoperative diagnosis The presence of labyrinthine fistula to be assumed to be present in every case of COM with cholesteatoma

79. Fistula test in relation to labyrinthine fistula Tragal pressure, Politzer bag with ear canal adapter, pneumatic speculum Conjugate ocular movements with vertigo Not sensitive; its absence does not rule out a labyrinthine fistula False positive fistula sign ( Hennebert’s sign) intact tympanic membrane no fistula characteristic, though not diagnostic, of labyrinthine syphilis False negetive fistula sign inadequate sealing cholesteatoma blocking the fistula wax in the external canal dead labyrinth

80. Treatment of labyrinthine fistula Tympanomastoidectomy (CWD) + addressing the fistula Removal of cholesteatoma , exteriorising the fistula covered by matrix (single sitting in open cavity/staged in closed cavity) – prevents aggravation of SNHL by minimising tissue handling removal of cholesteatoma itself releives pressure keeping matrix safe until no granulation tissue lies underneath Complete removal of cholesteatoma including matrix (single or staged/2 nd look sitting) , repair of fistula (fascia, bone pâté) prevention of bone erosion and infection prevention of SNHL in the long term

81. SEROUS LABYRINTHITIS Translocation of toxins and inflammatory mediators Associated perilabyrinthine infection, especially fistula Meningogenic (Pneumococcal mengitis → aqueducts) Tympanogenic (round window, internal auditory canal) Clinical diagnosis : Sudden onset vertigo in a patient with AOM IV antibiotics + myringotomy ± mastoidectomy (in progressive cases) Hearing loss, vertigo and imbalance are reversible

82. SUPPURATIVE LABYRINTHITIS Comparatively less common (<1%) Invasion of bacteria into the labyrinth Tympanogenic (round window, fistula) Haematogenic (venous channels) Endolymphatic hydrops ( resistence of Reissner’s membrane to bacterial invasion ) Meningitis, intracranial ( cerebellar ) abscess Clinical diagnosis (aided by CT scan) sudden onset severe rotatory vertigo with vomiting profound unilateral deafness disorder of balance spontaneous horizontal nystagmus Tissue destruction and loss of functions are permanent IV antibiotics + myringotomy + corticosteroids + labyrinthine sedatives + mastoidectomy ± drainage/ labyrinthectomy

83. FACIAL NERVE PARALYSIS

84. Otitis media → 3-5% of incidences of facial palsy More common in children, after ASOM Acute onset (<1 week) in AOM, chronic protracted course in COM Cholesteatoma , granulation tissue, suppurative labyrinthitis ( sequestra ) , petrous osteomyelitis Congenital petrous cholesteatoma (progressive palsy with longstanding severe deafness, without otorrhoea ) Facial nerve exposed by cholesteatoma mostly escapes palsy ( epineurium replaced by matrix)

85. Causes of Facial nerve palsy AOM Neurotoxic effect (inflammatory mediators, bacterial toxins through natural dehiscences and vascular channels) Mass effect on the bare nerve COM Osteitis, erosion, direct pressure Oedema , neuropraxia , neuronotmesis Cholesteatoma > granulation tissue Acquired Fallopian canal dehiscence Tubercular otitis media

86. Clinical diagnosis Role of CT scan not a routine procedure investigation of choice <2mm cuts, with proper exposure of tympanic cavity & facial canal IV antibiotics + myringotomy ± grommet [AOM ] Surgical exploration [COM] CWD modified radical mastoidectomy Removal of cholesteatoma and granulation tissue Facial nerve decompression by removing matrix from epineurium Nerve repair, if needed The management

87. Thank you