Complications of csom

Complications of CSOM are still prevalent in the developing countries.

1. Complications Of CSOM
Dr. Krishna Koirala
MBBS, MS ( ENT )
2019-09-03

2. •Complicationsoccurwheninfectionspreadsbeyond
themuco-periostealliningofmiddleearcleft
–Toinvolvethebone
–Intoneighboringstructurese.g.facialnerve,inner
ear,duralvenoussinuses,meninges,braintissue,
softtissue
•Multiplecomplicationsoccurin1/3ofpatients
•Childrenmorecommonlyaffectedthanadults

3. 1. Pathogen Factors
–High Virulence of Bacteria
–Antimicrobial Resistance
2. Patient Factors
–Young Children
–Poor Immune Status
–Concurrent Chronic Disease
–Poor socio-economic status
–Lack of health awareness
3. Physician Factors
–Non-Availability in
remote areas
–Injudicious Antibiotic
use (Masking Effect)
–Error in recognizing
“Danger symptoms /
signs”
Factors Affecting Complications

4. Etiology
•ASOM
–StreptococcusPyogenes
–HaemophilusInfluenzae
–MoraxellaCatarrhalis
–Staphylococcusaureus
•CSOM
–Multipleagents
•Pseudomonas
aeruginosa
•Bacteroidesfragilis
•ProteusMirabilis
•Klebsiella
•E.Coli

5. Routes of spread of infections
1 . Direct bone erosion
–Acute infection : hyperemic decalcification
–Chronic infection : resorption by cholesteatoma or
osteitis
2 . Thrombophlebitis
–From lateral sinus to cerebellum
–From superior petrosal sinus to temporal lobe

6. 3.Fromnormalanatomicalpathways
–Ovalandroundwindows,cochlearandvestibular
aqueducts,dehiscenceoftegmentympanietc.
4.Nonanatomicalbonydefects
–Accident/surgery/neoplasm
5.Intobraintissuealongtheperiarteriolarspacesof
Virchow-Robin

7. Classification
A) Intra-Temporal
1.Coalescent Mastoiditis
2.Petrositis
3.Labyrinthitis
4.Labyrinthine Fistula
5.Facial Nerve Paralysis
B) Extra-Temporal
1.Sub-periosteal Abscess
2.Citelli's Abscess
3.Bezold’s Abscess
4.Luc’s Abscess
5.Zygomatic Abscess
6.Occipital Abscess
C) Intra-Cranial
1.Meningitis
2.Extra-Dural Abscess
3.Sub-Dural Abscess
4.Brain Abscess
5.Lateral Sinus
Thrombophlebitis
6.Otitic Hydrocephalus
7.Brain Fungus
D) Systemic
1 .Septicemia
2.Otogenic Tetanus

8. Acute Coalescent Mastoiditis
•Acuteosteitisofmastoidaircells
•Coalescence-destructionofwallsoftrabecularair
cellsandtheirjoiningtogethertoformasingle,
irregularmastoidcavity
•Occursmorecommonlyin
–Children
–Wellpneumatizedmastoids
–ASOM

10. Aditus Blockage
Failure of Drainage
Stasis of Secretions
Hyperemic Decalcification
Resorption of bony walls of air cells
Coalescence of small air cells
to form an irregular cavity

11. Symptoms
•Earache : Persistent > 2 weeks, increased intensity or
recurrence of pain within 3 weeks
•Fever/post aural pain/decreased hearing
•Ear discharge : Increased on reservoir sign and
decreased in aditus block
•Masked mastoiditis : absence of classical symptoms
due to inadequate antibiotic use

12. •Signs
–Pinna:protrudedforwardsanddownwards
–Obliterationofpostauriculargroove
–Mastoidtenderness
–Smoothironedoutfeelofthemastoid
–Saggingofposterosuperiorbonycanalwallbut
unreliableTMfindings
–Reservoirsign(purulentdischargerefillsEACafter
cleaning)

13. Pinna -forward & downward -Ironed out mastoid
-Obliteration of retro auricular
groove
bulge

14. ASOM ASOM + MASTOIDITIS

15. Investigations
•CBC:TLCandESRraised
•X-rayMastoid
–HistoricalInterest
•Cloudingofaircells
•Indistinctpartitionsinaircells
•Irregularwalledcavity
•HRCTtemporalBone
–Investigationofchoice
•PusCulture:Helpsselectappropriateantibiotic

17. 1.Sub-Periosteal
Mastoid Abscess
2.Bezold Abscess
3.Citteli’s Abscess
4.Luc Abscess
5.Zygomatic Abscess
6.Occipital Abscess
Abscesses in relation to Mastoid

18. •Post-aural Sub-periosteal Mastoid Abscess
–Most common abscess
–Most common site –Mac Ewan’s Triangle
–Cause: Direct Cortex erosion / through vessels in mastoida
cribrosa
–Occurs in ~ 50 % of cases of Acute Coalescent Mastoiditis
•Subcutaneous Mastoid Abscess + Fistula
•Bezold’s Abscess –Along sternocleidomastoid muscle
•Citelli’s Abscess –Along Posterior belly of digastric muscle

19. •Temporo -zygomatic Abscess
–Along root of Zygomatic bone
•Occipital Abscess
–Along Mastoid Emissary Vein
•Deep Neck Space Abscess
–Parapharyngeal, Carotid Space

20. Post-Aural Fistula Mastoid Abscess

21. Treatment
•Medical Treatment : First line
•Admission, Broad spectrum I.V. Antibiotics, AntiInflammatory
agents
•Surgical
–Indications
•No response to medical treatment in 24-48 hours
•Poor response to 2 weeks of medical treatment
•Any new complication/abscess formation
–Myringotomy, I &D Of Abscess, Cortical mastoidectomy

22. Features Acute MastoiditisFurunculosis
History of ASOM+ ---
Pinna Forward, DownwardForward
Discharge Mucoid --/ purulent (thick)
Sagging EAC wall+ --
TM congestion + --
X-ray Mastoid Haziness,
Coalescence of cells,
Irregular cavity
Diplopic/ Sclerotic
Pain Pinna -- +
Lymphadenopathy-- +
Tenderness Mastoid Antrum Diffuse

23. Acute Petrositis (Gradenigo’s syndrome)
•Involvement of petrous apex air cells (pneumatized
in 20% cases only)
•Difficult to manage due to
–Poor drainage
–Proximity to neurovascular structures
•Clinical Features
–Gradenigo’s Syndrome

25. 1.Persistent Ear Discharge in
spite of adequate cortical
mastoid surgery
2.Retro -Orbital Pain due to V
cranial nerve involvement
3.Medial Squint due to
Abducens Nerve involvement
Gradenigo’s Syndrome

27. Treatment
•Medical
•I.V. Antibiotics / Anti-Inflammatory agents
•Surgical
–Without residual hearing
•Trans-labyrinthine Route -Posterior cells
•Trans-cochlear Route -Anterior cells
–With residual hearing
•Retro-labyrinthine Route /Sub -arcuate Route -Posterior
cells
•Infra-cochlear Route /Sub-temporal Route -Anterior cells

28. •Erosion of Dome of Lateral Semicircular Canal
•Usually asymptomatic
•Symptomatic : Episodic Vertigo lasting for seconds to
minutes
•Fistula Test : Positive
(In all patients of CSOM with vertigo, a labyrinthine fistula must
be presumed unless proven otherwise)
Labyrinthine Fistula

29. •Management: Surgical Only
–CWD Mastoidectomy:
•Large Fistula>2mm
•Multiple Fistulae / Promontory Fistula
( DON’T REMOVE MATRIX )
–CWU Mastoidectomy:
•Small fistula < 2mm only
(MATRIX CAN BE REMOVED)

30. Facial Paralysis
•ASOM
–Congenital Dehiscence
–Edema within fallopian canal
–Purulent erosion of fallopian canal
•CSOM
–Cholesteatoma erodes fallopian canal
–Granulations
–Osteitis
•Cholesteatoma matrix may protect the facial nerve

31. •Investigation : HRCT Temporal Bone
•Treatment
–ASOM
•I.V. Antibiotics/Myringotomy /Cortical Mastoidectomy
•Facial nerve exploration & Decompression not needed
–CSOM
•Urgent Facial nerve exploration & Decompression
•Canal Wall Down Mastoidectomy and exploration of
facial nerve from 1
st
genu to stylo -mastoid foramen
•Repair of facial nerve : Re-routing, End to end
anastomosis ,Nerve grafting

32. Intra-cranial Complications
•Features
–High grade fever/ altered sensorium/irritability
–Generalized malaise/photophobia/neck Stiffness
–Seizures / Focal Neurological Symptoms
–Deep Boring Headache

33. •Meningitis
–Most Common Intracranial
Complication
•Otogenic Intracranial Abscesses
–Extra-Dural Abscess
–Sub-Dural Abscess
–Brain Abscess
•Temporal lobe abscess
•Cerebellar abscess

34. Intra-Cranial Abscess
•75% Brain Abscess -Otogenic
•CT/ MRI Diagnostic
•Treatment
–Antibiotics
–Dexamethasone (↓ Cerebral edema)
–Mannitol(Decrease CSF pressure)
–Mastoid Exploration
–Abscess Drainage -Burr Holes /
Craniotomy
Temporal lobe Abscess
Cerebellar abscess

35. 1.Superior Petrosal Sinus
2.Transverse Sinus
3.Sigmoid Sinus
4.Inferior Petrosal Sinus
Lateral sinus ( Sigmoid
sinus+ Transverse sinus)
Lateral Sinus Thrombophlebitis

36. Fate of thrombus in lateral sinus
thrombosis

37. •Clinical Features
•Symptoms
–Long standing discharging ear (foul smell)
–High and swinging fever (Picket fence) with chills and rigors
( simulating malaria)
–Headache ,otalgia, neck pain, torticolis
–Wasting illness
–Impaired mental awareness( drowsiness, lethargy, coma)
–Decreased vision

38. Signs
•Anemic,wastedpt
•Eardischarges/oCSOMAA
•Tendernessatthemastoidprocessandneckalongthe
sternomastoidmuscle(Universalfinding)
•Signsofmeningealirritation(50%chanceofotherintracranial
complications)
•Papilledema :50%
•Griesinger’sSign
–Pittingedemaovertheoccipitalregionbehindthemastoid
process(d/tclottingwithinalargemastoidemissaryvein)

39. •Investigations
•FBC :Anemia,raisedWBC,raisedESR
•Bloodculture
•Lumbarpunctureifnotcontraindicated
•Crowe-BeckTest
–CompressionofnormalIJVengorgementof
retinalvessels(seenonophthalmoscopy)

40. •Tobey-Ayertest(Queckenstedttest):MeasuringtheCSF
pressureandobservingitschangesoncompressionofoneor
bothIJVontheneck
–Normalsubject:compressionofeachIJVrapidriseof
CSF(50-100mmH
20)abovenormallevelfollowedbyrapid
fallonrelease,normaldiffin2sidesbeing<50mmH
2O
–LateralSinusThrombosis:Pressureovertheveindraining
theoccludedsinusnonorveryslowriseofpressure(
10-20mmH
2O)butonCompressionofnormalIJVrapid
pressurerise2or3timesthenormalpressure
–False+and–veresults(Lowsensitivityandspecificity)

41. •CTScanofheadContrast
–Increaseddensityoffreshclot/fillingdefectswithinthesinus
–EmptyDeltasign:Intenseinflammatoryenhancementof
thesinuswallandadjacentdurabutnotthecontentsofthe
sinus
•DigitalsubtractionAngiography/venography
–Siteandextentofobstruction
•MRI
–IncreasedsignalintensityinbothT1andT2
–Venousflow
•Radio-isotopescan(Ga):Hotspotsofsepsis,blockedvenous
flow

43. Treatment
•Highdosebroadspectrumintravenousantibiotics
•Surgical:Completemastoidectomyperformed,sinusexposed
,abscessdrainedandclotisremoved(ENTemergency)
•Anticoagulants
–NoregularplaceexceptCavernoussinusthrombosis
•InternalJugularveinligation
–Septicemianotrespondingtoantibioticsandsurgery
–Childrenshowingsignsofembolisation

44. Otitic Hydrocephalus
•Occurs due to raised ICP due to failure of Arachnoid villi to
absorb CSF
•C/F
–Headache, nausea, vomiting, blurring of vision
–Lumbar Puncture: High pressure but normal lab findings
•Treatment
–Acetazolamide
–Dexamethasone
–Lumbar Drain, Lumbar -peritoneal Shunt

45. Brain Fungus
•BrainHerniationinMiddleEar/Mastoidusuallyafter
mastoidsurgeryduetodefectinthedura
•Commoninpre-antibioticerabutrarenowadays
•Diagnosis
–CTscanofheadandtemporalbone
•Treatment
–Cautery&Removalofprolapsedbrain&repairof
defect