Intratemporal complications of otitis media

1. INTRATEMPORAL
COMPLICATIONS OF OTITIS
MEDIA
Dr. Mohammed Shafeeq

2. ●Otitis media is an inflammation of part or all of
the mucoperiosteal lining of the
tympanomastoid compartment comprising of
eustachian tube, tympanic cavity, mastoid
antrum and all the pneumatized spaces of the
temporal bone.
●Complications of otitis media have been
defined as spread of infection beyond the
confines of lining mucosa of the middle ear cleft

3. ●Both acute and chronic otitis media can cause
complications
●In preantibiotic era, 52% of complications were
associated with virulent AOM
●Today, majority of complications result from
COM

4. ●Complications of otitis media can be classified
into two main categories:
●Intratemporal (those within the temporal bone)
●Intracranial (those within the cranial cavity)

5. Intratemporal complications
●MASTOIDITIS
●PETROSITIS
●FACIAL NERVE PALSY
●LABYRINTHITIS

6. Intracranial complications
●EXTRADURAL ABSCESS
●SUBDURAL ABSCESS
●MENINGITIS
●BRAIN ABSCESS
●LATERAL SINUS THROMBOPHLEBITIS
●OTITIC HYDROCEPHALUS

7. Pathways of spread of infections
●Direct bone erosion
●Acute infections – hyperaemic decalcification
●Chronic infections – bone resorption by
cholesteatoma / granulation tissue / osteitis
●Venous thrombophlebitis
●Infected clot within small veins – bone and dura –
venous sinuses
●Intact bone may be transgressed by
thrombophlebitis within haversian canal system –
dural veins – dural venous sinuses – superficial
veins of brain

8. ●Preformed pathways
●Anatomic pathways
–Oval window / round window
–Cochlear & vestibular ducts
–Dehiscence of thin bony covering of jugular bulb
–Dehiscence of tegmen tympani
–Dehiscent suture lines

9. ●Non anatomical defects
–Trauma:
●Accidental – through fracture lines
●Surgical - stapedectomy, fenestra
–Neoplastic erosions
●Into brain tissue along periarteriolar spaces of
Virchow-Robin

10. Factors influencing development of
complications
●Age
●Poor socioeconomic group
●Virulence of organisms
●Immunocompromised hosts

11. Acute Mastoiditis
●It is the extension of middle ear inflammation of
AOM into antrum and mastoid air cells
●This spread is because mastoid antrum and
epitympanum communicate freely through
aditus and antrum
●Common in children

12. ●Pathogenesis:
●Following otitis media – tympanomastoiditis
●Blockade of aditus – loculation of mucopurulent
material within antrum and air cells
●Persistent blockade of aditus – retrograde
thrombophlebitis – oedema and cellulitis of tissues
overlying mastoid
●If pus not drained – necrosis and demineralization
of bony trabeculae – 'Coalescent mastoiditis'

13. ●Further disease depends on direction of erosive
process
●Mastoid cortex is eroded – Subperiosteal abscess
●Medial progression – petrous pyramid
●Anterior – fallopian canal / labyrinth
●Mastoid tip – Bezold's abscess
●Towards tegmen / trautmann's triangle – epidural
abscess
●Invasion of perilymph / CSF - meningitis

14. ●Clinical features
Symptoms
●Pain behind the ear
●Fever
●Ear discharge
Signs
●Mastoid tenderness
●Ear discharge – 'light house sign'
●Sagging of posterosuperior meatal wall
●Perforation of pars tensa
●Swelling over mastoid
●Hearing loss

15. ●Masked Mastoiditis -
●Complication of COM with granulation tissue
formation and bone erosion which can occur
without ottorhoea
●Usually occurs in patients who have received
numerous courses of antibiotics
●Epitympanum and aditus is blocked so that middle
ear responds to antibiotics but mastoid does not

16. ●Symptoms & Signs
–Often occurs in children
–Mild pain behind the ear
–Persistent hearing loss
–TM – appears thick, loss of translucency
–Slight tenderness over mastoid
–PTA – conductive hearing loss
–X-ray mastoids – clouding of air cells

17. ●Differential diagnosis
●Furunculosis of meatus
●Suppuration of mastoid lymph node
●Infected sebaceous cyst

18. ●Managment
Investigations
●CBC / ESR
●X-ray mastoids
●Ear swab for C&S
Treatment
●Antibiotics
●Myringotomy
●Cortical mastoidectomy

19. ●Complications
●Subperiosteal abscess
●Labyrinthitis
●Facial paralysis
●Petrositis
●Extradural abscess
●Subdural abscess
●Meningitis
●Brain abscess
●Lateral sinus thrombophlebitis
●Otitic hydrocephalus

20. ●Abscesses in relation to mastoiditis
●Postauricular abscess
–Commonest abscess – forms over mastoid
–Pinna displaced – outward & forward
–Infection may spread from mastoid to subperiosteal
space
–Treatment includes incision and drainage along with
mastoidectomy

21. ●Bezold's abscess -
–Occur following acute coalescent mastoiditis
–Pus breaks through thin medial side of tip of mastoid
–Swelling in upper neck
–Abcess may
●Deep to SCM pushing the muscle outwards
●Along posterior belly of digastric – swelling between tip of
mastoid and angle of jaw
●Upper part of psterior triangle
●Parapharyngeal space
●Along the carotid vessels

22. ●Clinical features – insidous onset, h/o of ottorhoea,
sweeling in neck associated with pain, torticollis
●CT temporal bone & neck
●Treatment
–Drainage of abscess
–Cortical mastoidectomy

23. ●Luc's abscess -
–Meatal abscess
–Pus breaks through bony wall between antrum and bony
external auditory meatus
–It may burst into meatus
●Citelli's abscess -
–Abscess formed behind the mastoid towards the occipital
bone

24. Petrositis
●It is the inflammation of pneumatized spaces of
petrous portion of temporal bone
●Is pneumatised only in 30% of individuals
●Air cells of petrous pyramid are classified into
two groups

25. ●Anterior group – extends from mesotympanum,
hypotympanum and protympanum and passes
around cochlea to petrous apex
●Posterior group – continous with mastoid antrum
and epitympanum that cluster around semicircular
canals at base of pyramid and extend medially to
petrous apex

26. ●Acute Petrosistis -
●Middle ear inflammation – antrum and mastoid air
cells – medial progression involving petrous
pyramid
●If inflammatory products are retained – osteitis of
petrous apex – retro orbital pain, ipsilateral lateral
rectus palsy
●Gradenigo's syndrome – lateral rectus palsy
(Abducens N), deep seated ear / retroorbital pain
(Trigeminal N), Ear discharge
●Chronic Petrositis -
●In addition to inflammatory changes – new bone
formation and resorption

27. ●Management
Investigations
●CT temporal bone
Treatment
●Systemic Antibiotics
●Radical Mastoidectomy with skeletinization of
semicircular canals to remove disease from middle
ear and petrous apex

28. ●Approaches to Petrous apex
●Eagleton's approach -
–This is the superior approach to the petrous
apex involving removal of tegmen to base of
zygoma together with removal of part of
squamous temporal bone. Dura of MCF is now
elevated to expose the petrous apex
●Thornwaldt's operation -
–This approach is along the supralabyrithine
tracts. It merges with Eagleton's approach

29. ●Almoor's approach -
–It is an inferior approach to petrous apex through a space
bounded by cochlea, carotid artery and tegmen tympani
●Ramadier's operation -
–This approach is slightly anterior to that of Almmor's
approach that pursues the peritubal cells to petrous apex
between cochlea and carotid artery
●Frenckner's operation -
–This approach is through arch of superior semicicular
canal. Blood supply to the labyrinth arises from this arch
and some labyrinthine loss in inevitable in this approach.
This has to be combined with an inferior approach

31. Facial nerve palsy
●It can occur in acute and chronic otitis media
●Pathophysiology – routes of spread
●natural dehiscences – fallopian canal
●natural pathways – canal for stapedius,
neurovascular bundle, mastoid air cells
●direct infection - osteitis

32. ●Symptoms and Signs -
Insidious onset , gradually progressive
Unable to close the eyes
Facial asymmetry
Epiphora
Noise intolerance due to stapedial palsy
Loss of taste sensation
Bell's phenomenon

33. ●In AOM – pus/osteitis around dehiscent facial N
– inflammation / swelling around the nerve
●Management
●Treat AOM with antibiotics
●Myringotomy with/without tympanostomy tube
insertion
●Intact canal wall mastoidectomy – coalescent
mastoiditis
●Facial N decompression is not indicated as 95% of
casesnrecover completely secondary to AOM

34. ●In COM – cholesteatoma – bony erosion –
direect infection of nerve
●Management -
●Antibiotics
●Steroids
●Definitive treatment – Canal wall down
mastoidectomy and decompression of fallopian
canal

35. Labyrinthitis
●Inflammation of inner ear / labyrinth
●Pathogenesis -
●AOM:
–Spread through round window
–Round window : thinner , increased permeability
–Inflammatory products pass into perilymph of scala
tympani by diapedesis from adjacent labyrinthine
vessels
–Fibrilliary precipitate accumalates in perilymphatic
and endolymphatic spaces – endolymphatic hydrops
– destruction of membranous labyrinth

36. –Preformed fistula into labyrinth from middle ear after
stapedectomy offer another route for infective spread
●If inflammatory changes induced in labyrinth by
transgression are irreversible – Serous labyrinthitis
●If intralabyrinthine suppuration destroy cochlear and
vestibular function in affected ear – Suppurative
labyrinthitis

37. ●COM :
–Erode bony labyrinth by cholesteatoma or osteitis leading
to inner ear destruction
–Fully developed intralabyrinthine inflammation is
preceded by thining of labyrinthine wall and development
of fistula of labyrinth
–Labyrinthine damage from slowly eroding cholesteatoma
is followed by new bone deposition – destruction of part
of labyrinth with partitioning and preservation of rest
–Bony fistula are often closed by new bone deposition
after eroding disease has been eliminated

38. ●Suppurative labyrinthitis is a rare complication
of OM – prompt use of antibiotics
●Development of labyrinthine fistula has
remained common in COM – about 10%
●Rarely infection maay spread from meningitis to
labyrinth through internal auditory meatus or
through cochlear / vestibular aqueducts
●Most rarely infection may be blood borne

39. ●Symptoms and signs -
●Vertigo
●Loss of balance
●Tinnitus
●Nausea / vomiting
●Hearing loss – SNHL

40. ●Treatment
●Complete bed rest – with restriction of head movt
●Vertigo/vomiting – parenteral chlorperazine /
cinnarizine
●Dehydration – IV fluids
●IV antibiotics
●Acute infection – Myringotomy
●Chronic infection – Mastoid exploration
–Premature surgical trauma – dissemination of infection
●After recovery of acute symptoms
–Vestibular head exercises – Cawthrone-Cooksey regimen

41. ●Labyrinthine fistula
●Complication of COM
●Results from erosion of endochondral bone of bony
labyrinth – movement of perilymph and structures of
endolymphatic compartments when pressure in
EAC changes
●Most commonly – dome of lateral SCC
●Cholesteatoma is found in all cases
●Incidence of fistula in cholesteatoma is 7-10%

42. ●Symptoms / Signs -
●Short periods of imbalance
●Vertigo
●Tullio's phenomenon – feeling of imbalance on
sudden exposure to loud noise
●Fistula sign – positive
●Investigations:
–CT – erosion of lateral SCC, cholesteatoma

43. ●Treatment -
●Canal wall down mastoidectomy
–All cholesteatoma is removed except for small area
around fistula site. After careful removal of cholesteatoma
debri without disturbing matrix. Matrix is elevated. A
small piece of tissue / thin cap of bone placed over site
and secured with fibrin glue / packing after the
cholesteatoma is removed
–Risk of removing cholesteatoma from fistula is total /
partial loss of hearing

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