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irugía y Cirujanos. 2016;84(5):398---404

www.amc.org.mx www.elsevier.es/circir

CIRUGÍA y CIRUJANOSÓrgano de difusión científica de la Academia Mexicana de Cirugía

Fundada en 1933

LINICAL CASE

iagnosis and treatment of the complications of otitisedia in adults. Case series and literature review�

uis Humberto Govea-Camacho, Ramón Pérez-Ramírez ∗,rnulfo Cornejo-Suárez, Roberto Fierro-Rizo, Claudia Janet Jiménez-Sala,arlos Silvino Rosales-Orozco

torrinolaringología y Cirugía de Cabeza y Cuello, Hospital de Especialidades, Centro Médico Nacional de Occidente,nstituto Médico del Seguro Social (IMSS), Guadalajara, Mexico

eceived 28 January 2015; accepted 15 May 2015vailable online 1 September 2016

KEYWORDSOtitis media;Abscess brain;Venous thrombosis

AbstractBackground: The complications of otitis media (intra-cranial and extra-cranial) used to havea high morbidity and mortality in the pre-antibiotic era, but these are now relatively rare,mainly due to the use of antibiotics and the use of ventilation tubes, reducing the incidence ofsuch complications significantly. Currently, an early suspicion of these complications is a majorchallenge for diagnosis and management.Clinical cases: The cases of 5 patients (all male) are presented, who were diagnosed withcomplicated otitis media, 80% (4) with a mean age of 34.6 years (17---52). There was majorcomorbidity in 60% (3), with one patient with diabetes mellitus type 2, and two with chronicrenal failure. There were 3 (60%) intra-cranial complications: one patient with thrombosis ofthe sigmoid sinus and a cerebellar abscess; another with a retroauricular and brain abscess, anda third with meningitis. Of the 2 (40%) extra-cranial complications: one patient had a Bezoldabscess, and the other with a soft tissue abscess and petrositis. All patients were managed with

surgery and antibiotic therapy, with 100% survival (5), and with no neurological sequelae. The clinical course of otitis media is usually short, limiting the infection process in the majorityof patients due to the immune response and sensitivity of the microbe to the antibiotic used.However, a small number of patients (1---5%) may develop complications.

� Please cite this article as: Govea-Camacho LH, Pérez-Ramírez R, Cornejo-Suárez A, Fierro-Rizo R, Jiménez-Sala CJ, Rosales-Orozco CS.bordaje diagnóstico y terapéutico de las complicaciones de la otitis media en el adulto. Serie de casos y revisión de la literatura. Cir Cir.

016;84:398---404.∗ Corresponding author at: Belisario Domínguez 1000, Colonia Independencia, Guadalajara, Jalisco, Mexico. Tel.: +33 3618 9492;

ax: +33 3618 9492.E-mail address: dr ramon otorrino@yahoo.com (R. Pérez-Ramírez).

444-0507/© 2015 Academia Mexicana de Cirugıa A.C. Published by Masson Doyma Mexico S.A. This is an open access article under the CCY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Diagnosis and treatment of the complications of otitis media in adults 399

Conclusion: Otitis media is a common disease in our country, complications are rare, but shouldbe suspected when the picture is of torpid evolution with clinical worsening and manifestationof neurological signs.© 2015 Academia Mexicana de Cirugıa A.C. Published by Masson Doyma Mexico S.A. This is anopen access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

PALABRAS CLAVEOtitis media;Absceso cerebral;Trombosis venosa

Abordaje diagnóstico y terapéutico de las complicaciones de la otitis media en eladulto. Serie de casos y revisión de la literatura

ResumenAntecedentes: Las complicaciones de la otitis media (intracraneales y extracraneales) tuvieronalta morbimortalidad en la era preantibiótica. En la actualidad son relativamente raras conel uso de antibióticos, tubos de ventilación y otros cuidados médico-quirúrgicos, reduciendola incidencia de forma notable. Actualmente la sospecha oportuna de estas complicaciones esindispensable y constituye un gran reto para su diagnóstico y tratamiento adecuados.Casos clínicos: Presentamos 5 pacientes con diagnóstico de otitis media aguda complicada,el 100% (5) fueron de sexo masculino; el 80% (4) con edad media de 34.6 anos (17-52), y lacomorbilidad fue importante en el 60% (3): un paciente con diabetes mellitus tipo 2 y 2 con insu-ficiencia renal crónica terminal. Tres pacientes (60%) tuvieron complicaciones intracraneales:un paciente con trombosis del seno sigmoides y absceso cerebeloso, otro con absceso retroau-ricular y cerebral, y un tercero con meningitis. Dos pacientes (40%) tuvieron complicacionesextracraneales: un paciente con absceso de Bezold y otro con absceso de tejidos blandos ypetrositis. Todos fueron tratados con manejo quirúrgico y antibioticoterapia con supervivenciadel 100% (5), sin secuelas neurológicas. El curso clínico de la otitis media aguda suele ser corto,limitándose el proceso infeccioso en la gran mayoría de los pacientes debido a la respuestadel sistema inmune y de la sensibilidad del germen al antibiótico utilizado. Sin embargo, unpequeno número de pacientes pueden presentar complicaciones (1-5%).Conclusión: La otitis media aguda es una enfermedad muy frecuente en nuestro medio. Suscomplicaciones son raras, sin embargo se deben de sospechar cuando la evolución del cuadroes tórpida con empeoramiento clínico y manifestación de signos neurológicos.© 2015 Academia Mexicana de Cirugıa A.C. Publicado por Masson Doyma Mexico S.A. Este es unartıculo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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Five cases were presented of complicated otitis media with

Background

In the pre-antibiotic era morbidity and mortality fromacute otitis media was very high, because of the highfrequency of intracranial and extracranial complications.Nowadays these complications are relatively rare andongoing suspicion is required for diagnosis.1 Mastoiditisis a serious complication of acute otitis media that ismore common in paediatric patients, under the age of 4.Within its pathophysiology, its complications can developdue to contiguity or vascular invasion, and the infec-tion can reach the central nervous system. Complicationscan be subperiosteal abscess, Bezold abscess, facialparalysis, suppurative labyrinthitis, meningitis, epidural,subdural/cerebellar abscess, sigmoid sinus thrombosis andotitic hydrocephalus, some of which are potentially fatal.Management of acute mastoiditis varies and includes con-servative treatment using parenteral antibiotics, myringo-tomy (with or without placement of ventilation tubes)

or surgical intervention (more aggressive and includingmastoidectomy).2,3

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bjective

he objective of the study was to describe the cases ofomplications of otitis media that presented in the Centroédico Nacional de Occidente in 2014.

aterial and methods

case series with retrospective analysis of 5 cases fromhe ENT Department. The study included adult patients withomplications of otitis media attended in a third level hos-ital between January and December 2014. The patients’les were reviewed to verify diagnosis, complications, treat-ent, mortality and survival.

esults

mean age of 34.6 (17---52), 100% (5/5) were male, 60%3/5) were immunosuppressed. The clinical diagnosis was

400 L.H. Govea-Camacho et al.

Table 1 Outcomes of complications of otitis media.

Gender Age (years) Complication Germ Antibiotic Approach

1 M 17 Bezold abscess MethicillinresistantStaphylococcusaureus

Ceftriaxone/clindamycin

Drainage of abscessand simplemastoidectomy

2 M 43 Petrositis andsoft tissueabscess

Pseudomonasaeuriginosa

Levofloxacinor/metronidazole

Radicalmastoidectomy anddrainage of abscess

3 M 19 Thrombosis ofsigmoid sinusand cerebellarabscess

Negative Ceftriaxone,metronidazole andfluconazole

Decompressivecraniectomy ofposterior fossa,drainage of abscessand simplemastoidectomy

4 M 52 Brain and softtissue abscess

Negative Ceftriaxone andmetronidazole

Decompressivecraniectomy,capsulectomy anddrainage ofparenchymal abscess

5 M 42 Meningitis Negative Vancomycin andmeropenem

Simplemastoidectomy

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onfirmed in all cases by computed tomography (CT scan).ll of the patients were initially treated with empiricalntimicrobial therapy and subsequently treated accord-ng to the results of the antibiogram. Eighty percent ofhe cases underwent simple mastoidectomy and 20% (1/5)adical mastoidectomy. Eighty percent required multidis-iplinary care, 40% underwent decompressive craniectomynd drainage of intracranial abscess; 100% survival waschieved, therefore 0% mortality (Table 1).

linical cases

ase 1

17-year-old male patient, referred to the ENT and Headnd Neck Surgery Department with increased volume in theosterior triangle of the left side of the neck, with a his-ory of acute otitis media. CT scan confirmed diagnosis ofastoiditis complicated with Bezold abscess. The patientas managed surgically with drainage of the abscess via the

ranscervical approach and simple mastoidectomy (Fig. 1).

ase 2

43-year-old male patient with a history of chronic kidneyisease receiving replacement therapy with haemodialysis.he patient presented with increased volume in the rightetroauricular region and a 15-day history of otorrhoea.

maging study confirmed the diagnosis of otitis media com-licated by soft tissue abscess and petrositis. Therefore aadical mastoidectomy was performed and drainage of softissue abscess (Fig. 2).

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he neck (white arrow) and signs of ipsilateral mastoiditis (redrrow).

ase 3

19-year-old male patient, referred to our departmentith alterations in gait, stupor, otalgia and headache;apilloedema on fundoscopy. CT scan of the ears showed

eft-sided otomastoiditis, while nuclear magnetic resonanceNMR) of the skull showed a left sigmoid sinus thrombosis anderebellar abscess. Therefore a simple mastoidectomy was

Diagnosis and treatment of the complications of otitis media in adults 401

Figure 2 Showing the right mastoid (black arrow) and theipsilateral petrous apex occupied by an isodense image (bluearrow), and soft tissue abscess (white arrow).

Figure 3 Nuclear magnetic resonance of the skull, axial plane

Figure 4 Contrasted computed tomography of the skull;showing brain abscess with perilesional oedema and soft tissueoedema.

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in T1 gadolinium sequence; showing the cerebellar abscess (redarrow) and the swollen meninx at the level of the left sigmoidsinus (white arrow).

performed, a ventilation tube placed and exploration of thesigmoid sinus undertaken, with drainage and evacuation ofthe abscess by posterior fossa craniectomy (Fig. 3).

Case 4

A 52-year-old man with a history of chronic kidney diseasemanaged by peritoneal dialysis, referred to the department

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igure 5 Craniectomy + drainage of brain abscess and cap-ulectomy.

ith a month-long history of right otorrhoea and increasedolume in the ipsilateral retroauricular region, secondaryo trauma 7 days previously. The CT scan revealed soft tis-ue oedema in the temporal region, otomastoiditis and arain abscess in the temporal lobe (Fig. 4). The patientas treated by decompressive craniectomy, capsulectomy,rainage of the parenchymatous abscess, mastoidectomyith canal wall down and drainage of the retroauricularbscess (Fig. 5).

ase 5

42-year-old male patient, diabetic, referred for assess-ent after presenting 3 symptoms of meningitis in theast month. The CT scan revealed a right-sided mastoidi-is. Lumbar puncture reported turbid cerebrospinal fluid,

ith 6000 leukocytes/mm3 with 65% neutrophils, 332 mg/dlrotein, 107 mg/dl glucose, culture negative; serum glucosef 279 mg/dl, peripheral leukocytes 10,100 �L (73% totaleutrophils); polymerase chain reaction for tuberculosis,

402

Figure 6 Computed tomography of the ears, coronal planes,sd

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howing well-developed left mastoid with cells occupied by iso-ense image to soft tissues, no alterations in the right mastoid.

egative. The patient was treated with antibiotic therapyased on intravenous vancomycin and meropenem for 14ays and simple mastoidectomy (Fig. 6).

iscussion

cute otitis media can be divided into 5 clinical stages thatirectly correlate with the clinical symptoms, and thesean overlap: (1) Stage of tubotympanitis: causes discom-ort, a feeling of fullness inside the ear, retracted tympanicembrane, and loss of luminous reflex; initially a serousischarge might be observed. (2) Hyperaemic stage: causestalgia, general malaise and fever of up to 39 ◦C, the tym-anic membrane is congested and opaque. (3) Exudativetage: presents with intense otalgia, which can interruptleep, fever of over 39 ◦C, marked hyperaemia of the tym-anic membrane with loss of anatomical points of reference.4) Suppurative stage: accompanied by a fever of 40 ◦Cr higher, and intense throbbing ear pain, tense tympanicembrane, with hyperaemic areas that are occasionally

ellowish, denoting necrosis. (5) Stage 5: there can be spon-aneous perforation of the membrane and otorrhoea overore than 2 weeks.4

The clinical course of acute otitis media is usually short,he infectious process is limited in most patients due toheir immune system’s response and the germ’s sensitivityo the antibiotic used; however, a few patients can presentomplications (1---5%).

Acute mastoiditis is subdivided according to clinical stagento: (1) acute incipient mastoiditis, i.e., inflammation ofhe mastoid air cells, and (2) coalescent mastoiditis, whichs when the inflammatory process destroys the bony trabec-lae of the mastoids, resulting in an (organised) abscess.3

cute mastoiditis can spread anatomically in 6 differentirections: lateral, towards the soft tissues of the externalar; anterior, towards the external auditory canal; poste-ior, towards the sigmoid sinus or the posterior cranial fossa,ausing thrombosis of the lateral sinus; medial, towards theabyrinth or the petrous apex, causing labyrinthitis, and/orpicitis; superior towards the middle cranial fossa, causingn epidural abscess; and inferomedial, towards the mas-oid point, causing a Bezold abscess.4 The most commonntracranial complication of acute mastoiditis is menin-

itis. Other intracranial complications include: subduralmpyema, epidural empyema, intraparenchymal abscess,hrombosis of the transverse sinus, apicitis and otitic hydro-ephalus. Extracranial complications are: peripheral facial

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L.H. Govea-Camacho et al.

aralysis, labyrinthine fistula, Bezold abscess, osteomyelitisnd cervical fasciitis.5

The most commonly found germs in acute mastoiditis andts complications are: Streptococcus pneumoniae (S. pneu-oniae), group A streptococcus, Staphylococcus aureus (S.

ureus), Haemophilus influenzae (H. influenzae) and Pseu-omonas aeruginosa (P. aeruginosa), pneumococcus beinghe most common in the general population.6,7 In 60% ofur patients, 3 cases, no germ was isolated. Only 2 weresolated, one S. aureus and the other P. aeruginosa.

Otitis media complicated by Bezold abscess can occur inny age group, but more commonly in older children anddults, as in the former the pneumatisation of the mastoidxtends towards the point, easily enabling perforation of theortex. Adults affected by this complication usually have aistory of chronic disease such as sinusitis or cholesteatoma.he most common germs in most cases are S. pneumoniaend pyogenes. Within the pathophysiology, once mastoidi-is is found to be affecting the mastoid point, it causes ito erode with spread to the posterior triangle of the neck.atients diagnosed with Bezold abscess typically present:radual fever, otorrhoea, otalgia and hyperthermia in theeck with or without increased volume, over a period ofays.

These abscesses are treated by mastoidectomy andrainage.8---10 In our case, the patient with Bezold abscessresented with atypical symptoms, they consulted withncreased neck volume and an opaque tympanic membraneas found on physical examination. Initially, a diagnosisf deep abscess of the neck was considered. However,he imaging study revealed a purulent collection periph-rally enhanced by the contrast medium, with a largeroportion in the mastoid point, confirming the diagno-is of acute mastoiditis complicated by Bezold abscess.he developed and pneumatised mastoid with thinningf the cortex encouraged the formation of the Bezoldbscess.

In case 2, the patient presented with a soft tissue abscessnd petrositis secondary to the spread of the otitis medianfection, the latter being a rare and late complication ofurulent otitis media, with no history of otorrhoea withcute symptoms. The CT scan revealed the right mastoid hadigns of disease therefore aggravated chronic otitis mediaas confirmed. With respect to petrositis, Gradenigo’s syn-rome develops when the inflammation spreads in Dorello’sanal, which contains the sixth cranial nerve and the trigem-nal ganglion. This is characterised by a trio of symptoms:xternal rectus palsy (sixth cranial nerve), retro-orbitalain (in the distribution of the fifth cranial nerve) andtorrhoea.4,10 In our case, purulent material was found inhe ipsilateral petrous apex as well as the mastoid and theardrum, with no orbital and/or trigeminal symptoms. Thedditional risk factor in this patient was chronic kidney fail-re.

In case 3, the complication presented in a patient with noignificant ear history, with symptoms typical of acute oti-is media complicated by thrombosis of the sigmoid sinusnd hypertensive skull due to a cerebellar abscess. The

atter present as the most common cause secondary toar sepsis and they infect the cerebellum due to conti-uity. It is suggested that cerebellar abscesses representround 10---18.7% of intracranial abscesses. The proposed

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Diagnosis and treatment of the complications of otitis media

pathogenesis of this complication is the spread of the infec-tion from small veins of the mastoid towards the sigmoidsinus, with subsequent propagation of inflammation througheroded or coalescent bone, causing an abscess aroundthe longitudinal sinus and its thrombosis. Clinically it canpresent with fever, otorrhoea, retroauricular oedema, otal-gia, headache, nausea, vomiting and meningeal signs. Inthese cases, treatment consists of mastoidectomy, exposureof the sigmoid sinus, exposure of the dura mater and punc-ture of the sigmoid sinus. If there is no perisinus abscess andthe patient does not present symptoms of sepsis, coagula-tion of the sigmoid sinus should not be removed. If thereis a perisinus abscess and signs of septicaemia, the sinusshould be opened, the clot removed and the jugular vein lig-ated. In our case, no perisinus abscess was found, thereforethe lateral sinus was not involved, it was punctured solelydiagnostically.3,4,11

In case 4, the brain abscess was noteworthy in the patientwith chronic kidney disease because it was an incidentalfinding. Clinically the patient had no symptoms of neuro-logical involvement. Contrasted CT was performed to ruleout a soft tissue abscess, because 7 days prior to the assess-ment the patient had suffered cranioencephalic trauma tothat area when a ladder fell on him. The diagnosis of a brainabscess was confirmed by imaging studies. Within the patho-physiology of a brain abscess, the middle ear is of primeimportance in the onset of intraparenchymal infection dueto the frequency of otitis media and the possibility of itbeing difficult to control should it become chronic in theactive phase. It is sometimes difficult to treat because thecavity of the middle ear is so closed and because its wallsare in contact with pneumatised bone which encourages theprogression and spread of germs to the intracranial com-partments. When otitis is the predisposing factor it mostfrequently affects the temporal lobe or the cerebellum.Once a diagnosis has been made, emergency surgery is indi-cated to evacuate the pus collection and continuous flushingwith antibiotic. It is important to remember the narrowspace of the posterior fossa in which fast-growing massesrapidly cause a sudden loss of consciousness and the abscessto burst inside the fourth ventricle.3

In case 5, the patient presented with a history of dia-betes diagnosed 12 years previously, with no history of eardisease. He had experienced 3 symptoms of meningitis inthe past month, with cytochemical and cytological analysisof cerebrospinal fluid compatible with bacterial meningitis.With no history of temporal bone trauma, no labyrinthinefistula was encountered which would predispose the patientto recurrence of the neuroinfection. A viral panel was under-taken that was negative for human immunodeficiency virus,hepatitis B and C.

A complication must be suspected in acute otitis mediaof torpid evolution, when neurological signs appear withinits pathophysiology. The infection can spread through boneerosion, the oval or round windows or due to retrogradephlebitis. Chronic otitis media causes meningitis more,which results in greater mortality; therefore it must bestrictly monitored. In bacterial meningitis the microorgan-

isms can fill the subarachnoid space through 3 routes:haematogenous, as a consequence of a contiguous focusof infection, secondary to otitis or pericranial fistula; ret-rograde propagation, a mechanism which sends a small

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nfected thrombus through the emissary vein, when thenfection is near the central nervous system, as in sinus-tis, otitis or mastoiditis; and direct spread or spread due toontiguity, where the infection coming from nearby focusesf infection, such as orbital cellulitis, cranial osteomyeli-is, soft tissue infections, paranasal sinuses, dermal sinusesr myelomeningoceles (congenital malformations whichommunicate with the outside) propagates. Another con-enital route (preformed) has been described, especiallyn neonates and infants, due to the persistence of theetrosquamous suture.12 A diagnosis of meningitis is maderom the clinical symptoms, lumbar puncture, a studyhich shows an elevated cell count in the cerebrospinaluid. Because culture of cerebrospinal fluid requires timeo confirm a diagnosis it is recommended that treatments started immediately if the cytological profile in theerebrospinal fluid suggests bacterial meningitis, which typ-cally shows elevated pressure (200-500mmH2O), pleocytosis1000---5000 × 106 cells/l white cells), with a predomi-ance of neutrophils (≥80%), elevated protein (1---5 g/l)nd reduction in the proportion of glucose of the cere-rospinal fluid/serum (≤0.4).13 Antibiotic treatment oftogenic meningitis will depend on the causative germ andhe antibiogram but generally, the administration of highoses of appropriate antimicrobials is recommended. Incute otitis media the associated germs are S. pneumoniaend type b H. influenzae, although the latter has practicallyisappeared in many countries since the generalised usef the conjugate polysaccharide vaccine. Intravenous treat-ent with third generation cephalosporins is recommended,

he drug of choice being ceftriaxone, and tympanocente-is and myringotomy for culture and drainage. If infectiony S. pneumoniae is confirmed, the use of intravenous van-omycin has been protocolised.12

onclusions

maging studies (CT and NMR) help in the diagnosis of theomplications of otitis media. The use of antibiotics assistsn the appropriate surgical treatment of the complicationsf otitis media, reducing morbidity and mortality in mostatients who present with the disorder.

thical disclosures

rotection of human and animal subjects. The authorseclare that no experiments were performed on humans ornimals for this study.

onfidentiality of data. The authors declare that they haveollowed the protocols of their work center on the publica-ion of patient data.

ight to privacy and informed consent. The authorseclare that no patient data appear in this article.

onflict of interests

he authors have no conflict of interest to declare.

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cknowledgements

cknowledgements go to Dr Katia Gámez Zermeno and theeurosurgical Department for her participation in the man-gement of ear and neurosurgery in 2 patients.

eferences

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2. Abdel-Aziz M, El-Hoshy H. Acute mastoiditis: a one year study inthe pediatric hospital of Cairo university. BMC Ear Nose ThroatDisord. 2010;10:1---6.

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4. Obregón Marín A, Ramírez Picaso A, Wood Portuondo E, de laRosa Marín M. Hipertensión endocraneana secundaria a abscesocerebeloso. Tratamiento quirúrgico de urgencia. Rev Cub Med

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9. Akhvlediani T, Bautista CT, Shakarishvili R, Tsertsvadze T,Imnadze P, Tatishvili N, et al. Etiologic agents of central ner-vous system infections among febrile hospitalized patients inthe country of Georgia. PLOS ONE. 2014;9:e111393.

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2. Quintero Noa JL, Álvarez Lam I, Hernández Cordero MC, Melén-dez Quintero LL. Complicaciones de las otitis medias agudas ycrónicas en el nino. Rev Cuba Pediatr. 2013;85:89---105.

3. Hase R, Hosokawa N, Yaegashi M, Muranaka K. Bacterial menin-gitis in the absence of cerebrospinal fluid pleocytosis: a casereport and review of the literature. Can J Infect Dis Med Micro-biol. 2014;25:249---51.