COMPLICATIONS OF CSOM

IntroductionSequelae: The resultant disability caused by the disease and its healing.Complication: When the active disease process spreads or breaks out to involve the surrounding or distant areas or organ systems

Definitions

CSOM involves the Middle Ear CleftMiddle ear cleft consists of 1. E. Tube 2. Middle ear 3. Mastoid air cell system

Definition

In CSOM a complication is said to exist if the disease goes beyond the mucoperiosteum of the middle ear cleft

The Middle Ear RelationsMedial Superior 1. Superiorly: Temporal Lobe

Anterior 2. Posteriorly: Sigmoid Sinus Cerebellum Posterior 3. Anteriorly: Carotid siphon Petrous Apex Inner Ear Jugular Bulb Neck deep spaces Ext Auditory Canal

Lateral

4. Medially: 5. Inferiorly:

Inferior6. Laterally:

Complications

Complications1.Intracranial 1. Intracranial

OR2.Extracranial a)Intratemporal 3. Extratemporal 2. Intratemporal

b)Extratemporal

Routes of Spread1. Direct Routea) b) c) d) Direct extension by spreading osteitis Through an old # line Through pre existing pathways: labyrinth Surgically created pathways

2. Through thrombophlebitis emissary veins & venous drainage 3. Haematogenous spread through the Spaces of Virchow

Intracranial complications

Intracranial Complications1. 2. 3. 4. Meningitis Lateral sinus thrombosis Otitic hydrocephalus Intracranial abscess

a)b) c)

ExtraduralSubdural Parenchymal Cerebral (Temporal lobe) Cerebellum

In GeneralCertain features are common to all: Common Symptoms are because of a) Spread of Infection b) Increased Intracranial pressure

In GeneralSuspicious Symptoms1. 2. 3. 4. 5. 6. Persistent headache Lethargy Irritability Severe otalgia Persistent or intermittent fever Nausea and vomiting

In GeneralDefinitive1. 2. 3. 4. 5. Decreased mental status Stiff neck Ataxia Visual changes Seizures

In GeneralPrinciples of management: 1. Neurological takes priority 2. Investigations & go hand in hand 3. Broad spectrum Abs (blood brain barrier) 4. Supportive measures 5. Neurological Intervention if required

6. Otological intervention later(exception Lat Sin thrombosis)

Meningitis Meningitis - most common IC complication of CSOM Can be due to ASOM or CSOM 12% to 91% of all I/C complications More common in younger age group (12-20 yrs) Commonly associated with other I/C Complications Due to spread by all 3 routes Mortality rate reported a) ASOM 8% b) CSOM - 31%

MeningitisSymptoms & Signs

Severe and generalized headache Headache may radiate to the spine and lower limbs. The patient tends to lie quiet and immobile. Photophobia and general hyperesthesia occur. Vomiting is common. Nuchal rigidity. (most important sign of meningitis). Kernigs sign Brudzinskis sign Late papilloedema

MeningitisInvestigations

Imaging for CSOM (MRI & CT SCAN) LP Fundoscopy prior CSF pressure is elevated. Turbidity +ve The CSF glucose may be low compared with the blood glucose. Microorganisms can be shown on Grams stain and culture.

TLC, DLC Leucocytosis

MeningitisManagement 1) Initial stabilization 2) Radiologic evaluation for other intracranial complications 3) LP to obtain CSF for analysis and culture 4) initiation of broad-spectrum antibiotics.

Lateral Sinus ThrombosisSymptoms 1. Fever - Low grade or intermittent, - Spiking, picket-fence pattern 2. Neck tenderness, particularly over the sternocleidomastoid muscle 3. Torticollis- May mimic nuchal rigidity

4. Otalgia

Lateral Sinus ThrombosisSigns1. 2. 3. 4. 5. 6. Papilledema Greisingers sign: induration over the occiput Jugular foramen syndrome (paralysis of CN IX, X, and XI; CN XII is spared because of its separate hypoglossal canal) Palpable cord in the cervical internal jugular vein Toby-Ayer-Queckenstedt test +ve Elevated cerebrospinal fluid pressure

7.8. 9.

AnemiaLeukocytosis Elevated erythrocyte sedimentation rate

ManagementPrompt surgical intervention: - Cortical Mastoidectomy (? MRM) - Complete exposure of sigmoid sinus - Aspiration of sinus till blood comes - If pus aspirated, evacuate & obliterate sinus

Brain AbscessA brain abscess progresses through three clinical stages: 1. Initial encephalitis, 2. Latent or quiescent stage, 3. Manifest or expanding abscess.Symptoms & Signs varies as the stages

Stage 1:Initial encephalitisIt is the inflammation and edema in the white matter around an infected vein. Occurs in a few days - Chills with moderate rise in temperature - Headache - Nausea - Vomiting Depressed mental status (apathy, irritability, drowsiness) Seizure (in children) Slight neck stiffness CSF: elevated protein, no bacteria, normal cell count and glucose Vigorous antimicrobial therapy may arrest the infection in this stage, and brain abscess may not develop.

Stage 2: Latent or quiescent stage- Occurs over several days to several weeks or even months. - Signs and symptoms are very subtle or may be absent. - The body tries to localize the infection. Malaise & Poor appetite Intermittent headache

Slight temperature elevationListlessness, irritability Slowed cerebration No focal neurologic signs CSF: normal composition

Stage 3: Expanding abscessA fibrous capsule forms around the abscess. The surrounding brain tissue becomes involved with an advancing encephalitis. Severe and continuous headache Projectile vomiting Intermittent slowing of the pulse

Elevated, normal, or decreased temperatureApathy, drowsiness, or disorientation Paralysis of extraocular muscles Papilledema Cerebrospinal fluid: increased cells, elevated protein Focal Neurological signs develop

Focal signs : Temporal Lobe Aphasia Contralateral facial or upper extremity paresis

Visual field defect (upper quadrant homonymous hemianopsia)Oculomotor nerve paresis Visual hallucinations

Temporal Lobe Abscess

MRI

Focal Neurological signs : Cerebellum

Suboccipital headache Vomiting Ataxia Spontaneous and gaze nystagmus Past pointing Intention tremor

DysdiadochokinesisWeakness and incoordination of ipsilateral muscles

Brain Abscess: Management1.Multidrug I/V ABs (blood brain barrier) 2. Supportive measures for ICT 3. Anticonvulsive therapy 4. Neurological Intervention by drainage / excision of fibrous capsule 5. Otological intervention later: - Mastoid exploration

EXTRAcranial complications

Intratemporal Complications1.Mastoiditis 2. Petrous apicitis 3. Labyrinthitis a. Serous b. Suppurative 4. Labyrinthine fistula 5. Facial paralysis

Petrositis-Petrositis is an extension of the inflammation of the middle ear or mastoid cavity into the pneumatized cells of the petrous apex. -The petrous apex has no drainage system and spontaneous drainage of an abscess cannot occur -Petrositis has a greater tendency toward intracranial extension - Near petrous apex are 3, 5, & 6 CN

Petrositis

CT Scan

PetrositisGradenigo first described the triad of symptoms Classically, these are - Retro-orbital pain (from CN V irritation) - Otorrhea - Diplopia (CN VI paralysis). Others: - Fever - Sensorineural hearing loss, - Transient facial paresis, - Vertigo

Petrositis

Management: 1. ABs 2. Cortical Mastoidectomy along with petrous apex clearance 3. Adequate drainage of the petrous cells are to be ensured

AC COALESCENT MASTOIDITIS Mastoid Air cells are a part of the middle ear cleft Invariably involved in all cases of ASOM/CSOM However, Coalescent mastoiditis occurs in only few

AC COALESCENT MASTOIDITIS Blockage of Aditus due to inflammed mucosa Drainage blocked Pressure erosion of the bony septae One large pus filled cavity

AC COALESCENT MASTOIDITISSuggestive -Otorrhea persisting more than 2 weeks -Persistent otalgia -Edema over the mastoid tip

Definitive - Presence of a postauricular abscess - Mastoid tenderness Over mastoid tip Over root of Zygoma Through the concha

- Sagging of the posterosuperior external auditory canal wall - Loss of bony air cell septations on computed tomography

AC COALESCENT MASTOIDITIS

AC COALESCENT MASTOIDITIS Management: 1. ABs 2. Myringotomy for initial drainage 3. Cortical Mastoidectomy & drainage if:Pus discharge persists more than 2 wks pain, edema over the mastoid tip Sagging of posterior canal wall partitions Signs or symptoms of threatened or definite complication

Extratemporal complicationsSubperiosteal abscesses a. Mastoid (postauricular) b. Zygomatic c. Bezolds

Post auricular abscess When the infection erodes the outer cortex of the mastoid tip, a subperiosteal abscess results. Most common 1. The auricle is displaced anteriorly and inferiorly 2. The postauricular crease is obliterated 3. Skin over the mastoid process is fluctuant and erythematous.

Post auricular abscess

CT Scan

Post auricular abscess

Management: 1. ABs 2. Immediate drainage of postauricular abscess with drain left for 48 hrs 3. Cortical Mastoidectomy subsequently

Bezolds Abscess

Perforation on the medial aspect of the mastoid tip into the digastric groove produces a deep abscess of the neck known as Bezolds abscess

Bezolds Abscess Presents as a soft fluctuant swelling at the ant. edge of Sternocleidomastoid

CT Scan

Zygomatic Abscess Subperiosteal abscess at the root of the zygoma. It presents as a swelling above and in front of the ear Upper half of the auricle is displaced laterally At times there can be extension into the mandibular fossa displacing the mandible towards the normal side. Trismus is present has been and teeth no longer meet in occlusion.33

Zygomatic Abscess

Zygomatic Abscess

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