Download - Melss yr4 ent complication of cs om
COMPLICATION OF CHRONIC SUPPURATIVE OTITIS MEDIAAmalina Aminuddin0820121000 67
• Factors • Spread of infection• Classification• Sequelae• Complications:
• Intratemporal complication• Intracranial complication
Content
Factors
Age Poor socioeconomic group Virulence of organism Immune-compromised host Preformed pathways Cholesteatoma
Pathways spread of infection Direct bone erosion Venous thrombophlebitis Preformed pathways
Congenital dehiscences Patent sutures Previous skull fractures Surgical defects Oval and round windows Infection from labyrinth
Sequelae of otitis mediaPerforation of tympanic membrane
Ossicular erosion
Atelectasis and
adhesive otitis media
Tympanosclerosis
Cholesteatoma
formation
Conductive hearing loss
Sensorineural hearing loss
*Speech impairment
*Learning disabilities
Classifications
Mastoiditis Petrositis Facial paralysis Labyrinthitis
Extradural abscess Subdural abscess Meningitis Brain abscess Lateral sinus
thrombophlebitis Otitic hydrocephalus
INTRATEMPORAL INTRACRANIAL
Intratemporal
Complication
A. [i] ACUTE MASTOIDITIS Inflammation
of mucosal lining of antrum and mastoid air cell system
mucosa bony walls
Accompanies / follow ASOM1. Virulence of
organism 2. Lowered resistance 3. Children
1. Production of pus under tension Production > drainage
2. Hyperaemic decalcification and osteoclastic resorption of bony wall
Destruction, coalescence of mastoid air cell [empyema of mastoid] subperiosteal abscess fistula
Aetiology PATHOLOGY
Clinical Features
Pain behind the ear Fever Ear discharge
Mastoid tenderness Light house effect
( pulsatile purulent discharge)
Sagging of posterosuperior meatal wall
Perforation of tympanic membrane
Swelling over the mastoid Hearing loss
SYMPTOMS SIGNS
Blood counts (Polymorphonuclaer leucocytosis)
ESR
X-ray mastoid Ear swab
INVESTIGATION
Differential diagnosis Suppuration of
mastoid lymph nodes
Furunculosis of meatus
Infected sebaceous cyst
Treatment Hospitalization Antibiotics Myringotomy Cortical
mastoidectomy[Subperiosteal abscess, positive resevoir sign, no change despite medical treatment for 48hours]
Complications Subperiosteal
abscess Labyrinthitis Facial paralysis Petrositis Extradural
abscess
Subdural abscess Meningitis Brain abscess Lateral sinus
thrombophlebitis Otitic
hydrocephalous
Abscesses in relation to mastoid infection
Postauricular abscess Zygomatic abscess Bezold abscess
Meatal abscess (Luc abscess)
Behind the mastoid (Citelli’s abscess)
Para/retropharyngeal abscess
A. (ii) MASKED (LATENT) MASTOIDITIS
Slow destruction of mastoid air cells with no sign and symptoms
Destruction of air cells + dark gelatinous material + Eroded tegmen tympani and sinus plate + extradural or perisinus abscess
Aetiology : Inadequate dose/ duration/ frequency of
antibiotic
Mild pain behind ear + Persistent hearing loss
Thick , opaque tympanic membrane
Tenderness over mastoid Audiometry- conductive
hearing loss X-ray mastoid- clouding
of air cells with loss of cell outline
Cortical mastoidectomy
Antibiotics
CLINICAL FEATURES
TREATMENT
B.PETROSITIS Spread from middle
ear and mastoid to petrous part of temporal bone
Associated with acute coalescent /latent mastoiditis or chronic middle ear infection
Pathology Spread thorugh:
1. Posterosuperior tract- mastoid runs behind/ above labyrinth petrous apex
2. Anteroinferior tract- hypotympanum near Eustachian tube cochlea petrous apex
Clinical Symptoms Gradenigo syndrome
External rectus palsy Deep-seated ear /retro-
orbital pain Persistent ear discharge
Fever, headache, vomiting, neck rigidity
Facial paralysis, recurrent vertigo
Diagnosis- CT scan and MRI
Treatment Cortical, modified radical /radical
mastoidectomy Find fistulous tract, curette and
enlarge free drainage IV antibiotic + surgical intervention Only antibiotics: Initial 4-5 days of
high dose systemic antibiotics
C. FACIAL PARALYSIS Result from cholesteatoma /penetrating
granulation tissue Cholesteatoma destroys bony canal + edema
pressure on nerve Insidious but slowly progressive Treatment:
Exploration of middle ear and mastoid Uncapped cholesteatoma Remove granulation tissue if not involving nerve
sheath Resection of nerve and grafting after infection
controlled and fibrosis matured
D. LABYRINTHITIS Circumscrib
ed labyrinthiti
s
Diffuse suppurative labyrithitis
Diffuse serous
labyrinthitis
Circumscribed labyrinthitis Thinning/erosion of bony
capsule of labyrinth Aetiology:
Chronic suppurative otitis media
Neoplasm of middle ear Surgical or accidental
trauma Clinical Features
Transient vertigo by pressure on tragus/ Vasalva manoeuvre
Diagnosis: Fistula test Pressure on tragus Siegel’s speculum
Treatment Mastoid exploration
and systemic antibiotic therapy
Diffuse labyrinthitisSEROUS SUPPURATIVE • Diffuse intralabyrinthine inflammation • Diffuse pyogenic infection
• Reversible sensorineural hearing loss
• Permanent loss of vestibular and cochlear function
• Pre-existing circumscribed labyrinthitis • Acute infection of middle ear cleft, • follow stapedectomy /fenestration
operation
• follows serous labyrinthitis
• Mild vertigo, nausea, vomiting • Severe vertigo, nausea and vomiting• Appears more toxic
• Quick component of nystagmus toward affected side
• Quick component of nystagmus toward healthy side
Treatment Patient is put to bed, head immobilised with affected ear above Antibacterial therapy Labyrinthine sedatives (prochlorperazine ) Myringotomy Cortical /modified radical mastoidectomy
Intracranial Complication
s
A. EXTRADURAL ABSCESS Collection of pus
between the bone and dura
Pathology: Destroyed by
cholesteatomapus contact directly with dura
Venous thrombophlebitis dura is intact
Dura covered by granulations / appear unhealthy and discoloured
Asymptomatic Persistent headache on
the side of otitis media Severe pain in ear General malaise with
low grade fever Pulsatile purulent ear
discharge Disappearance of
headache with free flow of pus from the ear
Cortical / modified radical /radical mastoidectomy
Antibiotic X 5 days Diagnosis:
contrast enhanced CT or MRI
CLINICAL FEATURE TREATMENT
B. SUBDURAL ABSCESS Pus between dura
and archnoid Pathology
Spreads by erosion of bone and dura /thrombophlebitic process subdural space and comes to lie against the convex surface of cerebral hemisphere
Clinical features Meningeal irritation
[ headache, fever, neck rigidity, Kernig’s sign]
Cortical venous thrombophlebitis [ aphasia, hemiplegia]
Raised ICP [ papilledema, ptosis, dilated pupil ]
Treatment: burr holes /craniotomy for
drainage +IV antibiotics
C. MENINGITIS Inflammation of pia
and arachnoid Most common
intracranial complication
Mode of infection Blood-borne Chronic ear disease
Fever with chills and rigors Headache Neck rigidity Photophobia and mental
irritability Nausea and vomiting Drowsiness, delirium or
coma Cranial nerve palsies and
hemiplegia
CLINICAL FEATURES
Contrast CT or MRI, Lumbar puncture CSF examination
Antibiotics + corticosteroids
AOM :Myringotomy or cortical mastoidectomy
Cholesteoma :Radical or modified radical mastoidectomy
DIAGNOSIS TREATMENT:
D. OTOGENIC BRAIN ABSCESS Adult ( 50%) : CSOM with
cholesteatoma Child ( 25%) : acute otitis media
Route of infection: Cerebral : direct extension through
tegmen /retrograde thrombophlebitis Cerebellar : direct extension through
Trautmann’s triangle / retrograde thrombophlebitis
Bacteriology: aerobic [ SP, PM, EC,] Anaerobic [ BF, HI]
Pathology Stage of invasion (initial
encephalitis) Headache, low grade
fever, malaise, drowsiness Stage of localization
(latent abscess) Stage of enlargement
(manifest abscess) Edema raised ICP
Stage of termination (rupture of abscess)
Clinical features 1.Symptoms and
signs of raised ICP Headache Nausea and
vomiting
Level of consciousness
Papilloedema Slow pulse and
subnormal temperature
2.Localizing features
Nominal aphasia Homonymous
hemianopia Contralateral motor
paralysis Epileptic fits Pupillary changes and
oculomotor palsy
Headache Spontaneous
nystagmus Ipsilateral hypotonia Ipsilateral ataxia Past-pointing and
intention tremor Dysdiadokinesia
Temporal lobe abscess Cerebellar abscess
Skull x-ray CT scan X-ray mastoids or
CT scan Lumbar puncture
Antibiotics IV Dexamethasone or
mannitol Suction clearance and
topical drops Repeated aspiration
through a burr hole Excision of abscess Open incision of the
abscess and evacuation of pus
Radical mastoidectomy
INVESTIGATION TREATMENT
E.LATERAL SINUS THROMBOPHLEBITIS
Inflammation of inner wall of lateral venous sinus with formation of intrasinus thrombus
Occur due to acute coalescent mastoiditis, masked mastoiditis, chronic suppuration of middle ear and cholesteatoma
Pathology:Formation of
perisinus abscess
Endophlebitis and mural
thrombus formation
Obliteration of sinus lumen and intrasinus abscess
Extension of
thrombus
Acute- haemolytic streptococcus, pneumococcus or staphylococcus
Chronic- + cholesteatoma, Bacillus proteus, Pseudomonas pyocyaneus, E. coli and staphylococci
Hectic Picket-fence type of fever with rigors
Headache Progressive anaemia
and emaciation Griesinger’s sign Papilloedema Tobey-Ayer test,
Crowe-Beck test Tenderness along
jugular vein
BACTERIOLOGY CLINICAL FEATURES:
Blood smear Blood culture CSF examination X-ray mastoid Imaging studies Culture and
sensitivity
Septicaemia and pyaemic abscess in lungs, bones, joints or subcuteaneous tissue
Meningitis and subdural abscess
Cerebellar abscess Thrombosis of jugular
bulb and jugular vein Cavernous sinus
thormbosis Otitic hydrocephalus
INVESTIGATION COMPLICATION
Treatment Intravenous antibacterial drugs C/ MR mastoidectomy and exposure of sinus Ligation of internal jugular vein
Failed antibiotic and surgical treatment Spreading tenderness along jugular vein
Anticoagulant therapy Supportive treatment
F.OTITIC HYDROCEPHALUS Raised ICP with normal CSF findings In children with acute/ chronic middle ear
infection Lateral sinus thrombosis obstruction +
extension to superior sagittal sinus decreased absorption
Clinical featuresSymptoms:• Severe
headache• Diplopia • Blurring of
vision
Signs:• Papilloedema•Nystagmus
Treatment:
Reduce CSF pressure to prevent optic atrophy and blindness
Acetazolamide and corticosteroids
Repeated lumbar puncture / placement of lumbar drain, lumboperitoneal shunt
Antibiotic therapy and mastoid exploration