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Classification
The complications of acute and
• Intra-cranial
chronic otitis media

• Extra-cranial, Intra-temporal

• Extra-cranial, Extra-temporal

• Systemic: septicemia, otogenic tetanus

Definition Complications of otitis media

Infection spreads beyond muco-periosteal lining
Intratemporal
•Mastoiditis Intracranial
•Extradural abscess
•Petrositis
of middle ear cleft to involve bone & neighboring
•Subdural abscess
•Labyrinthitis •Brain abscess
•Facial paralysis •Meninigitis
•Sinus
•Labyrinthine
thrombophilbitis
fistula
structures like facial nerve, inner ear, dural
Extra-temporal

venous sinuses, meninges, brain tissue & extra- •Retropharyngeal

abscess
•Parapharyngeal
abscess
•Lymphadentitis
temporal soft tissue.

Features of Complications Classification

• Severe otalgia, painful swelling around ear

• Vertigo, nausea, vomiting

• Headache + blurred vision + projectile vomiting

• Fever + neck rigidity + irritability / drowsiness

• Facial paralysis

• Otorrhoea + Retro-orbital pain + diplopia

• Ataxia

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Routes of entry Intra-cranial Complications

1. Bony erosion (cholesteatoma destruction)
1. Extra-dural abscess
2. Retrograde Thrombophlebitis (Vascular extension )
2. Subdural abscess
3. Anatomical pathway: oval window, round window, internal

auditory canal, suture line, cochlear & vestibular aqueduct 3. Meningitis

4. Congenital bony defects: facial canal, tegmen plate 4. Brain abscess

5. Acquired bony defects: fracture, neoplasm, stapedectomy 5. Lateral Sinus thrombophlebitis

6. Peri-arteriolar space of Virchow-Robin: spread into brain 6. Otitic hydrocephalus

7. Brain fungus (fungus cerebri)

Intra-temporal Complications Intra-temporal Complications

• Acute mastoiditis 1.MASTOIDITIS
• DEFINITION
• Coalescent mastoiditis
• It is the inflammation of mucosal lining of
• Masked mastoiditis antrum and mastoid air cells system.
• Mastoiditis, per se, actually occurs with most
• Facial nerve palsy
infections of the middle ear. It is not considered
• Labyrinthitis a complication until bone destruction occurs.

• Labyrinthine fistula

• Apex Petrositis (Gradenigo syndrome)

Pathogenesis
Extra-temporal Complications Aditus Blockage
1. Post-auricular abscess
 Failure of drainage
2. Bezold abscess
 Stasis of secretions
3. Citelli abscess
 Hyperemic decalcification
4. Luc abscess  Resorption of bony septa

5. Zygomatic abscess of air cells

6. Retro-mastoid abscess  Coalescence of small air

cells to form cavity

 Empyema of mastoid

cavity
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Clinical Features & Investigation

Mastoid cavity
• Otorrhoea > 2 weeks, otalgia & deafness
• Mastoid reservoir sign : pus fills up on mopping
• Sagging of postero-superior canal wall due to
peri-osteitis of bony wall at antrum & posterior
E.A.C.
• Ironed out appearance of skin over mastoid due
to thickened periosteum
• Mastoid tenderness present
• Mastoid cavity in X-ray & CT scan

Mastoid cavity Ironed out appearance

Coalescent Mastoiditis
Acute Mastoiditis • AOM and mastoiditis that persist unabated for 2 to 4 weeks,
coalescent mastoiditis develops.
• when AOM fails to resolve
• signs of AOM and local inflammatory findings • disease of the young, especially of boys.<4y
over the mastoid proc
• Bacterial virulence and decreased host resistance are
• 22% : complications on admission, the most important in its etiology, but mastoid development also plays
a role
common of which was subperiosteal abscess
• changes in the bone and mucoperiosteum of the mastoid air
cell system.(decalcifies the bony partitions, causing the small
air cells to coalesce into a larger cavity .

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Masked Mastoiditis
• granulation tissue formation and bone erosion can
occur without otorrhea
• received numerous courses of antibiotics
• normal or near normal TM
• Age:M:13Y
• chronic but not severe auricular and postauricular
pain, tenderness to mastoid
• CT : localized opacification

Intratemporal complications
Chronic Mastoiditis
2.Labyrinthine fistula ( Labyrinthitis)
• 1)with a longstanding TM perforation, • communication between middle and inner ear
2)with cholesteatoma central perforation  • It is caused by erosion of boney labyrinth due
infected mastoid(chronically drain). Even cholesteatoma
though uninfected cholesteatoma for long • Lateral canal erosion is the most common
periods of time,  it tends to suppurate, form location
granulation tissue, and erode bone.
• purulent drainage> 8 W, the likelihood
of a complete resolution with antibiotics

Lateral SCC Fistula

ossicular erosion

cholesteatoma

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Intratemporal complications
Introduction 3. Facial nerve paralysis:
Inflammation of endosteal layer of bony labyrinth
Route of infection: • Congenital or acquired dehiscence of nerve
canal
 Round window membrane
• It is possibly a result of the inflammatory
 Pre-formed opening ( Stapedectomy) response within the fallopian canal to the
infection
 Retrograde spread of meningitis via IAC /
• Tympanic segment is the most common site to
aqueducts be involved

• Circumscribed: Fistula commonly involves lateral

Intratemporal complications
SCC. Presents with transient vertigo & positive
Facial nerve paralysis
fistula test  nystagmus with pressure;
Diagnosis
• Serous: Reversible, non-purulent, mild vertigo, • Clinical
• May occur in acute or chronic ottis media
nystagmus, mild sensori-neural hearing loss
• Ct scan
• Purulent: Irreversible, purulent, severe vertigo,

nystagmus, severe / profound hearing loss

Diagnosis
Intratemporal complications
• longstanding disease Facial nerve paralysis
• Ct scan of temporal bone Treatment :
• Hearing loss -Acute otitis media (cortical mastoidectomy
• Attack of vertigo mostly during straining +ventilation tube)
,sneezing and lifting heavy object - chronic otitis media with cholestetoma (
mastoidecomy ± facial nerve decompresion )
• Positive fistula test

Treatment :
Mastoidectomy

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Intratemporal complications
4.Petrous Apicitis :Gradenigo syndrome Etiology: Coalescent mastoiditis involving
 Persistent otorrhoea: despite adequate
petrous apex along postero-superior & antero-
cortical mastoidectomy
inferior tracts in relation to bony labyrinth
 Retro-orbital pain: Trigeminal nv involvement
Diagnosis: 1. C.T. scan temporal bone for bony
 Diplopia: convergent squint due to lateral rectus
details. 2. M.R.I. to differ b/w bone marrow & pus
palsy by injury to abducent nv in Dorello’s canal under
Treatment: Modified radical mastoidectomy &
Gruber’s petro-sphenoid ligament , at petrous apex
clearance of petrous apex cells

C.T. scan & M.R.I.

Persistent otorrhoea + Retro-orbital pain +

Convergent squint

Right Convergent squint Hearing sacrificing approaches to petrous apex

• Trans-cochlear approach
• Trans-labyrinthine approach
Right gaze Central gaze Left gaze

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Extracranial complications Pathology

• Extension of infection to the neck Production of pus under tension

• Bezold abscess ( extension of infection from
mastoid to Sternocleidomastoid Muscle )  hyperaemic decalcification ( halisteresis)

+ osteoclastic resorption of bone

 sub-periosteal abscess

 penetration of periosteum + skin

 fistula formation

Spread of pus Sub-periosteal abscess formation

Sub-periosteal fistula: dry

Sub-periosteal abscess &

fistula

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Types of sub-periosteal abscess

Postauricular Abscess
• Post-auricular • most common complication of mastoiditis
• accompanying acute or coalescent mastoiditis in young
• Bezold children
• mastoid near the spine of Henle exist in newborns as a series
• Citelli of open channels between the interior of the mastoid and
the cortex
• direct extension subsequent to bone destruction
• Zygomatic • process in that upper portion and the tissue edema and the
abscess drive the auricle downward and laterally
• Luc

• Retro-mastoid

• Parapharyngeal
&
Retropharyngeal

Post-auricular abscess

Commonest. Present behind the ear.

Pinna pushed forward & downward.

Bezold & Citelli abscesses

Bezold: neck swelling

over sternocleido-

mastoid muscle

Citelli: neck swelling

over posterior belly

of digastric muscle

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Luc: swelling in external auditory canal

Zygomatic: swelling antero-superior to pinna +

upper eyelid oedema

Intra-cranial complications
Retro-mastoid: swelling over occipital bone

(? Citelli’s abscess)

Parapharyngeal & Retropharyngeal: due to spread

of pus along Eustachian tube

Retromastoid abscess

Incision drainage of abscess

Intra-cranial complications
Brain Abscess:
Definition
• – Localized suppuration in the brain substance.
• – It is most lethal complication of suppurative otitis media
• Incidence:
• – 50% is Otogenic brain abscess
• – It is more common in males especially
• between 10 – 30 years of age.

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50-75 % adult brain abscess & 25% in child = otogenic

Cerebellar abscess
Temporal abscess : Cerebellar abscess = 2:1

Route of infection: 1. Direct spread:

 via Tegmen plate: Temporal abscess

 via Trautmann’s triangle: Cerebellar abscess (more dangerous)

2. Retrograde thrombophlebitis

Erosion of tegmen tympani

Extra-dural abscess

Trautmann’s triangle
Extra-dural abscess
Superiorly: superior
petrosal sinus
Posteriorly: sigmoid sinus
Anteriorly: solid angle
(semi-circular canals)
Pathway to posterior
cranial fossa from mastoid
cavity

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Commonest otogenic intra-cranial complication

Collection of pus b/w skull bone & dura of middle or Extra-dural abscess
posterior cranial fossa
Majority asymptomatic. Suspected in case of:
 Profuse, intermittent, pulsatile, purulent,
otorrhoea
 Low grade fever  I/L Persistent headache
 Recurring meningococcal meningitis
CT scan brain shows extra- dural abscess
Tx: I.V. Ceftriaxone + Metronidazole + Gentamicin
Modified Radical mastoidectomy
Drill tegmen or sinus plate  pus drained

Intra-cranial complications
Extradural Abscess:
Definition:
• Collection of pus against the dura of the middle Subdural abscess
or posterior cranial fossa.

• Extradural abscess is the commonest

intracranial complication of otitis media

Intra-cranial complications
Subdural abscess
Extradural abscess:
Diagnosis
– CT scans reveal the abscess
as well as the middle
ear pathology.
Treatment:
– Mastoidectomy and
drainage of the abscess

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Intra-cranial complications
Collection of pus b/w dura & arachnoid by erosion

of bone & dura mater or by retrograde Meningitis

Definition
thrombophlebitis – Inflammation of meninges meninges (pia & arachinoid)
Pathology:
– Occurs during acute exacerbation of chronic
Due to rapid spread of pus, symptoms of raised
unsafe middle ear infection.
intra-cranial tension & meningeal irritation develop – Two forms:

quickly • Circumscribed meningitis: no bacteria in CSF.

• Generalized meningitis: bacteria are present in CSF
CT scan brain shows subdural abscess

Subdural abscess
Intra-cranial complications
Meningitis

Clinical picture:
– General symptoms and signs:
• high fever, restlessness, irritability,
• photophobia, and delirium.
– Signs of meningeal irritation?

Intra-cranial complications
Intra-cranial complications
Subdural Abscess: Meningitis
Clinical picture:
– Headache without signs of meningeal
– Signs of meningeal irritation:
• Neck rigidity.
irritation • Positive Kernig’s sign: difficulty to straighten the
– Convulsions knee while the hip is flexed
– Focal neurological deficit (paralysis, Positive Brudzinski’s sign:
loss of sensation, visual field defects) – passive flexion of one leg results in a similar
movement on the opposite side or
Treatment: – if the neck is passively flexed, flexion occurs in the
hips and knees
– Drainage (neurosurgeons)
– Systemic antibiotics
– Mastoidectomy

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Test for neck rigidity

Intra-cranial complications
Meningitis

Diagnosis
• – Lumbar puncture is diagnostic:

Treatment:
– Treatment of the complication itself and control of ear
infection:
• Specific antibiotics.
• Antipyretics and supportive measures
• Mastoidectomy to control the ear infection.

• High grade persistent fever with rigors Intra-cranial complications

• Severe headache & neck stiffness Venous Sinus Thrombosis:
• Irritability  drowsiness  confusion  coma Definition
• Thrombophlebitis of the venous sinus.
• Neck rigidity positive
• Etiology:
• Kernig sign positive; Brudzinski sign positive • It usually develops secondary to direct
extension from a perisinus abscess due to
• Papilloedema
unsafe otitis media with cholesteatoma.
• Lumbar Puncture:  cell count,  protein,  sugar
• Radical Mastoidectomy once patient is stable

Retinal vein dilation &

Pathogenesis
optic disc edema
Lateral sinus = Sigmoid sinus + Transverse sinus

Erosion of sigmoid sinus plate  peri -sinus

abscess  inflammation of outer wall 

endophlebitis  mural thrombus  occlusion of

sinus lumen  intra-sinus abscess 

propagating infected thrombus

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Intra-cranial complications
Venous Sinus Thrombosis:
Diagnosis
• – CT scan with contrast
• – MRI, MRA, MRV
• – Angiography, venography
• – Blood cultures is positive during the febrile
phase.

Pathogenesis Intra-cranial complications

Venous Sinus Thrombosis:
Treatment
– Medical:
• Antibiotics and supportive treatment.
• Anticoagulants
– Surgical:
• Mastoidectomy with exposure of the affected
sinus and the intra-sinus abscess is drained.

Spread of thrombus
Intra-cranial complications
Proximal: 1. To superior sagittal sinus via torcula
Venous Sinus Thrombosis Hirophili  hydrocephalus
Clinical picture:
– Signs of blood invasion: 2. To cavernous sinus  proptosis
• (spiking) fever with rigors and chills
• persistent fever (septicemia). 3. To mastoid emissary vein  Griesinger’s sign
– Positive Greissinger’s sign which is edema and
tenderness over the area of the mastoid emissary Erythema and edema over the mastoid process due to septic thrombosis of
vein.
– Signs of increased intracranial pressure: the mastoid emissary vein andthrombophlebitis of the sigmoid sinus
headache, vomiting, and papilledema.
– When the clot extends to the jugular vein, the Distal: To internal jugular vein & subclavian vein  pulmonary thrombo-
vein will be felt in the neck as a tender cord. embolism & septicaemia

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A positive fistula test is diagnostic of Which is not true about CSF examination in
• a- serous labyrinthitis. case of meningitis:
• b- circumscribed peri-labyrintserous . • a. Protein diminished.
• c- suppurative labyrinthitis. • b. Sugar diminished..
• d- Oro-antral fistula. • c. Cell count increased.
• d. pressure increased.

Fever in lateral sinus thrombosis is usually: Most cases of extradural abscess of the
• a. Intermittent. temporal lobe
• a- are asymptomatic and discovered
• b. Remittent.
accidentally during mastoidectomy.
• c. Low grade. • b- present with persistent ipsilateral temporal
• d. High grade. headach.
• c- present with vertigo.
• d- present with pulsating discharge,hearing
loss and tinnitus.

The discharge in case of cholesteatoma is: 7- The type of hearing loss in otosclerosis may
• a. Copious purulent. be
• b. Copious offensive. • a- Conductive.
• c. Scanty offensive. • b- Sensorineural.
• d. Thick scanty creamy. • c- Mixed.
• d- all of the above.

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14- A positive Kernig sign means

An early and diagnostic sign of mastoiditis is :
• a- reflex flexion of the hips and knees when the neck is flexed
• b- inability to extend the knee completely when the hip is • a- Reservoir sign.
flexed on the abdomen
• c- inability to do rapid ulternating movement • b- sagging of the postero-superior part of the
• d- non of the above bony canal.
15- A positive Brudzniski sign means
• a- reflex flexion of the hips and knees when the neck is flexed • c- perforated tympanic membrane.
• b- inability to extend the knee completely when the hip is • d- post-auricular mastoid abscess .
flexed on the abdomen
• c- inability to do rapid ulternating movement
• d- non of the above

The combination of unilateral otorrhoea, severe Bezold’s abscess is a collection of pus

facial pain and diplopia is known as • a- above and in front of the auricle.
• a- Piere Robin syndrome • b- behind the auricle.
• b- Gradenigo’s syndrome • c- in the upper part of the neck deep to the
• c- Kartagner syndrome sternomastoid .
• d- Ramsay Hunt sundrome • d- in the peritonsillar space

In a case of cholesteatoma, sever spontaneous Cholesteatmoa causes fistula commonly in:

vertigo with Nausea and vomiting is suspicious • a- Promontory
of • b- Lateral semicircular canal
• a- circumscribed peri-labyrinthitis • c- Posterior semicircular canal
• b- diffuse serous labyrinthitis • d- Stapes footplate
• c- extradural abscess
• d- petrositis

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In Gradenigo syndrome diplopia is due to

inflammation of the following cranial nerve
• a- IV nerve
• b- V nerve
• c- III Nerve
• d- VI nerve

Thanks

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