Complications of suppurative otitis media

Extension of infection beyond the muco-perioseal limit of the middle ear cleft.
• AETIOLOGY:
1-AOM especially in infants and children.
2- CSOM especially cholesteatoma.
3-Acute exacerbation on top of CSOM.

n,
Extradural
Y Menin�itis abscess
• TPES: ,
I- Cranial complications (in the bone of the craniutrJ): , , Brain abscess
1- Mastoiditis.
2- Labyrinthitis. \
3- Petrositis.
,d

'
4- Facial paralysis.

II- Intra cranial

complications:
1- Extradural abscess.
2- Subdural abscess.
\
3- Meningitis.
Mast;,:,:l
4- Brain abscess.
5- Lateral sinus
thrombophlebitis.
6- Otitic hydrocephalus. ( Lavyrinthitis
,, "
,
/
/
I
I

Ill-Extra cranial complications: Petrositis

1- Diffuse otitis externa: secondary to discharge.
2- Jugular vein thrombosis: extension from lateral sinus thrombosis.
3- Bezold's abscess: extension from mastoid abscess.
4- Citteli's abscess: extension from mastoid abscess.

ail WARNING MANIFESTATIONS OF COMPUCA110NS IN CSOM:

1- Pain.
2- Headache.
3- Fever.
4- Vertigo.
5- Facial paralysis.

� CSOM is never painful except in:

1- Complications.
2- Acute exacerbations.
3- Rarely, malignant transformation.

IMPORTANT REMARKS
CSOM
When you suspect a complication, CT should be requested.
- More than one complication may be present at a time.
- Complications usually occur at the time of exacerbation.
- Don't suspect a complication in a dry CSOM.
Acute Mastoiditis
Acute inflammation of mastoid antrum and air cells with destruction of their bony
partitions. ..
• PATHOLOGY:
a. Destruction of bony partitions between mastoid air cells �
large cavity filled with pus.
b. Extension of infection under the periosteum:

1\- (
1-Post-auricular (mastoid) abscess: Lateral extension from
antrum.
2-Sagging of postero-superior meatal wall: Anterior extension ......
····-
from antrum (it is a diagnostic sign [1]).
3-Zygomatic abscess: Lateral extension from zygomatic air

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,.(1\;
cells.
4-Bezold's abscess: Inferior extension along the sternomastoid
muscle sheath.
5-Citteli's abscess: Inferior extension along the digastric muscle
sheath.
c. Rupture of periosteum and skin with fistula formation. Extension
• CLINICAL PICTURE: ruct10 of
Symptoms: bony I' rt1tlo11
General: fever, headache and malaise.
Local:
- Deafness, tinnitus and discharge (of otitis media).
- Pain: post-auricular (become throbbing on abscess
formation).
- Swelling: in abscess formation.
Signs:
- General: High temperature.
Rapid pulse (tachycardia). ....
- Local: Post-auricular
mastoid abscess
Ear examination:
* Otoscopy:
- Discharge: profuse and recollect rapidly after suction
(It is called Reservoir sign which is a diagnostic sign [2]).
- Sagging of postero-superior meatal wall (diagnostic sign).
- Perforated drum (may be intact and congested in infants).
Mastoid Examination:
- Swelling: either
* Post-auricular abscess: pushing the auricle downwards
and forwards.
* Zygomatic abscess: above and infront of auricle at root of
zygomatic process.
* Bezold's abscess: in upper lateral part of the neck (rare).
* Citteli's abscess: in submandibular region (rare). Fistula (after abaoeee rupture)
-Tenderness: over the antrum (marked by cymba concha), tip of mastoid and posterior
border (as these are the most superficial air cells).
• INVESTIGATIONS:
- PTA: CHL.
- Culture and sensitivity of discharge.
- X-ray mastoid 7 clouding (opacity) of mastoid air cells.
- CT� to detect the mastoiditis and to exclude other complications.

CT shows mastoid abscess: axial view (left) and coronal view (right)
• TREATMENT:
A) Medical:
- Hospitalization.
- Systemic antibiotics according to culture and sensitivity.
- Analgesic antipyretic.
- Frequent suction of discharge and local antibiotic ear drops.
B) Surgical: drainage by
Cortical mastoidectomy: if the medical treatment failed (for 48 hours), if there is absces
and if associated with other complication (also myringotomy is needed in children).
Bil Radical mastoidectomy is needed if it was associated with cholesteatoma (either in the
same stage during abscess drainage or after subsidence of infection 2 weeks later)
: Differential diagnosis of Mastoiditis
{!lFurunc/e:
Furuncle Mastoiditis
Scratch
Pain: On mastication Not related to mastication
Deafness: if it occludes the EAC Usually present and severe.
not severe
Tenderness: Over the tra us Over mastoid.
Discharge: Scanty, purulent and Profuse, Mucopurulent with +ve
chees Reservoir si n.
Swelling: In outer /3 of EAC. Deep in the posteor-superior part of
EAC (Sagging).

Post. auricular groove

Drum: erforated (con ested in infan

X-ray mastoid: Normal Clouding of air cells.

{J2l Post-auricular lymphadenltls: due to scalp infection.

26 8�r�
Facial Paralysis (due to otitis media)
• AETIOLOGY:
A- AOM with dehiscent facial bony canal.
B- CSOM with cholesteatoma eroding the facial bony canal.
• CLINICAL PICTURE:
- Deafness, tinnitus and discharge (of OM)+
- LMN {lower motor neuron) facial paralysis of acute onset in .....
AOM and gradual onset in CSOM (Partial or complete): see
clinical picture of facial paralysis. /
• INVESTIGATIONS:
- PTA: CHL
AOM ..... J
- Culture and sensitivity of discharge.
Facial paralysis due to AOM
- CT: to exclude other complications.
- Tests to detect the level of paralysis.
• TREATMENT: Horizontal part
A) Medical:
- Antibiotics (systemic and local).
- Steroid (anti-oedematous to decompress the nerve).
B) Surgical:
Myringotomy in AOM and radical mastoidectomy in
cholesteatoma.
Vertical part ······················"

Course of facial nerve in bony canal

Petrositis 5 i• .nerve
Inflammation of the air cells in the petrous apex 6''1 '1erve
(petrosal air cells present in 30% of people).
• PREDISPOSING FACTOR:
Complications to otitis media in diabetic
patients.
N
• CLI ICAL PICTURE:
Gradenigo� triad is characteristic for the .. ..........···
Petrous apex
diagnosis of petrositis:
- Discharging ear (of otitis media). Spread of infection from
- Diplopia and squint (6th nerve affection) ME to petrous apex
- Facial pain (5th nerve affection).
• INVESTIGATIONS:
- PTA: CHL.
- Culture and sensitivity of discharge.
- CT: to detect petrositis and to exclude other complications.
• TREATMENT:
a) Medical:
- Hospitalization and control of diabetes.
- Antibiotics (systemic and local) Rt abducent paralysis ........ .
b) Surgical:
Radical mastoidectomy and drainage of infected air cells.
Labyrinthitis
Inflammation of the inner ear.
• PATHOLOGY:
a) Localized Labyrinthitis:
Bone erosion by cholesteatoma leads to fistula.
The commonest site for fistula is the lateral sec.
b) Diffuse Labyrinthitis:
1.Serous labyrinthitis: serous fluid in the inner ear
2.Suppurative labyrinthitis: pus in the inner ear�
destruction of neuro-epithelium (permanent SNHL).
N.B.: Suppurative labyrinthitis may lead to Meningitis by Labyrinthitis
spread via internal auditory canal. Meningitis is indicated
by fever, headache and neck rigidity.
• CLINICAL PICTURE:
Deafness, tinnitus and discharge (of otitis media)+
I Labyrinthine fistula (Localized):
- It may be asymptomatic if small.
- Intermittent vertigo, without nausea or vomiting.
- Nystagmus; rapid phase towards the diseased ear (irritative).
- Positive fistula sign: Vertigo+ Nystagmus on
. Pressure on the tragus .
. t EAC pressure by Seigalization .
. Manipulation of aural polyp.
N.B.: The test may be -ve even in presence of a fistula (false -ve test) if:
* The fistula is very small.
" The fistula is closed by cholesteatoma.
* Inadequate sealing of EAC during Seigalization.
* Dead ear.
II Serous Labyrinthitis:
- Continuous vertigo with nausea and vomiting.
- Nystagmus; rapid phase towards the diseased ear (irritative).
- Reversible SNHL. Fistula test by
I Suppurative Labyrinthitis: Seigalizatlon
As Serous Labyrinthitis but the condition is more severe and the rapid phase of
nystagmus is directed towards the normal side (Paralytic), and the SNHL is irreversible.
rllD How to differentiate between serous and suppurative labyrinthitis?
Retrograde (if SNHL improved with treatment, the condition was serous, if not-+ suppurative).
• INVESTIGATIONS: - PTA: Mixed HL (CHL+ SNHL) in diffuse labyrinthitis.
- Culture and Sensitivity of discharge.
- CT: to exclude any other complications.
• TREATMENT:
a) Medical:
- Hospitalization with complete bed rest.
- Systemic antibiotics: that cross the blood brain barrier (Chloramphenicol or Cefuruxim).
- Sedatives: Diazepam.
- Antivertigo drugs: Dramamine.
- Antiemetics as Chlorpromazine.
b) Surgical: Radical mastoidectomy to remove the cholesteatoma with:
- In fistula: covering it with temporalis fascia graft.
- In suppurative labyrinthitis: Labyrinthectomy (rarely done nowadays with strong antibiotics)
N.B.: Serous labyrinthitis will be improved with medical treatment only.
Lateral sinus thrombophlebitis
Thrombosis and infection of lateral venous sinus (sigmoid sinus+ transverse sinus).
• PA lliOLOGY: Periphlebitis (infection of perisinus air cells) i.e. around the sinus ->
Endophlebitis i.e. irritation of intema which become rough -> thrombosis which propagate and
become infected, may be detached-> septic emboli (ftemperature).
• CLINICAL PICTURE:
* Symptoms: Sup. sagittal sinus
Deafness, tinnitus and discharge (of otitis media)+
1- Intermittent fever: Irregular attacks of high
temperature due to detached emboli,
(accompanied by rigors) which suddenly fall with
excessive sweating
(lnbetween the attacks � the patient is normal).
2- Pallor: due to anaemia. Transverse s.
* Signs: (of extension)
�.:;::��:.,w,..__,,,,
·············...
1-Tender cord like structure along the side of the , ······-..
neck: due to extension to Internal Jugular vein (IJV) ···.........-
2-0edema and tenderness over the posterior border
of mastoid process: due to extension to mastoid
emissary vein, It is called Griesenger's sign.
3-Headache, vomiting and blurring of vision with
papilloedema: t ICT due to extension to superior
sagittal sinus, it is called Otitic hydrocephalus
4-Proptosis, chemosis, ophthalmoplegia, diminution
Petrosal
of vision and oedema of eyelids: due to extension to cavernous sinus. sinuses
• INVESTIGATIONS:
- PTA� CHL
- Culture and sensitivity of discharge.
- CT with contrast: to show lat. sinus thrombosis and to exclude other complications.
- MRV (Magnatic resonance veinography): The most diagnostic.
- Blood picture: a) t WBCs count (leucocytosis) Pressure level
b) .J, RBCs (anaemia)
- Blood culture: +ve if sample is taken during the fever. ·········�
- Positive Tobey-Ayer's test: Lumbar puncture needle
connected to pressure manometer, then pressure on IJV
of diseased side (thrombosed) � no elevation of CSF
pressure. While pressure on IJV of normal side (patent)
� elevation of CSF pressure.
Tobey-Ayer's test
Differential Diagnosis:
- Malaria: characterized by regular attacks, leucopenia, parasite in blood film.
- Other intracranial complications: characterized by persistent fever.
• TREATMENT: ............ . ........
a) Medical: Ligation oflJVto
prevent embolism
- Hospitalization.
- Systemic antibiotics and Antipyretic (for fever).
- Anticoagulant: given after removal of thrombus
or if there is cavernous sinus thrombosis.
b) Surgical:
Radical mastoidectomy with removal of thrombus and ligation of IJV.

8� ruzda:t:- 29
Extradural abscess
Collection of pus between the dura and bone.
• PATHOLOGY:
The dura is covered with granulation tissue. It is either in middle or posterior cranial fossa.
Dura
• CLINICAL PICTURE: Extradural
Deafness, tinnitus and discharge (of OM)+ Eroded bone abscess
- Asymptomatic: discovered during surgery.
- lpsilateral earache or headache.
- Low-grade fever.
- Pulsating ear discharge.
ail Differential diagnosis of pulsating ear
discharge:
- ADM (after perforation)
- Acute exacerbation of CSOM.
- Extradural abscess.
• INVFSTIGATIONS:
- PTA: CHL
- Culture and sensitivity of discharge.
- CT: If suspected.
• TREATMENT:
a) Medical: Local and systemic antibiotics, and aural toilet.
b) Surgical: Drainage of abscess by either:
- Cortical mastoidectomy (in mastoiditis)
- Radical mastoidectomy (in cholesteatoma).
N.B.: The bone should be removed until the healthy dura is exposed all round the abscess. The
granulations over the dura should be left intact (no pulling) for fear of CSF leakage and infection

Brain abscess (otitic) iemporal

...
Accumulation of pus in an area of the brain .
• CAUSATIVE ORGANISM: Mixed infection
- Gram + ve: Stept, staph. n
- Gram - ve: pseudomonas, proteus.
- Anaerobes: bacteroids.
• PATHOLOGY:
-Sites: it is either in
. Temporal lobe (more common). Cerel,ellar
. Cerebellum (less common but more dangerous. As
the posterior cranial fossa is a limited space by the
tentorium cerebelli---+rapid t /CT� herniation of medulla
- Stages:
1- Encephalitis: diffuse inflammation of brain tissue.
2- Localization: formation of abscess cavity surrounded by glial capsule.
3- Enlargement (manifest stage): causes pressure on the surrounding tissues.
4- Terminal stage: either ruptures of the abscess into CSF space ---+ Meningitis, or
enlargement to cause herniation of the medulla then coma and death.
• CLINICAL PICTURE:
Deafness, tinnitus and discharge (of OM)+
1-Manifestations of increased intracranial tension (ICT):
* Headache: severe and persistent.
* Vomiting: projectile. Optic nerve .....
* Blurring of vision. .............
* Papilloedema. Optic radiation ....... .
2-Manifestations of focal neurological defects:
Caused by pressure of the abscess on the surrounding
area (according to its site).
*Temporal lobe abscess: AHHH
- Aphasia: due to pressure on speech area (in dominant
hemisphere). I
I

- Contralateral Hemiplegia (Motor area). I

I

- Contralateral Hemianaesthesia (Sensory area). I

I
I
- Homonymous Hemianopia (Optic radiation). ,I ,I
*Cerebellar abscess: AHMID + NSR , , "" ... ., Cerebellum
,
-Ataxia. ,,
- Hypotonia. 'femporal lobe
- Muscle incoordination.
- Intention kinetic tremors.
- Dysdiadokokinesia (inability to do fine repeated movements).
- Nystagmus.
- Staccato speech (interrupted explosive speech).
- Romberogism (tendency to fall to the diseased side)
• INVESTIGATIONS: either
- CT with contrast: to detect the site and size of abscess.
- MRI: it is more diagnostic.
II""!"!..

llar al,eceaa Ci: Temporal fol:,e abecse,e

• TREATMEN'f:"'RI: Cerebe
a) Medical:
- Hospitalization.
- Systemic antibiotics: Those cross the blood brain barrier as:
* Sulphonamide I.V. drips.
* Chloramphenicol l.V. or I.M.
* 3rd or 4th generation Cephalosporin I.V. or I.M.
* Metronidazole I.V. drips: for anaerobes.
M Dehydrating measure (to -J.. ICT): by one or more of the following: Mannitol 20% I.V.
drip, Lasix I.V., Glucose 25% I.V. drip, or even repeated lumbar puncture.
b) Surgical:
- Management of abscess by:
• Aspiration through burr hole (trephine) if the abscess wall is thin.
• Excision through craniotomy if the abscess wall is thick.
- Management of CSOM: Radical mastoidectomy (after abscess drainage) to prevent
recurrence.
Headache
Meningitis
Inflammation of meninges (pia + arachnoid)
and CSF (subarachnoid space).
• CLINICAL PICTURE:
Deafness, tinnitus and discharge (of OM) +
* Manifestations of infection:
Symptoms: fever, headache and malaise. Neck
Signs: high temperature and rapid pulse. rigidity
* Manifestations of increased intracranial tension:
- Headache: severe and persistent.
- Vomiting: projectile.
- Blurring of vision.
- Papilloedema.
* Manifestations of meningeal irritation:
Symptoms:
- Restlessness.
- Photophobia. Kernig's sign
- Neck rigidity and neck flexion is painful.
Signs:
- Kernig's sign: The patient is asked to lie in the
supine position; with hip and knee flexed�
He can not do extension (it is painful).
- Brudzinski's sign: Flexion of the neck will be
accompanied with reflex flexion of hip and knee.
6rudziksld's sign

• INVESTIGATIONS:
- CT: to exclude brain abscess.
- Lumbar puncture:
to take CSF sample for analysis, it should be done slowly in recumbant position.
CSF Meningitis Normal
Appearance Turbid Clear
Pressure More than 150 mmH20 150 mm H20
Cells Polymorphs Lymphocytes = 1-5/HPF
Organisms Present Absent
Proteins More than 40mg% About40 mg%
Surgar Less than 80mg% About 80mg%
Chloride Less than 750mQ% About 750mg%

• TREATMENT:
a) Medical: the same as brain abscess with nursing of the patient in quite semi dark
room (Photophobia).
b) Surgical: treatment of the cause by radical mastoidectomy for cholesteatoma after
improvement of the general condition.

323�r�