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Complications of suppurative OM
Terms in this set (25)
extention of infl process beyound the ME cleft es unsafe type e cholesteatoma.
- much less commonly they occur in acute OM when virulent infection spreads via congenital dehiscence or a preformed pathway
- virulent organisms
- cholesteatoma & bone erosion
- presence of a congenital dehiscence (eg: dehiscent facial canal) or a preformed pathway (eg: skull base fracture)
- obstruction of drainage eg: by a polyp
- low resistance of the pt
pathways of infection
- m/c bone erosion dt a cholesteatoma
- vascular extension (retrograde thrombophlebitis)
- extension along preformed pathways as congenital dehiscences, fracture lines, round window membrane, the labyrinth, and dehiscence dt previous surgery
1. cranial comp (temporal bone)
- acute mastoiditis and mastoid abscess (m/c)
- facial paralysis
- osteomyelitis of the temporal bone
2. intracranial comp
. extradural abscess (m/c for intracr)
. subdural abscess
- brain abscess
. temporal lobe abscess
. cerebellar abscess
. lat sinus thrombosis
. otitic hydrocephalus
3. extractanial comp
- ext otitis
- cervical lymphadenitis
acute mstoiditis def
acute infection of mastoid antrum and air cells w destruction of intercellular boney septae
pathology acute mstoiditis
- occur in well pneumatized mastoids and more common in children
- usually dt acute SOM or acute exacerbation on top of CSOM
- accum of pus under P inside mastoid air cells =€ P necrosis of the walls of the cells which coalesce together (coalescent mastoiditis)
- w further acc of pus it tracts its way via:
Outer table of mastoid bone giving rise to the classical post-auricular mastoid abscess (commonest form). The abscess may rupture to the outside causing mastoid fistula.
Root of zygoma giving rise to zygomatic abscess.
Mastoid tip giving rise to Bezold's abscess deep to the insertion of sternomastoid muscle.
Sagging of the postero-superior bony canal wall may also occur due to periosteal thickening adjacent to the antrum .
Clinical picture acute mstoiditis
Profuse mucopurulent discharge.
In the stage of acute mastoiditis:
Profuse mucopurulent discharge which may exhibit a positive reservoir sign i.e. rapid re-accumulation of discharge after cleaning of the ear.
Tenderness and redness over the mastoid.
Sagging (edema) of the postero-superior wall of the bony external ear canal due to periosteitis.
When post-auricular abscess develops:
The auricle is pushed outwards and downwards.
When the post-auricular abscess ruptures:
Mastoid fistula develops draining mucopus
1. xray: loss of bony septae
2. CT scan: bone erosion & extent of suppuration
The main differential diagnosis is from furunculosis of the external ear with
Age: Usually in children;Any age
hx: Upper respiratory infection Acute otitis media;Scratching of the ear, Diabetes
dischge: MucopurulentProfuseMay be reservoir sign; PurulentScanty Thick
tenderness: Over mastoid process;Over the tragus and on pulling the auricle
Sagging of the postero-superior wall of the bony external ear causing narrowing of the inner bony portion of the external canal.
Perforated drum; Narrowing of the cartilaginous portion of the external ear canal.
COMMON, Not relieved by the insertion of a speculum;
NOT COMMON Conductive
Relieved by the insertion of a speculum
Post-auricular groove:Maintained (due to the attachment of the periosteum); Flat ( obliterated due to subcutaneous edema)
Edema of the eyelids:May be upper if there is zygomatic abscess; If present will be only lower
Culture and sensitivity testing:Streptococcus hemolyticus ; Staphylococcus aureus
X-rays of the mastoid: Mastoiditis pr mastoid abscess; Normal
fever: presnt; absent
edema of eye lids: upper if zygomatic abscess; lower if present
culture: strept. haemolyticus; staph. aureus
xray on mastoid: mastoiditis or mastoid abscess; N
TM: perforated; N
RX: surgical (simple cortical mastoidectomy); medical
LNs ant to tragus: not enlarged; enlarged
Cleaning of discharge.
Antipyretics and supportive measures
The classical operation is simple (cortical mastoidectomy). The operation includes clearance of the infection from the mastoid antrum and air cells without entering the middle ear cavity through a postauricular incision. The indications for surgery include:
Failure of medical treatment
If there is associated middle ear pathology, e.g. cholesteatoma, then the appropriate procedure can be done at the same time.
Simple incision of the mastoid abscess is indicated in young children since the mastoid processes are under-developed in these cases. Also it may be preferred in some patients as a preparation for definitive surgery.
Other types of mastoiditis
A. Masked mastoiditis:
Incompletely resolved mastoiditis.
Insufficient medical treatment which controlled the acute symptoms but did not eradicate the infection completely.
Persistent discharge with occasional positive reservoir sign.
Persistent hearing loss.
X-rays of the mastoid reveal haziness and opacity of the mastoid air cells.
Simple (cortical) mastoidectomy
B. Chronic mastoiditis:
Chronic mastoiditis, contrary to acute mastoiditis, usually occurs in acellular mastoids in association with unsafe chronic suppurative otitis media. It has the same clinical presentation as unsafe chronic suppurative otitis media and requires mastoidectomy +- tympanoplasty. persistent dischage. xray: acellular mastoid.
-Spread of infection to the petrous apex air cells.
- more serious?? dt has a greater tendwncy towards intracranial extension.
- petrous apex is related to two cranial n
. 5th : carries sensation f face
. abducent n 6th: motor to lat rectus m (LR6)
It occurs only in pnuematized petrous bone and has a similar pathology to acute mastoiditis. However, it much less common than acute mastoiditis and, on the other hand, more serious because it has a greater tendency toward intracranial extension.
Clinical picture: of petrositis
Acute petrositis is usually suspected when there is persistent deep pain and discharge following mastoidectomy. It has a characteristic clinical triad which constitutes Gradenigo's syndrome.
The triad includes:
-Retrobulbar pain (i.e. pain behind the eye due to irritation of the trigeminal ganglion).
-Diplopia due to ipsilateral VI nerve (abducent) palsy.
ct scan of temporal bone: opaque petrous apex cells destruction of bony partitions bet. air cells
Treatment: of petrositis
-Appropriate mastoidectomy with surgical drainage along the track of infection
Two types of labyrinthitis may occur as a complication of suppurative otitis media: circumscribed labyrinthitis (labyrinthine fistula) and diffuse labyrinthitis. The formation of a fistula of the lateral semicircular canal is commonly the portal for entry of infection from the middle ear to the perilymphatic space i.e. (diffuse labyrinthitis).
Circumscribed Labyrinthitis (Labyrinthine Fistula)
Fistula of the lateral semicircular canal usually develops secondary to bone erosion by a cholesteatoma. The site of fistula is surrounded by a localized area of labyrinthitis (circumscribed labyrinthitis).
Labyrinthine fistula is suspected when the patient complains of vertigo, nausea, or vomiting when he cleans his ears.
Positive fistula sign: Nystagmus toward the diseased ear when a positive pressure is applied to the ear by a pneumatic speculum. The patient may experience dizziness at the same time.
No sensorineural hearing loss at this stage.
The appropriate mastoidectomy operation and grafting of the fistula.
Spread of toxins and/or bacteria from the middle ear through a fistula produces diffuse perilymphatic labyrinthitis. Toxins may also reach the inner ear through the round window membrane to the inner ear.
Typically four stages are described:
Diffuse serous stage (acute serous labyrinthitis):
This is an irritative stage characterized by:
1. Sensorineural hearing loss which is still reversible.
2. May be diplacusis (i.e. pure tone is heard differently in both ears).
3. Nystagmus, nausea, and vomiting. The nystagmus is toward the affected side.
Diffuse suppurative stage (acute suppurative labyrinthitis):
This is a destructive stage characterized by a complete loss of cochlear and vestibular function . Clinical features include:
1. Irreversible total sensorineural hearing loss.2. Nystagmus toward the normal ear, severe vertigo, nausea, and vomiting. 3. No reaction on caloric stimulation.
Fibrous stage (Chronic or healing labyrinthitis):
This stage is a healing stage characterized by fibroplastic proliferation within the perilymphatic space. Clinical features include:
1. Complete deafness.2. Mild dizziness.3. No reaction on caloric stimulation.
Osseous stage (labyrinthitis ossificans):
This is the final stage when the labyrinth becomes ossified. Clinical features include
1. Complete deafness.2. The residual vestibular symptoms depend upon the efficiency of vestibular compensation. When vestibular compensation is full all vestibular symptoms disappear.3. No reaction on caloric stimulation.
Rapid treatment is essential in order to stop the infection at the reversible serous stage. The treatment includes:
Treatment of ear infection: usually the cause is unsafe otitis media with cholesteatoma and therefore mastoidectomy is needed.
Drainage of the labyrinth (labyrinthectomy) is indicated if there is impending intracranial extension, e.g. meningitis.
Healed labyrinthitis requires no special treatment.
The facial nerve, in its canal, is closely related to the medial and posterior walls of the middle ear. The canal may be sometimes dehiscent in its horizontal part especially above the oval window.
The facial nerve may be involved in a variety of ways in suppurative otitis resulting into lower motor neuron facial paralysis:
The usual cause of facial paralysis is unsafe chronic suppurative otitis media with cholesteatoma eroding the bony canal and pressing on the nerve. Treatment is by mastoidectomy removal of the cholesteatoma and facial decompression .
Uncommonly facial paralysis may occur during acute suppurative otitis media if the facial canal is dehiscent due to edema and pressure of pus in the middle ear. Myringotomy to relieve the pressure on the nerve is indicated in these cases & systemic ABs.
Collection of pus against the dura of the middle or posterior cranial fossa by bony wall of skull.
When pus collects against the walls of the lateral sinus, it is called perisinus abscess.
Extradural abscess is the commonest intracranial complication of otitis media.
Persistent headache on the side of otitis media.
Asymptomatic (discovered during surgery)
CT scans reveal the abscess as well as bone erosion
Mastoidectomy and drainage of the abscess.
Systemic ABs for 6 weeks
Collection of pus between the dura and the arachnoid.
It's a rare pathology
Headache without signs of meningeal irritation
Focal neurological deficit (paralysis, loss of sensation, visual field defects)
CT scan, MRI brain & temporal bone : abscess (subdural collection) & bone erosion.
Inflammation of leptomeninges (pia & arachinoid)
Occurs during acute exacerbation of chronic
unsafe middle ear infection.
Type III pneumococcus infection.
- Circumscribed meningitis: no bacteria in CSF.
- Generalized meningitis: bacteria are present in CSF
3 stages (serous, cellular, bacterial st)
- General symptoms and signs:
high fever, restlessness, irritability,
photophobia, and delirium.
- Signs of meningeal irritation:
1. Neck rigidity.
2. Positive Kernig's sign: difficulty to straighten the knee while the hip is flexed dt spasm of hamstring ms.
3. Positive Brudzinski's sign:
passive flexion of one leg results in a similar movement on the opposite side or
if the neck is passively flexed, flexion occurs in the hips and knees (head to leg/ leg to leg)
- Signs of increased intracranial pressure:
the delirium progresses to coma,
the reflexes become weak or absent,
cranial nerve palsies occur.
Lumbar puncture is diagnostic:
CSF is cloudy and
CSF pressure is increased.
Contains bacteria and many polymorphs.
Protein concentration is raised but
Glucose and chlorides are decreased.
a) general rx:
1. dark quiet room as pr is irritable
2. IV nutrition as pt is vomiting
3. dec CSF P by dehydrating agents (25% glucose or Mg sulfate enema)
b) sp Rx
1. medical rx:
- ABs: immediate then acc to culture
- surgical rx
mastoidectomy to control ear infection & to Ex perilymphatic fistula
Lateral Sinus Thrombosis
Thrombophlebitis of the lateral venous sinus.
2nd m/c cause of death f OM
It usually develops secondary to direct extension
from a perisinus abscess due to unsafe otitis
media with cholesteatoma.
Inflammation of the walls of the sinus causes the formation of a mural thrombus which obstructs the lumen of the sinus.
Then become infected intra-sinus abscess.
Infected emboli are shed from the infected thrombus causing pyemia.
When the organisms reach the blood stream septicemia develops.
Progression of infection may lead to
cavernous sinus thrombosis or
cerebellar brain abscess.
Signs of blood invasion:
- mcq** hectic (spiking) intermittent fever with rigors and chills due to the showers of septic emboli. D.D: malaria.
persistent fever (septicemia).
- mcq **Positive Greissinger's sign which is edema and tenderness over the area of the mastoid emissary vein.
- Signs of increased intracranial pressure: headache, vomiting, and papilledema.
When the clot extends to the jugular vein, the vein (int jugular vein) will be felt in the neck as a tender cord.
- CT scan with contrast=> filling defect
- MRI, MRA, MRV
- Angiography, venography
- Blood cultures is positive during the febrile phase.
- mcq** Queckentedt's test (Tobey-Ayer's test) : CSF P measurement to detect obstruction of lat-sinus by compression of IJV.
systemic Antibiotics and supportive treatment.
Mastoidectomy with exposure of the affected sinus (lat sinus) -> needle aspiration-> and the intra-sinus abscess is drained.
Ligation of the internal jugular vein distal to the facial vein is indicated in recurrent embolism.
Localized suppurative inflm in the brain substance.
It is most lethal complication of suppurative OM
50% is Otogenic brain abscess
It is more common in males especially between 10 - 30 years of age.
Temporal lobe or
Less frequently, in the cerebellum. (more dangerous)
1. Stage of encephalitis: brain tissue inflammation
2. Stage of localization (latent stage): small cavities filled with pus
3. Stage of acute abscess (Manifest stage)
Compress other brain centers
4. Stage of chronic abscess:
Stationary, low virulent organism, thick wall
- Stage of invasion (encephalitis):
fever, headache, delirium, and
Signs of meningeal irritation.
- Latent stage (stage of localization):
Minimum symptoms ,mild headache
The patient may be lethargic & irritable.
- Manifest stage (acute abscess):
a) Symptoms and signs of increased intracranial pressure:
Projectile vomiting (no nausea).
b) Characteristic signs and symptoms of brain abscess:
Marked toxemia and loss of appetite.
Delirium and lethargy.
. Temporal lobe abscess:
Aphasia (left-sided lesions of Brochas area)
Hemianopia (optic radiation).
Hemiplegia or hemiparesis. (1ry motor area)
Uncinate: olfactory hallucinations.
. Cerebellar abscess:
Intention tremors (finger-to-nose test).
Positive Romberg's sign.
Wide based drunken gait
Terminal stage: 4th stage
Brain abscess unless treated usually ends by death either due to:
Coning of the brain stem into foramen magnum=> resp center=> resp arrest ,
Rupture of the abscess.
Measure to decrease intracranial pressure.
Neurosurgical drainage of the abscess or excision.
Aspiration via burr hole.
Appropriate mastoidectomy operation after subsidence of the acute stage.
Increased CSF volume in patients with CSOM due to thrombosis of the superior sagittal sinus(arachnoid villi) (dec) interfering with the absorption of CSF.
More common in children.
Headache, projectile vomiting, and papilledema.
Diplopia due to VI nerve palsy.
Increased CSF pressure,
otherwise CSF is normal.
IX: CT: dilated ventricles; lumbar puncture: inc CSF P e N physical &. chemical parameters.
- Reduction of CSF pressure (diuretics, lumber puncture).
- Treatment of ear infection.
- Shunt operation (ventriculo-peritoneal shunt in refractory cases)
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