Complications Of CSOM

Moderator-Dr.Swaroop DevPresenter –Dr.Razal

Classified as

• Intra cranial • Extra-cranial, Intra-temporal

Factors affecting Pathogen Factors• High virulence bacteria• Antimicrobial resistance

Patient Factors• Young age/Elderly• Poor immune status• Chronic disease(DM,TB)• Poor socio-economic status

Routes of entry• Bony erosion (cholesteatoma,osteitis)

• Anatomical pathway: oval window, round window, internal auditory canal, suture line, cochlear & vestibular aqueduct

• Retrograde Thrombophlebitis

• Congenital bony defects: facial canal, tegmen plate

• Acquired bony defects: fracture, neoplasm, stapedectomy

Extra-Cranial

Mastoiditis• It is the inflammation of mucosal lining of mastoid

antrum and air cells system.• Pathology

o Production of pus under tensiono Hyperaemic decalcificationo Osteoclastic resorption of bony walls

Clinical Features• Otorrhoea > 2 weeks, otalgia & deafness• Mastoid reservoir sign: pus fills up on mopping• Sagging of postero-superior canal wall• Ironed out appearance of skin over mastoid due

to thickened periosteum• Mastoid tenderness Investigation• X-ray & CT scan

Mastoid reservoir sign

Sagging of posterior wall

Ironed out appearance Mastoid cavity

Treatment• Urgent hospital admission• Broad spectrum I.V. antibiotics

No response to medical treatment in 48 hrs

• Cortical Mastoidectomy

Facial Nerve Paralysis

• Seen in AOM,COM(both mucosal and squamosal variety)

• Predisposing factors: 1.congenital dehescence of FC 2.canal erosion by cholesteatoma/granulation

• AOM: sudden onset, full recovery• COM: gradual onset, paralysis persist(erosion)

Treatment:• Medical(Corticosteroids)• Modified Radical Mastoidectomy(Sq CSOM)• Facial nerve decompression if required• Physioyheraphy

Labrynthitis

• Inflammation of bony labyrinth Route of infection:• Round window membrane• Pre-formed opening (Stapedectomy)• Retrograde spread of meningitis types:• Serous labyrinthitis • Otogenic suppurative labyrinthitis • Meningitic suppurative labyrinthitis

• Serous labyrinthitis occurs during acute or chronic otitis media. It is presumed that bacterial exotoxins enter the inner ear via the oval or round window or a labyrinthine fistula.

• there is no clinical method for differentiating serous from suppurative labyrinthitis. If vestibular and auditory functions are partially or completely retained, it can be assumed that the infection was serous.

Treatment• Bed rest (affected ear up). Avoid head

movement.

• Labyrinthine sedative: Prochlorperazine, Cinnarizine

• Broad spectrum I.V. antibiotics

• Modified Radical Mastoidectomy: removes infection

PETROSITIS

• Spread of infection from middle ear and mastoid to the (peumatised) petrous part of temporal bone.

• Petrous bone are of three types; 1.Well peumatised(25-30%) 2. Diploic 3. Sclerotic(Most common)

Gradenigo syndrome• It is triad of,• Persistent otorrhoea

• Retro-orbital pain: Trigeminal nerve involvement

• Diplopia: Convergent squint due to lateral rectus palsy by injury to abducent nerve

Etiology: • mastoiditis involving petrous apex along

postero-superior & anteroinferior tracts in relation to bony labyrinth

• Anteroinferior tract : starts at the hypotympanum near the eustachian tube runs around the cochlea to reach the petrous .

• Posterosuperior tract :starts in the mastoid and runs behind or above the bony labyrinth to the petrous apex.

Diagnosis: • C.T. scan temporal bone• M.R.I. to differ b/w bone marrow & pus

Treatment: • Modified radical mastoidectomy & clearance of

petrous apex cells

Sub-Periosteal abscess & Fistula

PathologyProduction of pus under tension

hyperaemic decalcification (halisteresis)

osteoclastic resorption of bone

sub-periosteal abscess

penetration of periosteum + skin

fistula formation

Sub-periosteal fistula: dry

Sub-periosteal fistula: wet

Types of sub-periosteal abscess

• Post-auricular• Bezold• Citelli• Zygomatic• Luc

Post-auricular Abscess

• Commonest.• Present

behind the ear.

• Pinna pushed forward & downward.

• Luc: swelling in external auditory canal• Bezold absceses-swelling over

sternocleidomastoid muscle• Citelli absceses-swelling over posterior

belly of digastric muscle• Parapharyngeal & Retropharyngeal: due to

spread of pus along Eustachian tube

Intra Cranial

Meningitis It defined as inflammation of leptomeninges

(Pia & Arachnoid) with bacterial invasion of CSF in subarachnoid space.

Mode of invasion • Preformed pathway (patent petro squamus

suture or labyrinth)• Venous thrombophlebitis• Direct erosion of bone by cholesteatoma

Clinical features 1. Fever with chills and rigor2. Headache3. Neck rigidity4. Photophobia, irritability5. Nausea, Vomiting

On examination 1. Kernig’s sign– Extension of leg with thigh

flexed causes pain2. Brudzinski’s sign– Flexion of neck causes

flexion of hip and knee.3. Exaggerated tendon reflex4. Papilloedema

Otogenic brain abscess

• 50-70 % adult & 25% in child abscess are otogenic

• Route of infection: 1. Direct spread:• via Tegmen plate: Temporal abscess• via Trautmann’s triangle: Cerebellar abscess2. Retrograde thrombophlebitis

Trautmann’s Triangle

• Superiorly: superior petrosal sinus

• Posteriorly: sigmoid sinus

• Anteriorly: semi-circular canals)

• Pathway to posterior cranial fossa from mastoid cavity

Stages of Brain Abscess• Early cerebritis(invasion)- 1-3 days

• Late cerebritis(Localization)-4-10days

• Early capsule formation(Enlargement)-10-13 days

• Late capsule formation(termination)-14

days.

Investigations • CT scan of brain • MRI brain • Avoid lumbar puncture to prevent coning

Medical Treatment• High dose broad spectrum I.V. antibiotics:

Ceftriaxone + Metronidazole + Gentamicin

• I.V. Dexamethasone : reduce oedema

• I.V. Mannitol : reduce I.C.T.

• Anti-epileptics: Phenytoin sodium

• Antibiotic ear drops & aural toilet

Surgical Treatment• Repeated burr hole aspirations

• Excision of brain abscess with capsule

• Open incision & evacuation of pus

• Radical mastoidectomy after pt becomes stable

Otitic Hydrocephalus

• Defined as raised intracranial pressure with normal CSF finding

• Seen in children and adolescent with acute and chronic middle ear infection

Mechanism Retrograde extension of thrombophibittis

from sigmoid sinus to superior sagittal sinus

Blockage of arachnoid villi

Dec CSF absorption/Inc Secretions

Raised CSF pressure

Symptoms • Severe headache, • Drowsines• Vomiting• Blurring of vision,Diplopia Signs • Papilloedema• Nystagmus• CSF pressure > 300 mm of water.

Treatment I.V. antibiotics & MRM

• Reducing CSF pressure (prevents optic atrophy) by:

I.V. Dexamethasone I.V. Mannitol Repeated lumbar puncture / lumbar drain Ventriculo-peritoneal shunt

Extradural Abscess

• It is collection of pus between dura matter and the bone of the IC

Pathology • Bone over the dura destroyed by

decalcification (Acute) or cholesteatoma (Chronic)

• Spread of infection by venous thrombophlebitis

Clinical features 1. Persistent headache2. Severe pain in the ear3. Low grade fever and malaise.

• Collection of pus between dura and arachnoid

• Erosion of bone and dura by thrombophlebitic process

• Pus may get loculated at various places in subdural space

Clinical features –1. Due to meningeal irritation – Fever,

malaise, headache, neck rigidity, positive kernig’s sign

2. Due to raised intra cranial tension – papilloedema, ptosis.

Lateral sinus thrombosis • Syn – Sigmoid sinus thrombosis• Definition – It is an inflammation of inner

wall of lateral venous sinus with thrombus formation.

• Aetiology –CSOM with cholesteatoma.

Pathology 1. Formation of perisinus abscess(outer wall

sinus)2. Endophlebitis and mural thrombus

formation(inner Wall)3. Thrombus enlarges to Obliterate the sinus

lumen and leads to intrasinus abscess4. Extension of the thrombus-Septicemia.

• Clinical features • Rise of temperature• Headache, neck pain• Papilloedema• Tenderness along jugular veinInvestigation – CSF examination X-ray mastoid CECT scan, MRI Culture and sensitivity of ear swab

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