Department of

Otorhinolaryngology

COMPLICATIONS
of Suppurative Otitis
Media
Ossama
Mahmoud
Professor of
Otorhinolaryngology
Ain Shams

Complications of Otitis
Media
The temporal bone is a
complex anatomic region
with close proximity to a
variety of critical structures.
These structures are at risk
during both acute and
chronic suppurative otitis
media.

Complications of Otitis
Media
Due to antibiotics, the incidence of
complications has greatly declined.
(also treating surgical problems with
antibiotics alone or giving incomplete
courses that mask the infection lead to
complications)
Complications are usually associated
with granulation tissue formation
and/or the presence of a
cholesteatoma (bone erosion).

Complications of Otitis
Media
Complications arise mostly due to:
-- Infection spreading by direct
extension from the middle ear or
mastoid
cavity
to
adjacent
structures.
- Thrombophlebitis (haematogenous)

Complications of Otitis
Media
Patients appear more ill than
expected
fever, new onset vertigo, sensorineural hearing
loss, fetid drainage, facial nerve weakness,
proptotic ear
lethargy and mental status changes

CT and MRI are indicated

CT is superior for evaluating the bony details of
the middle ear and mastoid space
MRI is more sensitive for diagnosing suspected
intracranial complications.

Complications of Otitis
Media

Treatment is:
Parentral Broad
Spectrum
Antibiotics and
Surgery are required

Complications of
.Suppurative O.M
Cranial (or Temporal bone)
complications:
1234-

Acute Mastoiditis.
Acute Petrositis.
Otitic Facial paralysis.
Acute Labyrinthitis.

Complications of Suppurative O
M (cont.)
Intracranial Complications
1234-

Extra-dural (epidural) abscess.

Meningitis.
Brain abscess (cerebral or cerebellar).
Lateral sinus thrombosis.

Extracranial complications
1- External otitis.
2- Jugular vein thrombophlebitis
3- Bezolds abscess
4-Retropharyngeal abscess.

Acute Mastoiditis

Acute Mastoiditis
Extension of the suppurative
inflammatory process beyond the
mucous membrane lining of the
mastoid air cells leading to osteitis of
the bony septa.
N.B. At this early stage resolution is
possible without surgery, if proper
medical treatment is given.

Acute Mastoiditis
The bony intercellular septa will
break down with
coalescence of the
infected cells to form
one cavity full of pus
leading to
Coalescent
Mastoiditis or
Mastoid Abscess.

(cont.)

Acute Mastoiditis

(cont.)

In early Coalescent Mastoiditis

the outer cortex of mastoid is intact
but with extension of the disease pus
may erode outer cortex of mastoid
leading to Subperiosteal Mastoid
Abscess which can extend by
perforating the periosteium to
became Subcutaneous
Mastoid
Abscess. If it opens through the
skin Mastoid Fistula will result.

Clinical Picture
Exaggerated symptoms of ASOM (fever, pain and HL)
1- Tenderness over mastoid antrum and
2-External swelling
A- Post-auricular abscess
- Auricle is displaced outwards, forwards and
downwards (erect auricle).
- Post-auricular groove is preserved but if the
abscess ruptures through periosteum and
becomes subcutaneous , the groove will be
obliterated.
- DD. Post auricular lymphadenitis 2ry to
Furunculosis of external auditory meatus.

Clinical Picture
Early stage of Mastoiditis

Mastoid fistula

Mastoid Abscess

Clinical Picture
B- Zygomatic abscess ;
It is due inflammation of the zygomatic air
cells. The swelling is above and in front of
the ear.
C- Bezolds abscess;
Pus pierces the tip or inner surface of mastoid
and form abscess in the sternomastoid
muscle In the neck.
D- Retropharyngeal abscess;
Pus tracking from the peritubal cells along
the Eustachian tube.

Clinical Picture
3- Internal swelling
Sagging of posterosuperior bony
meatal wall, due to periostitis and
edema over the anterior antral wall.
4- Ear discharge usually profuse ,
"Mucopurulent or purulent and may be
pulsating with reservoir sign rapid
re-accumulation "
5- Drum membrane perforated (small
with pulsating discharge) or intact and
bulging.

Investigations
1- C&S of ear
discharge
2- CT scan of the
temporal bone
to detect any
additional
cranial or
intracranial
complications

Treatment of Acute
Mastoiditis
1- Conservative treatment
is to be tried for 48 hours in mild cases
without evidences of abscess formation;
parentral broad spectrum antibiotics.
Myrigotomy if DM found intact and bulging.
2- Cortical Mastoidectomy operation
is the standard treatment if the patient is
not responding to conservative treatment, or
if a mastoid abscess is evident or if other
complications are suspected to be present.

Masked Mastoiditis
It Is the result of INCOMPLETE
TREATMENT of ASOM with antibiotics
leading to masking of the acute symptoms
while the pathological process is
progressing in the mastoid.
Clinical picture:
- Slight pain and tenderness over the
mastoid.
- Intra-cranial complications may occur
and may be the presenting symptom.

Chronic Mastoiditis
There is thick unhealthy chronically
inflamed
mucosa with granulation
tissue and osteitis with sclerosis of
mastoid air cells.(sclerosed mastoid in
X-Ray)
It is condition which may be present in
CSOM
(tubo-tympanic type and atticoantral types).
Persistent ear discharge is the main
presenting symptom

Cortical Mastoidectomy
Operation
It is a drainage operation in
which exentration of the mastoid
air cells is done.
It is a preliminary step in most of
ear surgeries

INDICATIONS
1- Acute Mastoiditis with failure
of medical treatment (persistent
pain, tenderness and fever , etc ,
for more than 2 days).
2- Subperiosteal Mastoid abscess.
3- Mastoid fistula.
4- Mastoiditis with complications as
facial paralysis, meningitis or lateral
sinus thrombosis.

INDICATIONS
5- Persistent ear discharge in cases
of ASOM or CSOM (tubo-tympanic) for
more than one month despite proper
conservative treatment
6-Resistant cases of OME.
7- Part of ear surgeries (e.g. Sac
operations in Menieres disease ------etc.).

Petrositis

It is inflammation of the air cells in the

petrous apex of the temporal bone , the
6th (abducent) and 5th (trigeminal)
cranial nerves are affected as they are
closely related to the petrous apex.

Petrositis (cont.)

Clinical Picture

The condition is called

GRADINIGO
SYNDROME

Triade of :
1- Diplopia with
convergent squint
due to 6th nerve
paralysis.
2- Trigeminal neuralgia
(retro-orbital pain and
headache) due to
irritation of the
trigeminal ganglion.
3- Discharging ear.

Petrositis

(cont.)

Investigations:
1- CT scan of temporal bone
2- C&S of ear discharge
Treatment :
1- Conservative in mild and early cases
2- Mastoidectomy with exentration of
petrous apex air cells or subtotal
petrosectomy

Otitic Labyrinthitis
It is a complication of
ASOM or more
common CSOM.
Types:
1.Circumscribed
Labyrinthitis.
(labyrinthine fistula).
2.Diffuse serous
Labyrinthitis.
3.Diffuse suppurative
Labyrinthitis.

Circumscribed Labyrinthitis
Labyrinthine Fistula/ Paralabyrinthitis

It results from erosion of the bony

wall of one of the SSC (usually the
lateral) , or less commonly the
promontory by cholesteatoma.
The inflammatory process is
outside the endosteal lining of the
labyrinth (intact inner ear
function).

Labyrinthine Fistula
Clinical Picture
In addition to the clinical picture of
OM new symptoms appear in the
form of
Intermittent attacks of vertigo
Usually not accompanied by nausea
and vomiting and usually
precipitated by pressure on the
tragus or sudden head movement.

Labyrinthine Fistula
Clinical Picture

Nystagmus accompanies the

vertigo and usually horizontal
with rapid component to the
affected side (irritant lesion).

Labyrinthine Fistula
Clinical Picture
Fistula test
is positive
(pressure on
tragus, use of
pneumatic
otoscope or
manipulating an
aural
polyp
induces vertigo
and nystagmus).

Diffuse serous
Labyrinthitis
Catarrhal Labyrinthitis

It is a serous inflammation of the

membranous labyrinth (inflamatory cells in
the peri-lymph without organisms).
Clinical Picture:
1. That of ASOM or CSOM.
2. Vertigo, nausea & vomiting are severe.
3. Nystagmus is usually horizontal with
rapid component to affected side (irritant
lesion).
4. Deafness becomes severe and mixed
(Conductive & SNHL).

Diffuse purulent
Labyrinthitis
At first the previous symptoms increase
markedly and HL may be severe or total.
Nystagmus is beating first towards the
affected side (irritant) but changes to the
other side (dead labyrinth) when
destruction of the labyrinth becomes
complete.
Nystagmus will disappear later as it
will be compensated by the healthy
side.

Diffuse Purulent
Labyrinthitis
Absent or minimal toxic
manifestations as the surface area of
the inner ear is small so there is no
or little diffusion of toxins.
Presence of fever and other toxic
manifestations may suggest
occurrence of

meningitis.

Treatment of
Labyrinthitis

Conservative Treatment
- Antibiotics that cross the BBB to guard
against meningitis.
- Labyrinthine sedatives and anti-emetics :
as Dramamine , stugeron,
diazepam valium and zofran (4mg) amp. .
Surgical Treatment either;
- Cortical mastoidectomy for control of
suppurative otitis media, or
- Radical mastoidectomy and
labyrinthectomy in cases of supprative
labyrinthitis with dead labyrinth to prevent
intracranial extension of infection

Otitic Facial Nerve Paralysis

As a complication of ASOM facial nerve paralysis
occurs in children if there is congenital
dehiscence in the bony canal of the nerve
(20% of population). Paralysis is usually
incomplete and is due to inflammation of the
nerve sheath and compression by pus.
Treatment:
Early myringotomy (usually with Grommets
tube)
Antibiotics (parentral) and steroids.
Cortical mastoidectomy if the paralysis
persist in spite of other lines of treatment or if
there is acute mastoiditis.

Facial Nerve Paralysis as a

complication of CSOM
Destruction of the bony
canal and pressure on
the nerve is either by:
1) Cholesteatoma
2) Osteomylitis of the
mastoid.
3) Tuberculous OM.
(Multiple Drum M.
perforations & pale
mucosa).

Facial Nerve Paralysis as a

complication of CSOM
Treatment
1- Mastoidectomy operation with
exposure and decompression of the
facial nerve.
2- In case of tuberculous OM Antituberculous ttt usually gives
cure of the paralysis. Surgical ttt is
only for cases showing no recovery
after the disease has been cured.

Post operative Facial

Paralysis
(Iatrogenic)
1.Immediate after the operation is

due

to direct trauma to the nerve.

Treatment :
If Partial: corticosteroids & antibiotics.
If Complete: Immediate exploration of
the nerve and remove any bone specule
compressing the nerve or do nerve
suturing or nerve graft if needed
(from Greater Auricular nerve).

Post-operative facial
paralysis
2. Delayed (few hours or days
after recovery)
usually due to pressure on the
nerve by edema ,haematoma or tight
pack.
Treatment:
1) Removal of the pack.
2) Antibiotics & Cortisone.

Extradural Abscess
It is collection
of pus and /or
granulation
tissue between
skull bone and
dura.

Extradural Abscess
Clinical Picture
The condition is usually symptomless
and accidentally discovered during
mastoidectomy.
Presentations :
There may be persistent
1- Earache or headache.
2- Low grade Fever (about 37.5 - 38C).
3- Pulsating ear discharge.

Extradural Abscess
Treatment
1- Antibiotics (Injection) that cross
BBB.
2- Cortical Mastoidectomy operation ,
abscess must be evacuated and
bone must be removed until
healthy dura is reached.

Diffuse
Leptomeningitis
It is diffuse inflammation of the arachnoid,
subarachnoid space & pia mater.
Symptoms
1) Symptoms of infection e.g. high fever,
malaise. etc.
2) Symptoms of increased intracranial
tension:
- Severe headache. - Vomiting.
- Blurring of vision.
3) Symptoms of meningeal irritation Irritability
, Photophobia , neck rigidity and retraction.

Diffuse Leptomeningitis
Signs
1) High fever (> 39 C) and tachycardia.
2) Neck Rigidity.
3) Signs of meningeal irritation:
a- Kernigs sign
Flex hip and knee ,then trying to extend
the knee will produce severe pain and will
be resisted by the patients.
b- Brudziniskis sign
Flex the neck , hip and knee will become
flexed.
4- Papilloedema (edema of optic disc) on fundus
examination.

Investigations of
Meningitis
A- CT Temporal Bone & Brain (To
detect probable intracranial
complication if any).
B- Lumbar Puncture:
1- CSF examination.
2- Culture & Sensitivity.

Aspect
Pressure

C.S.F. In
meningitis
Turbid.
High.

Cells

Thousands, mainly
polymorphs.

Proteins

Increased (due to
the bacteria).
Decreased

Sugar

Chloride

normal CSF
Clear.
60-180mm Of
CSF.
1-5 lymphocytes
per c mm.
40 mg/100 ml.
80 mg/100 ml.

( nutrition of
bacteria).
Decreased
750 mg/l00 ml.
(due to vomiting).

Treatment of Meningitis
1- Antibiotics:
i- Intrathecal injection of crystalline penicillin
ii- Intravenous injection of drugs crossing BBB
as, 3rd generation cephalosporins & Flagyl
for anerobes
2- Measures to reduce the increased
intracranial tension:
i- Repeated lumbar punctures.
ii- Hypertonic glucose solution IV & Diuretics.
iii- Dexamethason injections.

Brain Abscess

It is either Temporal or Cerebellar

Brain Abscess
Clinical Picture
I- Stage of encephalitis:
1- High fever & rapid pulse.
2- Rigors or convulsions specially in
children.
3- Headache.

Brain Abscess
Clinical Picture

(cont.)

II- Latent Stage:

(weeks to months)
Due to localization of the abscess
with diminished brain. Most of
symptoms disappear and patient
may feel some headache and lack of
concentration.

Brain Abscess
Clinical Picture
III- Manifest Stage:
Due to increase in the size of the abscess.
A- Manifestations of Toxaemia:
i. Anorexia and loss of weight.
ii. Mental dullness , slow cerebration and
delirium.
iii. Leucocytosis which may reach 20.000
or more.

Brain Abscess
Clinical Picture
B- Manifestations of Increased
Intracranial Tension:
1- Headache which is severe and not
relieved by analgesics.
2- Projectile vomiting (not preceded by
nausea and not related to meals).
3- Blurring of vision due to papilloedema.

Brain Abscess
Clinical Picture
Prolonged increased ICT
may lead to
- Slow full pulse(40/min.)
- Subnormal temperature
- Slow cerebration
- Slow deep respiration

Brain Abscess
C- Manifestations of Localization:
Temporal Lobe Abscess
- Nominal Aphasia (inability to name
objects due to pressure on Brocas area)
- Homonymous hemi-anopia( defect in
field of vision)
- Uncinate fits (epileptic fits preceeded by
aura)
- Hemiplegia
- Hemianesthesia

Brain Abscess
Clinical Picture
Cerebellar Abscess:
1.Tremors with muscle weekness (hypotonia).
2.Slurred speech

3.Incoordination of movements (asynergia

and dysmetria) can be shown by finger nose

test.
4.Ataxia: unsteadiness of gait with deviation
to the side of lesion.
5.Vertigo and nystagmus.
6.Dysdiadokokinesis: ( patient is unable to
do rapid pronation and supination ).

Brain Abscess
Clinical Picture

IV- Terminal Stage:

Due to rupture of the abscess
resulting in either:
1) Diffuse encephalitis. or
2) Diffuse meningitis.
Coma and death will occur.

Brain Abscess
Investigations
1. CT scan with contrast &/ or MRI show site ,
size of abscess and whether acute or chronic
2. Fundus examination show Papilloedema.
3. Field
of
vision
examination
show homonymmous hemianopia.
4. CBC show marked leucocytosis (20000).
5. C/S from pus from abscess after drainage
or from ear discharge.
N.B. Never do Lumber Puncture as
CONIZATION of medulla may occur due to
marked rise of I.C.T.

Brain
Abscess

Brain Abscess
Treatment
Acute Abscess
1. Antibiotics that cross BBB.
2. Measures to Lower the increased

ICT.
3. Repeated Tapping of abscess through
burr holes by neurosurgery or through
mastoidectomy (N.B. Repeated CT must be
done to ensure complete drainage).
4. Mastoidectomy of the affected ear as a
treatment for otitis media when the
condition of the patient allows.

Brain Abscess
Treatment
B. Chronic Abscess
1. Excision
2. Antibiotics (Parentral-crossing BBB) .
3. Mastoidoidectomy for affected ear
when the condition of the patient
allows.

Lateral Sinus
Thrombophlebitis

It is infective thrombosis of the

lateral (sigmoid) venous sinus.

Lateral Sinus
Thrombophlebitis
Pathogenesis
Peri-sinus abscess (type of extra-dural
abscess) is formed as an extension from
infected mastoid
Infection extends into the sinus wall and
lumen causing thrombophlebitis.
Infected thrombus may be fragmented with
detachment of septic emboli in blood stream
Extension of thrombosis to cavernous ,
supermay take placeior petrosal, superior
sagittal sinus or to the internal jugular vein
may occur

Lateral Sinus Thrombosis

Clinical Picture
1- Pyaemic Type (Malarial
like)
- Remittent fever and rigors
occurring at irregular intervals,
between them temp. reach near
the base line ( remains above
37C).
- Multiple pyaemic abscesses in
different parts of the body due
to separation of septic emboli.

Lateral Sinus Thrombosis

Clinical Picture
D.D. from Malaria
a- Fever and rigors in malaria occurs at
regular intervals and between
them temp. can reach 37C.
b- Leucopenia in malaria instead of
leucocytosis in thrombosis.
c- Blood film will show malaria
parasites. (during the attack)

Lateral Sinus Thrombosis

Clinical Picture (cont.)

2- Septicaemic or Typhoid Type

Continuous fever without remissions
or rigors.
D.D. from Typhoid fever:
a- Widal test Is positive in typhoid.
b- Leucopenia in typhoid.

3- Latent Type
Condition may be asymptomatic and
discovered only during Mastoid
Operation for acute mastoiditis.

Lateral Sinus Thrombosis

Clinical Picture
4- If Septic thrombosis extend to the
Jugular vein in the neck.
a- Cord like mass in the neck.
b- Torticollis.
c- Cervical lymphadenitis may occur.

Lateral Sinus Thrombosis

Treatment
1) Antibiotics (according to blood culture??? )
2) Antipyretic analgesics, light diet, fluids.
3) Anticoagulants as heparin may be given in
cases with extension of the thrombus ????.
4) Mastoidectomy operation and exposure
of the sinus with removal of bone
until healthy dura is reached.
Incision of the sinus and evacuation of the
infected clot is done until unclotted blood is
reached.

Lateral Sinus Thrombosis

Treatment

Ligation of the internal Jugular

vein can be done if we cannot
reach the lower limit of the
thrombus and it must be ligated
below the level of common facial
vein which must be ligated also
to avoid cross thrombosis to the
cavernous sinus.

Lateral Sinus Thrombosis

Treatment

N.B. During operation we must

differentiate between thrombosed
sinus and healthy one by the
following:
Thrombosed sinus is:
1)Grayish and dull instead of bluish
and glistening.
2)Firm and pulsating instead of soft
and not pulsating.