BY
DR. AMER SALIH
• COMPLICATIONS OF SUPPURATIVE OTITIS MEDIA.
• IT IS SPREAD OF INFECTION BEYOND MIDDLE EAR CLEFT INTO
INTRACRANIAL AND EXTRACRANIAL STRUCTURES.
• *ROUT OF EXTENSION OF INFECTION
• 1-DIRECT EXTENSION THROUGH BONE AFFECTED BY OTITIS
AND ABSORPTOIN
• 2-THROMBOPHILIBITIS.
• 3-THROUGH NORMAL ANATOMICAL PATHWAYS.
• 4-THROUGH NON ANATOMICAL DEFECT .
• 5-SURGICAL DEFECT.
• 6-ALONG THE PERIARTERIOLAR SPACE INTO THE BRAIN TISSUE.
• FACTOR AFFECTING THE SPREAD OF INFECTION AND DEVELOPMENT OF
COMPLICATION.
• 1-PATIENT
FACTORS
E.G.
AGE
,IMMUNE
STATUS,CHRONIC
DISEASES(D.M.R.F)
• 2-BACTERIAL FACTORS E.G.VIRULENCE , SUSCEPTIBILITY TO ANTIBIOTIC.
• CLASSIFICATION.
• I : INTRATEMPORAL COMPLICATIONS.
•
1.MASTOIDITIS (ACUTE,MASKED,CHRONIC).
•
2.PETROSITIS (PETROUS APICITIS).
•
3.LABYRINTHITIN COMPLICATIONS .
•
A. LABYRINTHITIS
•
B. LABYRINTHINE FISTULA.
•
4.FACIAL NERVE PARALYSIS.
• II.INTRACRANIAL COMPLICATION
•
1. EXTRADURAL ABSCESS
•
2. SUBDURAL ABSCESS
•
3. MENINGITIS
•
4. BRAIN ABSCESS:
•
A. TEMPORAL LOBE ABSCESS.
•
B. CEREBELLAR ABSCESS.
•
5. LATERAL SINUS THROMBOSIS/THROMBOPHLEBITIS
•
6. OTITIC HYDROCEPHALUS (BENIGN INTRACRANIAL HYPERTENSION).
• III.EXTRACRANIAL EXTRATEMPORAL COMPLICATIONS.
•
1.MASTOID ABSCESS.
•
2.OTITIS EXTERNA.
• 1-MASTOIDITIS
• IT IS ABACTERIAL INFECTION OF THE MASTOID AIR CELLS SURROUNDING
THE INNER AND MIDDLE EAR.THE MASTOID BONE FULL OF THESE AIR CLLS
WHICH RESPONSIBLE FOR PROTECTION OF DELICATE STRUCTURES OF THE
EAR,REGULATE EAR PRESSURE AND POSSIBLY PROTECT THE TEMPORAL BONE
DURING TRAUMA . MASTOIDITIS MORE COMMON IN CHILDREN THAN
ADULT.
• CAUSATIVE
ORGANISMS
THE
MOST
COMMON
PATHOGEN
IS
STREPTOCOCCUS
PNEUMONIAE.
STREPTOCOCCUS
PYOGENES,
H.INFLUENZAE, STAPHYLOCOCCUS AUREUS.
*TYPES.
•
A-ACUTE. B-CHRONIC.
C-MASKED.
*A. ACUTE MASTOIDITIS :
• IS SUPPURATIVE INFLAMMATION OF MASTOID AIR CELLS IN THE TEMPORAL
BONE.
• IT IS THE MOST COMMON INTRATEMPORAL COMPLICATIONS OF ACUTE
SUPPURATIVE OTITIS MEDIA.
• PROGRESS OF ACUTE MASTOIDITIS
• ACUTE MASTOIDITIS PROGRESSES IN THE FOLLOWING STAGES AND MAY
BE ARRESTED AT ANY POINT.
• 1.SUPPURATIVE INFLAMMATION OF MASTOID AIR CELLS
LEADS TO
• 2.DESTRUCTION
OF
BONY
SEPTA(OSTEITIS)
(DUE
TO
HYPEREMIC
DECALCIFICATION.)
• 3.ACCUMULATION OF PUS IN LARGE MASTOID CAVITY (COALESCENT
MASTOIDITIS)
• 4.EXTENSION BY DESTRUCTION OF BONY BOUNDARIES LATERALLY CAUSES
SUBPERIOSTEAL OR MASTOID ABSCESS.
• 5-MASTOID ABSCESS SOMETIME RUPTURE FORMING FISTULA.
• CLINICAL FEATURES.
• 1-OTOLGIA.
• 2-FEVER,IRRITABILITY AND LETHARGY.
• 3-REDNESS AND TENDERNESS BEHIND THE EAR.
• 4-EAR DISCHARGE.
• 5-BULGING AND DROOPING OF THE EAR.
• 6-HEARING LOSS(CONDUCTIVE TYPE)
• OTOSCOPIC FINDINGS.
• THE TYMPANIC MEMBRANE EITHER INTACT CONGESTED OR BULGING, OR
PERFORATED (IN PARS TENSA) WITH PUS FLOWING OR PULSATING.
• SAGGING OF POSTEROSUPERIOR CANAL WALL .
• INVESTIGATIONS.
• 1-EAR SWAB FOR CULTURE AND SENSITIVITY.
• 2-BLOOD TEST . LEUCKOCYTOSIS.
• 3-X-RAY OF MASTOID BONE . CLOUDY AIR CELLS IN EARLY STAGE AND
LOSS OF BONY SEPTUM AND COALESCENCE IN LATE STAGE.
• CT SCAN. BONY DESTRUCTION AND EXTENSION OF INFECTION.
Left ear acutes mastoiditis Mastiod abscess
• TREATMENT.
• 1-HOSPITALIZATION AND GIVE THE PATIENT PRANTERAL ANTIBIOTICS FOR 7-
10 DAYS BEST TO DEPEND ON CULTURE AND SENSITIVITY . THE BEST
ANTIBIOTIC HERE IS VANCOMYCINE PLUS CEFTRIAXONE . THEN CHANGE TO
ORAL
ANTIBIOTICS
LIKE
CLINDAMYCIN
PLUS
THIRD
GENERATION
CEPHALOSPORIN OR AMOXICILLIN +CLAVULANIC ACID
• ANALGESIA AND ANTIPYRETIC.
• 2-HIGH DOSE STEROID.
• 3-NASAL DECONGESTANTS.
• 4-MARINGOTOMY.TO DRAIN THE PUS AND IMPROVE THE SYMPTOMS.
• 5-CORTICAL MASTOIDECTOMY.
• INDICATIONS.
• 1-FAILURE OF MEDICAL TREATMENT.
• 2-MASTOID ABSCESS.
• 3-FACIAL PARALYSIS.
• 4-INTRACRANIAL COMPLICATIONS.
B. MASKED MASTOIDITIS.
INCOMPLETELY RESOLVED ACUTE MASTOIDITIS.
DUE TO INSUFFICIENT MEDICAL TREATMENT WHICH CONTROLLED THE ACUTE
SYMPTOMS BUT DID NOT ERADICATE THE INFECTION COMPLETELY.
C-CHRONIC MASTOIDITIS.
ONGOING INFECTION OF MIDDLE EAR AND MASTOID THAT CAUSES PERSISTENT
DRAINAGE FROM THE EAR.
• 2-PETROSITIS
• AN EXTENSION OF INFECTION FROM THE MIDDLE EAR INTO A PNEUMATIZED
PETROUS APEX . CALLED GRADENIGO’S SYNDROME.
• CLINICAL FEATURE
• 1-OTORRHEA
• 2- HEARING LOSS.
• 3- RETRO-ORBITAL PAIN. DUE INVOLVEMENT OF V NERVE
• 4- DIPLOPIA AND SQUINT; LATERAL RECTUS PALSY DUE TO ABDUCENT (IV) N.
• TREATMENT.
• ANTIBIOTICS.
• MASTOIDECTOMY WITH DRAINAGE OF THE APICAL CELLS.
• 3-LABRYNTHINE COMPLICATIONS.
• A-LABRYNTHITIS. IT IS INNER EAR INFLAMMATION WHICH AFFECT HEARING
AND BALANCE.
• CLINICAL FEATURES
• 1-NAUSEA AND VOMITING.
• 2-VERTIGO.
• 3-SENSERINEURAL HEARING LOSS.
• 4-NYSTAGMUS TO OPPOSITE SIDE.
• 5-TINNITUS.
• DIAGNOSIS.X-RAY OF MASTOID.
•
*CT SCAN.
• COMPLICATIONS.
•
*MENINGITIS.
•
*LONG TERM EFFECT ON HEARING AND BALANCE
• TREATMENT
.
• 1-MEDICAL TREATMENT.
•
*BED REST.
•
*FLUID REPLACEMENT TO PREVENT DEHYDRATION.
•
*LABRYNTHINE SEDATION(CINNIRAZINE OR STEMETIL)
•
*I.V.ANTIBOITIC.
•
*OBSERVATION FOR SIGNS AND SYMPTOMS OF MENINGITIS.
• 2- SURGICAL TREATMENT;
• BETTER TO DO THE OPERATION AFTER7-10 DAYS
WHEN ACUTE
SYMPTOMS OF SUPPURATIVE LABYRINTHITIS SUBSIDED
• *IN ASOM . MARINGOTOMY OR CORTICAL MASTOIDECTOMY.
• *IN CSOM. MASTOID EXPLORATION AND ERADICATE INFECTION AND
REPAIRING THE FISTULA IF PRESENT.
• B-LABRYNITHINE FISTULA:
• IT IS OCCUR DUE TO BONY EROSION OF LATERAL SEMICIRCULAR CANAL
,BUT CAN BE OCCUR IN THE PROMONTORY INCIDENCE IS ABOUT 10% OF
CASES OF CSOM .IT MAY BE SILENT OR ASYMPTOMATIC AND DISCOVERED
AT THE OPERATION. CT SCAN MAY DEMONSTRATE THE FISTULA.
• CALORIC TEST NEVER USE WATER IN PATIENT WITH CSOM.
• FISTULA SIGN :
• IT DEPEND ON THE TRANSMISSION OF AIR PRESSURE CHANGE THROUGH
THE EXTERNAL AUDITORY CANAL TO THE FISTULA IN THE LABYRINTH
CAUSING PERILYMPH MOVEMENT.
• THE TEST DONE BY PRESSURE ON THE TRAGUS LEAD TO INCREASE THE AIR
PRESSURE CAUSE CONJUGATE DEVIATION OF THE EYE TOWARD THE
AFFECTED EAR WITH JERKY NYSTAGMUS , WHEN THE PRESSURE RELEASE
,THE EYE RETURN TO THE MIDLINE AND THE PATIENT FEEL DIZZY.
• TREATMENT :
• IN CSOM WITH VERTIGO, SURGICAL EXPLORATION IS THE BEST CHOICE.
• FACIAL PARALYSIS:
• 1-ACUTE OTITIS MEDIA:
LESS THAN 10% OF PATIENT WITH CONGENITAL DEHISCENCE OF BONY
FALLOPIAN CANAL ,SO THE INFECTION EASILY TRANSMITTED.
• TREATMENT
: ANTIBIOTIC,MARINGOTOMY AND CORTICAL MASTOIDECTOMY ARE THE MAIN TREATMENT.
• 2-CHRONIC OTITIS MEDIA:
THE BONY COVERING IS ERODED BY CHOLESTEATOMA,GRANULATION
TISSUE OR OSTEITIS .IT ALMOST ALWAYS AFFECT THE TYMPANIC PORTION.
• TREATMENT:
• 1-URGENT EXPLORATION OF THE HORIZONTAL TYMPANIC PORTION.
• 2-ANY ATTACHED GRANULATION TISSUE SHOULD BE LEFT
• 3-HEALTHY TISSUE SHOULD BE REMOVED TO ALLOW SPACE FOR OEDEMA.
• 4-GENTLE PACKING
• II: INTRA-CRANIAL COMPLICATIONS
• PATIENT WITH SUPPURATIVE OTITIS MEDIA HAVE THE
FOLLOWING
SYMPTOMS
GIVE
THE
DOCTOR
A
SUSPICION OF INTRACRANIAL SPREAD OF INFECTION.
•
*HEAD ACHE.*FEVER,*NAUSEA AND VOMITING,
•
* PAPILLEDEMA
•
*VERTIGO AND DIZZINESS.
•
*FIT, PARALYSIS OR OTHER FOCAL NEUROLOGICAL
SIGNS.
• INTRACRANIAL COMPLICATIONS ARE
• 1.
EXTRADURAL
ABSCESS:
THE
COMMONEST
INTRACRANIAL
COMPLICATIONS . IT IS OCCUR DUE TO EXTENSION OF INFECTION OR
CHOLESTEATOMA , FURTUNATLY THE DURA RESISTANT TO INFECTION AND
DESTRUCTION SO THE PUS ACCUMULATE BETWEEN THE DURA AND BONE.
• 2-SUBDURAL ABSCESS . THE SPREAD OF INFECTION OCCURS THROUGH THE
DURA LEAD TO MENINGITIS OR ONLY FLUID COLLECTION IN THE SUBDURAL
SPACE LEAD TO SUBDURAL EFFUSION OR ABSCESS , THE ABSCESS MAY BE
SMALL DUE TO LIMITATION BY GRANULATION TISSUE OR LARGE LEAD TO
SPACE OCCUPYING LESION.
• 3. MENINGITIS: IS INFLAMMATION OF THE MENINGES OF THE BRAIN AND
SPINAL CORD; CAUSED BY INVASION OF THE CEREBROSPINAL FLUID BY AN
INFECTIOUS ORGANISM.
• 4-BRAIN ABSCESS : IT OCCURS IN THE TEMPORAL LOBE AND CEREBELLUM .
MORTALITY RATE IS 6%,THE SPREAD OF INFECTION THROUGH OSTIETIC
TEGMEN TYMPANI AND LATERAL SINUS
• THROMBOSIS.50% OF BRAIN ABSCESS IS OTOGENIC
• LATERAL SINUS THROMBOSIS:
• IT IS THROMBOPHLIBITIS OF THE LATERAL SINUS WHICH IS FILLED
SUPPURATING BLOOD CLOT.
• DEATH RATE IS ABOUT 50%..THE CLOT PARTLY ORGANIZED AND PARTLY
SOFTEN AND BY SUPPURATION THE INFECTED MATERIAL SPREAD TO
VENOUS CIRCULATION LEAD TO BACTERAMIA AND SEPTICEMIA.
• 6.OTITIC HYDROCEPHALUS
• A BENIGN INTRACRANIAL HYPERTENSION ASSOCIATED WITH EAR DISEASE. DUE TO
OBSTRUCTION OF DRAINAGE OF CSF .
• TREATMENT OF INTRACRANIAL COMPLICATIONS.
• 1.LARGE DOSE OF I.V ANTIBIOTICS
• THE DRUG CHOSEN ON PROBABILITY WITHOUT WAITING FOR CULTURE AND SENSITIVITY
TEST, THEN CHANGES DEPENDING ON CLINICAL RESPONSE.
•
*IN ACUTE SUPPURATIVE OTITIS MEDIA =CEFTRIAXONE +VANCOMYCIN.
•
*IN CHRONIC SUPPURATIVE OTITIS MEDIA =CIPROFLOXACIN +CLINAMYCIN.
• 2.TREATMENT OF LOCAL NEUROLOGICAL COMPLICATIONS .
•
* BRAIN ABSCESS (ASPIRATION,EXCISION).
•
*EXTRA DURAL AND SUBDURAL ABSCESS .EARLY DRAINAGE
• 3.TREATMENT OF EAR DISEASE.
•
*IN ASOM = MYRINGOTOMY+CORTICAL MASTOIECTOMY.
•
*IN CSOM = MASTOID EXPLORATION(MODIFIED RADICAL MASTOIDECTOMY
, RADICAL MASTOIDECTOMY )
• LATERAL SINUS THROMBOPHLEBITIS OPEN LATERAL SINUS TO REMOVE CLOT; IF
PUS IN SINUS, EVACUATE PUS, RARELY LIGATION OF INTERNAL JUGULAR VEIN
TO PREVENT DISSEMINATION OF INFECTED CLOT.
• DECREASE ICP ; DEXAMETHAZONE ,MANNITOL, ANTIEPILEPTIC WHEN NEEDED.
* OTITIC HYDROCEPHALUS; REPEATED LUMBER PUNCTURE (DRAIN),AND
VENTRICULO-PERITONEAL SHUNT MAY NEEDED.)
• III.EXTRACRANIAL EXTRATEMPORAL COMPLICATIONS;
• 1.MASTOID ABSCESSES
• IS SUBPERIOSTEAL COLLECTION OF PUS,IT IS A COMPLICATION OF
MASTOIDITIS.
• TYPES OF MASTOID ABSCESS
• 1. POST AURICULAR ABSCESS. THE COMMONEST.
• 2. BEZOLD’S ABSCESS: SPREAD THROUGH A PERFORATION IN THE
MASTOID CORTEX AT MASTOID TIP ALONG DEEP TO INSERTION OF SCM.
• 3. LUC'S ABSCESS : SWELLING ALONG THE POSTERIOR BONY PART OF
THE EXTERNAL AUDITORY CANAL
• 4. ZYGOMATIC ABSCESS. ROOT OF ZYGOMA .
• 5. CITELLI'S ABSCESS ; NECK SWELLING OVER POSTERIOR BELLY OF
DIAGASTRIC MUSCLE.OVER OCCIPITAL BONE
• 6. MOURET'S ABSCESS; PARA PHARYNGEAL SPACE.
• TREATMENT OF MASTOID ABSCESS:
• I.V ANTIBOITIC
•
IS DRAINAGE OF ABSCESS + CORTICAL MASTOIDECTOMY.
•
IN INFANTS. DRAIN OF MASTOID ABSCESS ONLY.
Zygomatic abscess