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Complications of Suppurative Otitis Media

Complications of Suppurative Otitis Media. Dr. Vishal Sharma. Definition. Infection spreads beyond muco-periosteal lining of middle ear cleft to involve bone & neighboring structures like facial nerve, inner ear, dural venous sinuses, meninges, brain tissue & extra-temporal soft tissue.

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Complications of Suppurative Otitis Media

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  1. Complications of Suppurative Otitis Media Dr. Vishal Sharma

  2. Definition Infection spreadsbeyond muco-periosteal lining of middle ear cleftto involve bone & neighboring structures like facial nerve, inner ear, dural venous sinuses, meninges, brain tissue & extra-temporal soft tissue.

  3. Features of Complications • Severe otalgia, painful swelling around ear • Vertigo, nausea, vomiting • Headache + blurred vision + projectile vomiting • Fever + neck rigidity + irritability / drowsiness • Facial asymmetry • Otorrhoea + Retro-orbital pain + diplopia • Ataxia

  4. Classification • Intra-cranial • Extra-cranial, Intra-temporal • Extra-cranial, Extra-temporal • Systemic: septicemia, otogenic tetanus

  5. Classification

  6. Intra-cranial Complications • Extra-dural abscess • Subdural abscess • Meningitis • Brain abscess • Lateral Sinus thrombophlebitis • Otitic hydrocephalus • Brain fungus (fungus cerebri)

  7. Intra-temporal Complications • Acute mastoiditis • Coalescent mastoiditis • Masked mastoiditis • Facial nerve palsy • Labyrinthitis • Labyrinthine fistula • Apex Petrositis (Gradenigo syndrome)

  8. Extra-temporal Complications • Post-auricular abscess • Bezold abscess • Citelli abscess • Luc abscess • Zygomatic abscess • Retro-mastoid abscess

  9. Factors Affecting Pathogen FactorsPatient Factors  High virulence bacteria  Young age  Antimicrobial resistance  Poor immune status  Chronic disease (DM, TB) Physician Factors Poor socio-economic status  Non-availability Lack of health awareness  Injudicious antibiotic use  Error in recognizing dangerous symptoms & signs

  10. Routes of entry 1. Bony erosion (cholesteatoma destruction, osteitis) 2. Retrograde Thrombophlebitis 3. Anatomical pathway: oval window, round window, internal auditory canal, suture line, cochlear & vestibular aqueduct 4. Congenital bony defects: facial canal, tegmen plate 5. Acquired bony defects: fracture, neoplasm, stapedectomy 6. Peri-arteriolar space of Virchow-Robin: spread into brain

  11. Erosion of tegmen tympani

  12. Coalescent Mastoiditis or Surgical Mastoiditis

  13. Pathogenesis Aditus Blockage  Failure of drainage  Stasis of secretions  Hyperemic decalcification  Resorption of bony septa of air cells  Coalescence of small air cells to form cavity  Empyema of mastoid cavity

  14. Pathogenesis

  15. Clinical Features & Investigation • Otorrhoea > 2 weeks, otalgia & deafness • Mastoid reservoir sign: pus fills up on mopping • Sagging of postero-superior canal wall due to peri-osteitis of bony wall b/w antrum & posterior E.A.C. • Ironed out appearance of skin over mastoid due to thickened periosteum • Mastoid tenderness present • Mastoid cavity in X-ray & CT scan

  16. Mastoid reservoir sign

  17. Sagging of posterior wall

  18. Ironed out appearance

  19. Mastoid cavity

  20. Mastoid cavity

  21. Treatment • Urgent hospital admission • Broad spectrum I.V. antibiotics  No response to medical treatment in 48 hrs  Development of new complication  Presence of sub-periosteal abscess • Myringotomy to drain out painful pus • Incision drainage of sub-periosteal abscess • Cortical Mastoidectomy

  22. Sub-periosteal abscess & fistula

  23. Pathology Production of pus under tension  hyperaemic decalcification (halisteresis) + osteoclastic resorption of bone  sub-periosteal abscess  penetration of periosteum + skin  fistula formation

  24. Sub-periosteal abscess formation

  25. Sub-periosteal fistula: dry

  26. Sub-periosteal fistula: wet

  27. Types of sub-periosteal abscess • Post-auricular • Bezold • Citelli • Zygomatic • Luc • Retro-mastoid • Parapharyngeal & Retropharyngeal

  28. Types of sub-periosteal abscess

  29. Post-auricular abscess Commonest. Present behind the ear. Pinna pushed forward & downward.

  30. Bezold & Citelli abscesses Bezold: neck swelling over sternocleido- mastoid muscle Citelli:neck swelling over posterior belly of digastric muscle

  31. D/D of Bezold’s abscess • Suppurative lymphadenopathy of upper deep cervical lymph node • Para-pharyngeal abscess • Parotid tail abscess • Infected branchial cyst • Internal jugular vein thrombosis

  32. Luc: swelling in external auditory canal Zygomatic:swelling antero-superior to pinna + upper eyelid oedema Retro-mastoid: swelling over occipital bone (? Citelli’s abscess) Parapharyngeal & Retropharyngeal: due to spread of pus along Eustachian tube

  33. Retromastoid abscess

  34. Incision drainage of abscess

  35. Gradenigo syndrome  Persistent otorrhoea:despite adequate cortical mastoidectomy  Retro-orbital pain: Trigeminal nv involvement  Diplopia: convergent squint due to lateral rectus palsy by injury to abducent nv in Dorello’s canal under Gruber’s petro-sphenoid ligament, at petrous apex

  36. Persistent otorrhoea + Retro-orbital pain + Convergent squint

  37. Right Convergent squint Right gaze Central gaze Left gaze

  38. Etiology:Coalescent mastoiditis involving petrous apex along postero-superior & antero-inferior tracts in relation to bony labyrinth Diagnosis: 1. C.T. scan temporal bone for bony details. 2. M.R.I. to differ b/w bone marrow & pus Treatment:Modified radical mastoidectomy & clearance of petrous apex cells

  39. C.T. scan & M.R.I.

  40. Hearing preserving approaches to petrous apex • Eagleton’s middle cranial fossa approach • Frenckner’s subarcuate approach • Thornwaldt’s retro-labyrinthine approach • Dearmin & Farrior’s infra-labyrinthine approach • Farrior’s hypotympanic sub-cochlear approach • Lempert Ramadier’s peri-tubal approach • Kopetsky Almoor’s peri-tubal approach

  41. Hearing sacrificing approaches to petrous apex • Trans-cochlear approach • Trans-labyrinthine approach

  42. Spread of pus

  43. Labyrinthitis

  44. Introduction Inflammation of endosteal layer of bony labyrinth Route of infection:  Round window membrane  Pre-formed opening (Stapedectomy)  Retrograde spread of meningitis via IAC / aqueducts Clinical forms: 1. Circumscribed (labyrinthine fistula) 2. Diffuse serous 3. Diffuse suppurative

  45. Circumscribed: Fistula commonly involves lateral SCC. Presents with transient vertigo & positive fistula test  I/L nystagmus with +ve pressure; C/L nystagmus with -ve pressure • Serous: Reversible, non-purulent, mild vertigo, I/L nystagmus, mild sensori-neural hearing loss • Purulent: Irreversible, purulent, severe vertigo, C/L nystagmus, severe / profound hearing loss

  46. Treatment: Bed rest (affected ear up). Avoid head movement. Labyrinthine sedative:Prochlorperazine, Cinnarizine Broad spectrum I.V. antibiotics Modified Radical Mastoidectomy:removes infection Open labyrinthine fistula:cover with temporalis fascia Fistula covered with cholesteatoma matrix < 2 mm: remove matrix & cover with temporalis fascia > 2 mm / multiple / over promontory:leave it Rehabilitation by Cawthorne-Cooksey Exercises

  47. Lateral SSC Fistula

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