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Introduction
Sequelae: The resultant disability caused by the disease and its healing.
Complication: When the active disease process spreads or breaks out to involve the surrounding or distant areas or organ systems
Definitions
Definition
In CSOM a complication is said to exist if the disease goes beyond the mucoperiosteum of the middle ear cleft
Anterior 2. Posteriorly: Sigmoid Sinus Cerebellum Posterior 3. Anteriorly: Carotid siphon Petrous Apex Inner Ear Jugular Bulb Neck deep spaces Ext Auditory Canal
Lateral
4. Medially: 5. Inferiorly:
Inferior
6. Laterally:
Complications
Complications
1.Intracranial 1. Intracranial
OR
2.Extracranial a)Intratemporal 3. Extratemporal 2. Intratemporal
b)Extratemporal
Routes of Spread
1. Direct Route
a) b) c) d) Direct extension by spreading osteitis Through an old # line Through pre existing pathways: labyrinth Surgically created pathways
2. Through thrombophlebitis emissary veins & venous drainage 3. Haematogenous spread through the Spaces of Virchow
Intracranial complications
Intracranial Complications
1. 2. 3. 4. Meningitis Lateral sinus thrombosis Otitic hydrocephalus Intracranial abscess
a)
b) c)
Extradural
Subdural Parenchymal
Cerebral (Temporal lobe) Cerebellum
In General
Certain features are common to all: Common Symptoms are because of a) Spread of Infection b) Increased Intracranial pressure
In General
Suspicious Symptoms
1. 2. 3. 4. 5. 6. Persistent headache Lethargy Irritability Severe otalgia Persistent or intermittent fever Nausea and vomiting
In General
Definitive
1. 2. 3. 4. 5. Decreased mental status Stiff neck Ataxia Visual changes Seizures
In General
Principles of management: 1. Neurological takes priority 2. Investigations & go hand in hand 3. Broad spectrum Abs (blood brain barrier) 4. Supportive measures 5. Neurological Intervention if required
Meningitis
Meningitis - most common IC complication of CSOM Can be due to ASOM or CSOM 12% to 91% of all I/C complications More common in younger age group (12-20 yrs) Commonly associated with other I/C Complications Due to spread by all 3 routes Mortality rate reported a) ASOM 8% b) CSOM - 31%
Meningitis
Symptoms & Signs
Severe and generalized headache Headache may radiate to the spine and lower limbs. The patient tends to lie quiet and immobile. Photophobia and general hyperesthesia occur. Vomiting is common. Nuchal rigidity. (most important sign of meningitis). Kernigs sign Brudzinskis sign Late papilloedema
Meningitis
Investigations
TLC, DLC
Leucocytosis
Meningitis
Management 1) Initial stabilization 2) Radiologic evaluation for other intracranial complications 3) LP to obtain CSF for analysis and culture 4) initiation of broad-spectrum antibiotics.
4. Otalgia
7.
8. 9.
Anemia
Leukocytosis Elevated erythrocyte sedimentation rate
Management
Prompt surgical intervention: - Cortical Mastoidectomy (? MRM) - Complete exposure of sigmoid sinus - Aspiration of sinus till blood comes - If pus aspirated, evacuate & obliterate sinus
Brain Abscess
A brain abscess progresses through three clinical stages: 1. Initial encephalitis, 2. Latent or quiescent stage, 3. Manifest or expanding abscess.
Symptoms & Signs varies as the stages
MRI
Suboccipital headache Vomiting Ataxia Spontaneous and gaze nystagmus Past pointing Intention tremor
Dysdiadochokinesis
Weakness and incoordination of ipsilateral muscles
EXTRAcranial complications
Intratemporal Complications
1.Mastoiditis 2. Petrous apicitis 3. Labyrinthitis a. Serous b. Suppurative 4. Labyrinthine fistula 5. Facial paralysis
Petrositis
-Petrositis is an extension of the inflammation of the middle ear or mastoid cavity into the pneumatized cells of the petrous apex. -The petrous apex has no drainage system and spontaneous drainage of an abscess cannot occur -Petrositis has a greater tendency toward intracranial extension - Near petrous apex are 3, 5, & 6 CN
Petrositis
CT Scan
Petrositis
Gradenigo first described the triad of symptoms Classically, these are - Retro-orbital pain (from CN V irritation) - Otorrhea - Diplopia (CN VI paralysis). Others: - Fever - Sensorineural hearing loss, - Transient facial paresis, - Vertigo
Petrositis
Management: 1. ABs 2. Cortical Mastoidectomy along with petrous apex clearance 3. Adequate drainage of the petrous cells are to be ensured
AC COALESCENT MASTOIDITIS Mastoid Air cells are a part of the middle ear cleft Invariably involved in all cases of ASOM/CSOM However, Coalescent mastoiditis occurs in only few
AC COALESCENT MASTOIDITIS Blockage of Aditus due to inflammed mucosa Drainage blocked Pressure erosion of the bony septae One large pus filled cavity
AC COALESCENT MASTOIDITIS
Suggestive -Otorrhea persisting more than 2 weeks -Persistent otalgia -Edema over the mastoid tip
- Sagging of the posterosuperior external auditory canal wall - Loss of bony air cell septations on computed tomography
AC COALESCENT MASTOIDITIS
AC COALESCENT MASTOIDITIS Management: 1. ABs 2. Myringotomy for initial drainage 3. Cortical Mastoidectomy & drainage if:
Pus discharge persists more than 2 wks pain, edema over the mastoid tip Sagging of posterior canal wall partitions Signs or symptoms of threatened or definite complication
Extratemporal complications
Subperiosteal abscesses a. Mastoid (postauricular) b. Zygomatic c. Bezolds
Post auricular abscess When the infection erodes the outer cortex of the mastoid tip, a subperiosteal abscess results. Most common 1. The auricle is displaced anteriorly and inferiorly 2. The postauricular crease is obliterated 3. Skin over the mastoid process is fluctuant and erythematous.
CT Scan
Management: 1. ABs 2. Immediate drainage of postauricular abscess with drain left for 48 hrs 3. Cortical Mastoidectomy subsequently
Bezolds Abscess
Perforation on the medial aspect of the mastoid tip into the digastric groove produces a deep abscess of the neck known as Bezolds abscess
Bezolds Abscess Presents as a soft fluctuant swelling at the ant. edge of Sternocleidomastoid
CT Scan
Zygomatic Abscess
Subperiosteal abscess at the root of the zygoma. It presents as a swelling above and in front of the ear Upper half of the auricle is displaced laterally At times there can be extension into the mandibular fossa displacing the mandible towards the normal side. Trismus is present has been and teeth no longer meet in occlusion.33
Zygomatic Abscess
Zygomatic Abscess
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