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Common Sites of Origin

  1. Posterior epitympanum
    (Prussack’s space) commonest
  2. Posterior mesotympanum
  3. Anterior epitympanum
    Retraction pocket (R.P)Exam Imicroscope required
  4. Features: Self- cleaning type: no treatment required
    1. Attic retraction pockets: Required to be observed to confirm whether stable
    2. Thin retracted segment: Excise and left to heal on its own
    3. R.P. without Cholesteatoma: Everted or excised and reinforced with tragal cartilage and
    4. Perichondrium or temporalis fascia

Complications of C.S.O.M.

  1.  Within the cranial cavity:
    1. Extradural abscess                  
    2. Subdural abscess
    3. Brain abscess                         
    4. Meningitis
    5. Otitic hydrocephalus              
    6. Lateral sinus thrombophlebitis
  2. Within the temporal bone:
    1. Facial paralysis                      
    2. Labyrinthitis
    3. Mastoiditis                            
    4. Petrositis

 Features indicating a complication

  1. Pain                                       
  2. Vertigo
  3. Headache (persistent)            
  4. Facial weakness
  5. Restlessness esp children        
  6. Fever/ nausea/ vomiting
  7. Meningismus                          
  8. Diplopia
  9. Ataxia                                   
  10. Abscess (mastoid)

Pathway of spread of infection to intracranial compartment

  1. Direct bone erosion              
  2. Venous thrombophlebitis
  3. Performed paths
  1. Extradural Abscess:
    Abscess between the skull bone and the dura mater.
    1. Pott’s Puffy Tumor:
      1. Erosion through the skull to the exterior leading to subperiosteal abscess
      2. Seen in both ASOM and CSOM
    2. Symptoms: (mostly asymptomatic)
      1. (Spontaneous) Headache broadly spread on the side of the affected ear. Relieved with free flow of pus
      2. Ear-ache (severe when +)
      3. Low -grade fever with general malaise
    3. Signs:
      1. Pulsatile discharge (purulent)
      2. May have features suggestive of Gradenigo’s syndrome
    4. Treatment:
      1. Surgery - cortical in ASOM in cases / MRM à in CSOM cases
      2. Antibiotics
  2. Subdural Abscess
Accumulation of pus between the dura and the arachnoid
  1. Non-hemolytic streptococci
  2. Anaerobic streptococcus milleri
Rate of development of symptoms is over hours and not in days à Rapid development

Symptoms: Due to
  1. Meningeal irritation
    1. Fever
    2. Headache
    3. Neck rigidity
    4. Drowsiness
  2. Cortical venous thrombophlebitis
    1. Hemiplegia
    2. Hemianopia
    3. Hemianesthesia
    4. Epileptic fits (Jacksonian type)
    5. Aphasia (Dominant hemisphere)
​​Raised ICT
  1. Papilledema
  2. Ptosis
  3. Dilated pupil
  1. CECT/MRI (CECT is diagnostic)
  2. CSF- CSF pressure, sugar (N), culture sterile
  1. Systemic antibiotic
  2. Surgical intervention (with neurosurgeon) à mainstay of treatment (craniotomy and  abscess excision)
  3. Antiepileptics for months​
Lateral Sinus Thrombophlebitis:
Inflammation of the inner wall of the lateral venous sinus 2° to CSOM or acute mastoiditis (ASOM)
  1. Stages:
    1. Perisinus abscess
    2. Endophlebitis mural thrombus
    3. Obliteration of mural and intrasinus abscess
    4. Extension of thrombosis
  2. Organism:
    1. β - hemolytic streptococcus
    2. Staphylococcus
    3. Pseudomonas pyocyaneus
    4. B proteus
    5. E.coli
    6. Staphylococcus
  3. Spread of the infective emboli
    1. Torcular Herophili: Superior
    2. Confluence of sagittal sinus
    3. Straight sinus
    4. Superior sagittal
    5. Occipital sinus
    6. Superior and inferior petrosal sinus: Cavernous sinus
    7. Internal jugular vein: Subclavian vein
    8. Mastoid emissary vein
  4. Clinical features  Symptoms:
    1. ​​Fever:
      1. Picket fence type/ Hectic fever/due to septic emboli in blood
      2. High grade
      3. Irregular in nature à like malaria but lacks regularity
      4. With sweats
    2. Headache:
      Initially due to perisinus abscess. Later due to increased intracranial tension-
    3. Proptosis and Chemosis and decreased vision: If cavernous sinus involvement
    4. Progressive anaemia and emaciation
    5. Otalgia
    6. Neck pain with mastoid tenderness
    7. Drowsy, lethargic and comatosed
  5. Signs:
    1. Pallor: due to the hemolytic nature of the infected organism
    2. Tenderness over the mastoid and along the stemocleidomastoid (along IJV)
    3. Griesinger’s sign: Pitting oedema over the occipital region (due to mastoid emissary vein thrombosis)
    4. Cerebellar signs
    5. Tobey-Ayer test/Queckenstedt test:
      1. ​Tests the change in the C.S.F following compression of either jugular veins
      2. (N) compression of the I-J.V. causes an increase of 50-100 mm Hg-
      3. Compression of the I.J.V. on the affected side causes either no increase or a 10-20 mm Hg­
      4. Compression on the non-affected side causes an increase of two-three times the normal.
  6. Crowe-Beck Test:  Pressure on jugular vein of the healthy side produces engorgement of the retinal and supraorbital veins.
  7. Delta sign --> Increase Radiological Sign.
  1. Blood culture P. Smear → to exclude malaria
  2. CSF examination:- WBC count: ↑endolymphatic in ASOM ↓endolymphatic in CSOM pressure
  3. CECT:  Delta sign: Enhancement of the sinus walls but not contents
  4. MRI with Gd enhancement
  1. IV antibiotics & strict vitals chart (Penicillin/blood)
  2. Surgery as early as possible not wait
  3. If with ASOM  Cortical mastoidectomy and evacuation of the thrombus
  4. With CSOM  Modified radical mastoidectomy with evacuation of the thrombus.
  5. Anticoagulant therapy
  6. If thrombus extending into the cavernous sinus-
  7. IJV ligation if emboli continue despite surg + med t/t
  8. Blood transfusion may be required
  1. Inflammation of the leptomeninges (Pia and the arachnoid)
  2. Features: - Meningitis in children - A.S.O.M. (but not-exclusively)
  3. Adult-Unsafe C.S.O.M.
  4. Associated with other otogenic complications in 30% of cases
  5. Symptoms
    1. Fever (102-104o F) often with chills & rigors
    2. Headache
    3. Neck stiffness
    4. Photophobia: Constant characteristic symptoms
    5. Mental hyperactivity/irritability
    6. Feature of increased intracranial tension
    7. Drowsiness
  6. Signs
    1. Neck stiffness
    2. Kernig’s signs
    3. Brudzinski sign
    4. Tendon reflexes becomes less marked
    5. Abdominal reflexes becomes less marked
    6. Cranial nerve palsies
    7. Cheyne - stokes respiration follows fixed dilated pupils - coma - death
  7. Investigation
    1. CSF picture: protein: ↑↑(N)=150-400mg/l)
    2. Chloride-↓= 80mm d/l(N)= 120 mmol/l)
    3. Glucose ↓= Falls to zero((N)=1.7- 3.0 mmol/1)
      i.        WBC = ↑↑↑
    4. P.S. There is no other condition in which CSF sugar falls to zero and WBC markedly↑
    5. C-T. scan: may be (N) (±) done: 1/3 rd will pick up associated complications
    6. MRI : Exudate and adhesions in basal cisterns.
      High signal intensity–T2 weighted images
  8. Treatment
    1. Medical Management
      1. Treat meningitis before treating the ear surgically
      2. I.V. antibiotics to be given and to be continued for at least 10 days after apparent clinical cure.
    2. Surgical Treatment​
Otogenic Brain Abscess
Temporal lobe abscess: Cerebellar abscess = 2:1
Children: 25% of brain abscess is otogenic
Adults: 50% of brain abscess is otogenic
Spread to the cerebellum
Subsequent to lateral sinus thrombosis
Through the Trautmann’s triangle - associated with extradural/subdural sinus or perisinus/abscess/IST/labyrinth initis.
  1. Trautmann’s triangle is bounded by the bony labyrinth anteriorly, sigmoid sinus posteriorly and the dura or supe­rior petrosal sinus superiorly.       
Stages of brain abscess
  1. Stage of Invasion                                                                  
  2. Stage of Localization                    
  3. Stage of    Enlargement                                                                                                   
  4. Stage of Termination
  1. Organisms:
    1. Commonest: Anaerobic streptococci
    2. Other: Strep. Pneumoniae
    3. Gram Negative Organisms-
      1. Proteus mirabilis
      2. E. Coli
      3. Ps. Aeruginosa
  2. ​​Features:
    1. Temporal lobe abscess
      1. Aphasia
      2. Quadrantic hemianopia
    2. Cerebellar abscess
      1. Cerebellar Vermis (Maintains body posture)
      2. Truncal ataxia
      3. Wide–based gait
  3. Cerebellar Cortex : Synchronized movements
    1. ​Dyssynergia
    2. Dysmetria
    3. Dysdiadochokinesis
    4. Dysarthria
    5. Intention tremors
  4. Investigation
    1. CSF=
      1. - Pressure↑
      2. - Glucose: (N)
      3. - WBC:↑↑
      4. - Protein:↑
    2. ​CECT
    3. MRI
  5. Treatment
    Medical Treatment
    1. High dose antibiotics for 3-4 wks followed by radical mastoidectomy 10-14 days later.
    2. Lower ICT: Dexamethasone 4mg iv 6 hourly
      20% mannitol: 0.5 mg/kg
    3. Antiepileptics: 70% of cases in temporal lobe abscess
    4. Neurosurgical:
      1. ​Repeated needle aspiration through the burr holes preferred, Followed by surgery for the ear in mastoidectomy MRM)
      2. Excise the abscess as whole
      3. Open incision and drainage​

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