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Complications

ofChronicOtitisMediaChunfuDai1Complications

ofChronicOtitThreecategories

onananatomicbasisExtratemporalextracranialBezoldabscessSubperiostealabscessIntratemporalMastoiditis,labyrinthitis,sensorineuralhearingloss,petrositisFacialparalysis,cholesteatoma,labyrinthinefistulaIntracranialEpiduralabscess,lateralsinusthrombosis,otitichydrocephalus,meningitis,brainabscess,subduralabscess2Threecategories

onananatomCausesHyper-functionofimmunesystemInfant,olderStrongbacteriaDamagedstructurescholesteatomaUnreasonableinterventionsDrugresistant,Poordrainage3CausesHyper-functionofimmunTransmissioncoursePathwaysofspreadDirectextensionofinfectiontostructure(boneerosion)Hemogenousroutine(microbiologicanhostfactors)Bacteriagainaccesstointracranialthroughunsealedgap,innerear4TransmissioncoursePathwayso55BezoldabscessDefinition:ErosionthetipofthemastoidboneInfectsthesofttissueoftheneck,DeeptothesternocleidomastoidmuscleDiagnosisEarinfectionMassintheneckFever,neckstiff,otorrheaCTscan6BezoldabscessDefinition:6BezoldabscessTreatmentAntibioticAbscesscavityshouldbeevacuatedAnexternaldrainageshouldbeplacedMastoidectomyAntrumdrainagerequired,viaepitympanumtothemiddleear7BezoldabscessTreatment7SupperiostealabscessDefinition:Boneerosion,viaosteitisornecrosis,leadstoadehiscenceintothepostauricularsofttissue.DiagnosisFever,painandotorrheaFollowedbyappearanceofthepostauricularmass,displacingtheauricleanteriorlyCTscan8SupperiostealabscessDefinitiSupperiostealabscessManagementsAntibioticDrainage,usingpostauriclarincisionAfterachievingeffectivedrainageofthemastoidinfection,thesiteofsuppurationcanbeaddressedNecrotictissuesrequiredebridement9SupperiostealabscessManagemeLabyrinthitisClassificationsCirvumscribedlabyrinthitis(fistulaoflabyrinth)CommunicationofmiddleearwithperilymphaticspaceSerouslabyrinthitisToxin,inflammatorymediaSuppurativelabyrinthitisBacteria10LabyrinthitisClassificationsFistulaoflabyrinthIncludingboneerosion,exposureoftheendostealmembraneandatruefistulaintothefluidcompartmentoftheinnerear.Itoccursin5-10%ofcaseswithcholesteatomaLateralsemicircularcanalisthemostcommonlocation(90%)MechanismofboneerosionOsteolysisresorptiveosteitis11FistulaoflabyrinthIncludingFistulaoflabyrinthDiagnosisVertigo(intermittentorconstant)HearinglossFistulatest(only50%ofpatientsarepositive)CTscanmaydemonstrateevidenceoffistula,however,smallfistulacanbeoverlooked12FistulaoflabyrinthDiagnosis1FistulaoflabyrinthManagementsSurgicalinverventionmastoidectomyRemovalcholesteatomamatrixattheprimaryoperation,fistulaclosedwithtemporalfasciaLeavingcholesteatomamatrixundisturbed.9-12monthslater,secondoperationisperformed.antibiotic13FistulaoflabyrinthManagementSerouslabyrinthitisOccursfrominflammation,ratherthaninfectionCausedbybacterialtoxins,inflammtorymediatorsInflammatorycellsratherthanbacteriaarefoundinthelabyrintinefluidsVertigo,sensorineuralhearingloss14SerouslabyrinthitisOccursfroSuppurativelabyrinthitisBacteriainfiltratesthefluidspaceofinnerearVestibularsymptomsAcutephaseofinflammation:Vertigo,nauseaThephaseofcentralcompensation:imbalanceorunsteadinessRecoveryphase:severeperturbation,patientsexperiencesabriefsensationofvertigo.15SuppurativelabyrinthitisBacteSuppurativelabyrinthitisSymptomsassociatedwithcochleaPermanentsensorineuralhearinglossTinnitus16SuppurativelabyrinthitisSymptSuppurativelabyrinthitisInterventionsAntibioticAddresstheproblemoftheunderlyingCOMandcholesteatomaElectrolyte(duetovomiting)PreventionEarlyandeffectivetreatmentoftheCOMandcholesteatoma17SuppurativelabyrinthitisInterPetrousapicitisThemostmedialandanteriorportionofthetemporalbone30%oftemporalboneswithpneumatizationofthepetrousapexProximitytotheposteriorandmiddlecranialfossae18PetrousapicitisThemostmediaPetrousapicitisClassictriad(Gradenigo’ssyndrome)Deepearandretroorbitalpain(irritationofthetrigeminalnerve)AuraldischargeIpsilateralabducentsnervepalsy19PetrousapicitisClassictriadPetrousapicitisManagementsAntimicrobialsdirectedagainstthemostlikelypathogens.Ifhearingpresentintheaffectedear,oticcapsuleshouldbepreservedwhileeffectivedrainageachievedretrolabyrinthine,infralabyrinthine,infracochlearapproachscangainaccesstothepetrousapex20PetrousapicitisManagements20PetrousapicitisManagementsTheaffectedearisdeadear,translabyrinthineortranscochlearapproachesaffordgreateraccesstothepetrousapex21PetrousapicitisManagements21IntracranialcomplicationsOverviewItislessfrequently,duetoImprovedaccesstomedicalcareandmedicationBroadspectrumantibioticPathwaysofspreadDirectextensionofinfectiontointracranialstructure(boneerosion)Hemogenousroutine(microbiologicanhostfactors)Bacteriagainaccesstointracranialthroughunsealedgap,innerear22IntracranialcomplicationsOverEpiduralabscessEpidualspaceisapotentialspacebetweentheperiosteumandouterdurallayer,thetoughduraoftenwilllimitthespreadofinfection.diagnosisNospecificsymptomsandsignstoanepiduralabscess,PulsativeoticdischargeHeadache(associatedwiththesizeofabscess)CTrevealsboneerosion,abscessMRIcandetectduralthickeningandinflammation23EpiduralabscessEpidualspaceEpiduralabscessManagementsSurgicalexplorationanddrainageBoneoverlyingthetemgentympani,sigmoidsinus,andposteriorfossaduramustbethinned,epiduralspaceshouldbevisualized,noninflamedduraisencountered.MedicaltreatmentAntibiotic24EpiduralabscessManagements24SigmoidsinusthrombosisPathwayDirectextensionofmastoidinfectionRetrogradethrombosisAntergradethrombosis.25SigmoidsinusthrombosisPathwaSigmoidsinusthrombosisDiagnosisClinicalpresentation:high,spikingfevers,Headache,IntracraninalhighpressureactiveeardiseaseAcutephaseofthrombosis,absenceofflowsignalinMRvenographyimages26SigmoidsinusthrombosisDiagnoSigmoidsinusthrombosisManagementsSurgicalexplorationMastoidectomytoexposethesigmoidsinusAneedlemaybeusedtoaspiratethesinus,iffree-flowingbloodreturns,thennoadditionalsurgeryisneeded.Ifnobloodreturns,thenopenanddrainingthesinusareindicated.Inthefaceofongoingsepticpulmonaryemboli,internaljugularveinligationcanbeperformed.27SigmoidsinusthrombosisManageSigmoidsinusthrombosisManagementsMedicaltreatmentAntibioticsAnticoagulation(inindividualcases,inthefaceofpropagatingthrombosis)28SigmoidsinusthrombosisManageMeningitisAmongintracranialcomplicationsofCOM,meningitisisoneofthemostcommon,itaccountfor50%oftheintracranialcomplications.InCOM,bacterialcontaminationmayoccurviaboneerosionwithepiduralabscess/granulationformationorretrogradethrombophlebitisofemissaryveins.29MeningitisAmongintracranialMeningitisDiagnosisSymptomsofCOMHighfever,headache,vomitingNeckstiffnessandalteredmentalstatusCTorMRIwilldocumentmeningealenhancementLumbarpunctureandexaminationoftheCSFismandatory(CFSleukocytosisandlowglucose,elevatedlevelofproteinandlactate,bacteriaculturepresentpositive)30MeningitisDiagnosis30MeningitisManagementsUrgentantibiotic(cultureandsensitivityreportsfromtheCSFsamplescanfurtherdirectantibiotictherapyAdjunctivetherapy(dexamethasonecanreducetheneurologicandauditorysquelaeofbacterialmeningitisReducethehighintracranialpressureMastoidectomy(removallesionandachievementofdrainage)31MeningitisManagements31Brainabscess62%ofabscesseswerelocatedinthetemporalobeand34%inthecerebellumDirectextensionalongpreformedpathwaysorperivascularchannelsismorelikelyrouteofinfection.Thethinboneoftegmenmaybemoreeasilyviolatedthantheboneoverlyingtheposteriorfossadura,giventheincreasedfrequencyoftemporallobeversuscerebellarabscess.32Brainabscess62%ofabscessesBrainabscessphasesInitialphase:localizedmicrofociandcerebritisorencephalitisSecondphase:expansionandsecondarydelineationoftheabscessFinalphase:adensefibroglialscar(capsule)orrupture.33Brainabscessphases33BrainabscessDiagnosisFever,headacheandvomiting.SymptomsandsignsarederivedfromthelocationandsizeofabscessMRImaybemoresensitiveindefiningareaofcerebritis34BrainabscessDiagnosis34BrainabscessTemporalabscessContralateralbodyparalysisFacialparalysis(central)MutismCerebellarabscessCentralnystagmusReductionofmuscletensionAtaxiaDysfunctionofdistanceperception35BrainabscessTemporalabscess3BrainabscessTreatmentsAntibiotic(penetrationoftheblood-brainbarriershouldbeconsidered)Steroidisadministeredtoreducebrainswelling,dehydrationagentwillreduceintracranialpressure.SurgicaldrainageandexcisionofabscessrequiredOtologicsurgerydependsonthepatient’sclinicalstability36BrainabscessTreatments363737Complications

ofChronicOtitisMediaChunfuDai38Complications

ofChronicOtitThreecategories

onananatomicbasisExtratemporalextracranialBezoldabscessSubperiostealabscessIntratemporalMastoiditis,labyrinthitis,sensorineuralhearingloss,petrositisFacialparalysis,cholesteatoma,labyrinthinefistulaIntracranialEpiduralabscess,lateralsinusthrombosis,otitichydrocephalus,meningitis,brainabscess,subduralabscess39Threecategories

onananatomCausesHyper-functionofimmunesystemInfant,olderStrongbacteriaDamagedstructurescholesteatomaUnreasonableinterventionsDrugresistant,Poordrainage40CausesHyper-functionofimmunTransmissioncoursePathwaysofspreadDirectextensionofinfectiontostructure(boneerosion)Hemogenousroutine(microbiologicanhostfactors)Bacteriagainaccesstointracranialthroughunsealedgap,innerear41TransmissioncoursePathwayso425BezoldabscessDefinition:ErosionthetipofthemastoidboneInfectsthesofttissueoftheneck,DeeptothesternocleidomastoidmuscleDiagnosisEarinfectionMassintheneckFever,neckstiff,otorrheaCTscan43BezoldabscessDefinition:6BezoldabscessTreatmentAntibioticAbscesscavityshouldbeevacuatedAnexternaldrainageshouldbeplacedMastoidectomyAntrumdrainagerequired,viaepitympanumtothemiddleear44BezoldabscessTreatment7SupperiostealabscessDefinition:Boneerosion,viaosteitisornecrosis,leadstoadehiscenceintothepostauricularsofttissue.DiagnosisFever,painandotorrheaFollowedbyappearanceofthepostauricularmass,displacingtheauricleanteriorlyCTscan45SupperiostealabscessDefinitiSupperiostealabscessManagementsAntibioticDrainage,usingpostauriclarincisionAfterachievingeffectivedrainageofthemastoidinfection,thesiteofsuppurationcanbeaddressedNecrotictissuesrequiredebridement46SupperiostealabscessManagemeLabyrinthitisClassificationsCirvumscribedlabyrinthitis(fistulaoflabyrinth)CommunicationofmiddleearwithperilymphaticspaceSerouslabyrinthitisToxin,inflammatorymediaSuppurativelabyrinthitisBacteria47LabyrinthitisClassificationsFistulaoflabyrinthIncludingboneerosion,exposureoftheendostealmembraneandatruefistulaintothefluidcompartmentoftheinnerear.Itoccursin5-10%ofcaseswithcholesteatomaLateralsemicircularcanalisthemostcommonlocation(90%)MechanismofboneerosionOsteolysisresorptiveosteitis48FistulaoflabyrinthIncludingFistulaoflabyrinthDiagnosisVertigo(intermittentorconstant)HearinglossFistulatest(only50%ofpatientsarepositive)CTscanmaydemonstrateevidenceoffistula,however,smallfistulacanbeoverlooked49FistulaoflabyrinthDiagnosis1FistulaoflabyrinthManagementsSurgicalinverventionmastoidectomyRemovalcholesteatomamatrixattheprimaryoperation,fistulaclosedwithtemporalfasciaLeavingcholesteatomamatrixundisturbed.9-12monthslater,secondoperationisperformed.antibiotic50FistulaoflabyrinthManagementSerouslabyrinthitisOccursfrominflammation,ratherthaninfectionCausedbybacterialtoxins,inflammtorymediatorsInflammatorycellsratherthanbacteriaarefoundinthelabyrintinefluidsVertigo,sensorineuralhearingloss51SerouslabyrinthitisOccursfroSuppurativelabyrinthitisBacteriainfiltratesthefluidspaceofinnerearVestibularsymptomsAcutephaseofinflammation:Vertigo,nauseaThephaseofcentralcompensation:imbalanceorunsteadinessRecoveryphase:severeperturbation,patientsexperiencesabriefsensationofvertigo.52SuppurativelabyrinthitisBacteSuppurativelabyrinthitisSymptomsassociatedwithcochleaPermanentsensorineuralhearinglossTinnitus53SuppurativelabyrinthitisSymptSuppurativelabyrinthitisInterventionsAntibioticAddresstheproblemoftheunderlyingCOMandcholesteatomaElectrolyte(duetovomiting)PreventionEarlyandeffectivetreatmentoftheCOMandcholesteatoma54SuppurativelabyrinthitisInterPetrousapicitisThemostmedialandanteriorportionofthetemporalbone30%oftemporalboneswithpneumatizationofthepetrousapexProximitytotheposteriorandmiddlecranialfossae55PetrousapicitisThemostmediaPetrousapicitisClassictriad(Gradenigo’ssyndrome)Deepearandretroorbitalpain(irritationofthetrigeminalnerve)AuraldischargeIpsilateralabducentsnervepalsy56PetrousapicitisClassictriadPetrousapicitisManagementsAntimicrobialsdirectedagainstthemostlikelypathogens.Ifhearingpresentintheaffectedear,oticcapsuleshouldbepreservedwhileeffectivedrainageachievedretrolabyrinthine,infralabyrinthine,infracochlearapproachscangainaccesstothepetrousapex57PetrousapicitisManagements20PetrousapicitisManagementsTheaffectedearisdeadear,translabyrinthineortranscochlearapproachesaffordgreateraccesstothepetrousapex58PetrousapicitisManagements21IntracranialcomplicationsOverviewItislessfrequently,duetoImprovedaccesstomedicalcareandmedicationBroadspectrumantibioticPathwaysofspreadDirectextensionofinfectiontointracranialstructure(boneerosion)Hemogenousroutine(microbiologicanhostfactors)Bacteriagainaccesstointracranialthroughunsealedgap,innerear59IntracranialcomplicationsOverEpiduralabscessEpidualspaceisapotentialspacebetweentheperiosteumandouterdurallayer,thetoughduraoftenwilllimitthespreadofinfection.diagnosisNospecificsymptomsandsignstoanepiduralabscess,PulsativeoticdischargeHeadache(associatedwiththesizeofabscess)CTrevealsboneerosion,abscessMRIcandetectduralthickeningandinflammation60EpiduralabscessEpidualspaceEpiduralabscessManagementsSurgicalexplorationanddrainageBoneoverlyingthetemgentympani,sigmoidsinus,andposteriorfossaduramustbethinned,epiduralspaceshouldbevisualized,noninflamedduraisencountered.MedicaltreatmentAntibiotic61EpiduralabscessManagements24SigmoidsinusthrombosisPathwayDirectextensionofmastoidinfectionRetrogradethrombosisAntergradethrombosis.62SigmoidsinusthrombosisPathwaSigmoidsinusthrombosisDiagnosisClinicalpresentation:high,spikingfevers,Headache,IntracraninalhighpressureactiveeardiseaseAcutephaseofthrombosis,absenceofflowsignalinMRvenographyimages63SigmoidsinusthrombosisDiagnoSigmoidsinusthrombosisManagementsSurgicalexplorationMastoidectomytoexposethesigmoidsinusAneedlemaybeusedtoaspiratethesinus,iffree-flowingbloodreturns,thennoadditionalsurgeryisneeded.Ifnobloodreturns,thenopenanddrainingthesinusareindicated.Inthefaceofongoingsepticpulmonaryemboli,internaljugularveinligationcanbeperformed.64SigmoidsinusthrombosisManageSigmoidsinusthrombosisManagementsMedicaltreatmentAntibioticsAnticoagulation(inindividualcases,inthefaceofpropagatingthrombosis)65SigmoidsinusthrombosisManageMeningitisAmongintracranialcomplicationsofCOM,meningitisisoneofthemostcommon,itaccountfor50%oftheintracranialcomplications.InCOM,bacterialcontaminationmayoccurviaboneerosionwithepiduralabscess/granulationformationorretrogradethrombophlebitisofemissaryveins.66MeningitisAmongintracranialMeningitisDiagnosisSymptomsofCOMHighfever,headache,vomitingNeckstiffnessandalteredmentalstatusCTorMRIwilldocumentmeningealenhancementLumbarpunctureandexaminationoftheCSFismandatory(CFSleukocytosisan

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