Prof. Dr. Mohamed Talaat EL.

Ghonemy
1- Cranial complications ;
- Mastoiditis - Petrositis
- Labyrinthitis - Facial nerve paralysis
2- Intracranial Complications ;
- Extradural abscess - Meningitis
- Lateral sinus thrombosis - Brain abscess
3- Extracranial Complications ;
- Otitis Externa - Jugular vein thrombosis
- Bezold’s abscess - Retropharyngeal abscess
1- Direct spread through bone .
2- Retrograde thrombophlebitis.
3- Labyrinth ; via round or oval
window .
4- preformed pathway.
- Congenital dehiscences
(facial nerve, tegmen tympani).
- Fracture lines.
- Surgical trauma.
- Un-united cranial sutures .
Pathology ;
-Osteitis of the bony walls of the
mastoid air cells and formation of an
abscess cavity.
-Pus erodes the mastoid cortex
forming a subperiosteal abscess
causing a fluctuant swelling usually in
the postauricular area (mastoid abscess).
-The abscess may burst through the
skin leading to formation of a mastoid
fistula.
Symptoms ;
- Fever and pain, deafness, recurring middle ear discharge.
- A swelling appears behind the ear.
Signs ;
1- Swelling &Tenderness over the
mastoid .

2- Positive reservoir sign :

discharge is profuse
mucopurulent and recurs after
removal from the external canal.

3- Sagging of the posterosuperior

meatal wall(area related to the
mastoid antrum) .
4- Congested or perforated T.M.
5- Conductive deafness(due to
necrosis of ossicles) .
6-Swelling over the mastoid:
forming a postauricular
abscess pushing the auricle
forwards, downwards and
outwards which may extend
to form a zygomatic abscess
infront of the auricle, Citelli's
(in the digastric triangle) or a
Bezold's (in the neck deep to
sternomastoid muscle).
Subperiosteal abscess Mastoid fistula
Treatment ;
1- Antibiotic & Analgesic.
2- Cortical mastoidectomy if no improvement
after 48 hours .
 Differential diagnosis ;
1- Postauricular Lymphadenitis due to external otitis.
2- Furunculosis of the E.A.C.
Furunculosis Acute mastoiditis
History Of ear scratch Of otitis media
Pain On mastication No pain on mastication
Deafness If canal is obstructed Marked deafness
Tenderness Over the tragus Over the mastoid
Posterior Swelling Obliterates postauricular groove Increases postauricular groove

Edema of meatus In outer cartilagenous part Sagging of skin of posterosuperior

bony meatal wall
Discharge Purulent, scanty, never mucoid Mucopurulent or purulent, perfuse
with +ve reservoir sign.
Drum Normal Congested or perforated
Organisms Staphylococci Streptococcus
CT scan Normal outlining of mastoid cells Haziness of the mastoid cells outline
Petrositis (Petrous apicitis)
Clinical picture:
(Gradenigo's syndrome)
a triad of:
-Deep temporal and retro-orbital
pain due to irritation of the 5th
nerve.
-Diplopia due to paralysis of the
6th nerve.
-Discharge from the diseased
ear.
Treatment:
-Antibiotics.
-Mastoidectomy and drainage of the cells in the petrous apex of
the temporal bone.
Pathology ;
-Localised labyrinthitis: Fistula of the lateral
semicircular canal in the middle ear due to erosion
by cholesteatoma.
-Serous labyrinthitis: is due to early inflammation in
the labyrinth.
-Suppurative labyrinthitis: The labyrinth becomes
infected.
-Dead labyrinth: Destruction of sensory cells
following suppuration.
During the course of otitis media, the patient
complains of intermittent attacks of vertigo, nausea
and vomiting which is accompanied by deafness and
tinnitus. Pressure changes in external auditory canal
produce vertigo and nystagmus (positive fistula
sign). The symptoms become worse disabling the
movement of the patient. The patient falls to the
opposite side. With progression of the disease, all
symptoms fade away as the sensory cells in the
labyrinth become destroyed and compensation of
vertigo occurs from the healthy side.
Treatment

 -Antibiotics, antivertigenous drugs.

 -Mastoidectomy to clear the infection.
 -In persistent cases, labyrinthectomy to
drain the affected labyrinth.
 Otitic Facial Paralysis
Causes:
1-Acute suppurative otitis media if the
bony facial canal is congenitally deficient.
2- Chronic suppurative otitis media due to
erosion of the facial canal by cholesteatoma.
3-Ear surgery injury:
-Cortical or radical mastoidectomy and during
stapedectomy
-Long postauricular incision in children where the
facial nerve is superficial.
 Treatment
-In acute suppurative otitis media:
Antibiotics and myringotomy.
-In chronic suppurative otitis media:
Antibiotics, mastoidectomy, decompression
of the facial nerve.
-In surgical injury:
The nerve is grafted from the greater auricular
nerve, or the lateral cutaneous nerve of the
thigh.
Facial nerve grafts
Intracranial Complications
Extradural abscess
Collection of pus between the dura and bone of the middle
or posterior cranial fossa .
Clinical Picture ;
- Usually asymptomatic & discovered accidentally at
operations.
- Earache , Headache or profuse pulsating discharge .
- Conductive deafness .
Investigation: C.T mastoid, MRI brain
Treatment ;
- Antibiotics .
- Drainage through mastoidectomy .
Meningitis
Inflammation of the pia – arachnoid mater and infection
of the C.S.F around the brain and spinal cord. It is
caused by ;
- In suppurative otitis media : Haemophilus influenza
or staph .
- In epidemics : Meningococcus or pneumococcus .
Clinical Picture

Symptoms :
- General manifestations as fever , headache &
malaise .
- Symptoms of increased intracranial pressure
(headache, vomiting and blurred vision).
- Symptoms of meningeal irritation (Photophobia,
irritability, head retraction and neck rigidity).
Signs :
- Kernig’s Sign : flexion of the hip limits extension of
the knee .
- Brudzinski’s Sign : flexion of the neck leads to flexion
of the hip & knee .
Investigations ;
- Lumbar puncture :
1- C.S.F. analysis .
2- Culture and sensetivity of the C.S.F.

C.S.F. Normal Meningitis

Colour Clear Turbid
Pressure Up to 150mm water Increased
Cells 1- 5 lymphocytes Increased
Proteins 40mg/ 100ml Increased
Sugar 80mg/ 100ml Decreased
Cloride 720-750mg/100ml Decreased
Culture Sterile no organism Organism
Treatment ;
- Hospitalization: in dark room.
-IV antibiotics cross the blood brain barrier to C.S.F.
- Sulphonamide and cephalosporines.
-Lumbar puncture and intrathecal penicillin (10.000
units in 5cc).
-Reduction of intracranial tension by intravenous
mannitol or repeated lumbar puncture.
-Mastoidectomy to clear the source of infection once
the condition of the patient permits.
 Lateral Sinus Thrombophlebitis
It is an inflammation of inner wall of lateral venous sinus with formation
of a thrombus during the course of chronic suppurative otitis media.

Pathology :
Spread of inflammations to inner
wall of the lateral sinus with
deposition of fibrin, platelets,
and blood cells leading to
thrombus formation within the
lumen of sinus which enlarges
to occlude the sinus lumen.
Organisms may invade the
thrombus causing intra-sinus
abscess which may release
infected emboli into the blood
stream causing septicaemia.
The venous sinuses are the final drainage channels for blood from
the head.
Superior saggital sinus thrombosis is more likely to be associated with stroke, but
transverse or lateral sinus thrombosis is more likely to cause raised intracranial
pressure.
Symptoms:

-Intermittent fever and rigors due to detachment of

septic emboli followed by sweating and drop of
temperature.
-Thrombosis of the lateral sinus may be
symptomless and only discovered during
mastoidectomy operation.
- Symptoms of chronic otitis media.
Signs of extension of the thrombus:
a) Tender cord like internal jugular vein caused
by downward extension.
b) Griesinger's sign: Postauricular edema and
tenderness over mastoid bone due to lateral
extension through the mastoid emissary vein.
c) Cavernous sinus thrombosis due to medial
extension through the superior petrosal sinus.
d) Otitic hydrocephalus due to upward extension
to the superior sagittal sinus leading to
increased intracranial tension.
Dural sinuses
 Investigations

Investigations:
-Leucocytosis above 20.000/cu.mm.
-Blood culture is positive during rigors.
-CT scan & MRI : Definitive diagnosis.
Differential diagnosis:
-Malaria: fever and rigors at regular intervals.
Leucopenia and parasites in blood film.
-Typhoid fever: Step ladder fever. Leucopenia and
positive Widal test.
-Positive Tobey-Ayer's test: Pressure on the diseased internal jugular
vein will not cause rise of C.S.F pressure in the lumbar puncture
manometer while pressure on the healthy side causes rise of the C.S.F
pressure (old test not done nowadays).

Toby – Ayer’s test

Complications:
1. Otitic hydrocephalus: when thrombosis extends
upwards to obstruct the superior sagittal sinus and
arachnoid villi, this interferes with C.S.F
absorptions. Headache, vomiting, papilloedema
and sixth nerve paralysis; due to increased
intracranial tension up to 300 mm. CT scan shows
dilated ventricles of the brain.
2. Cavernous sinus thrombosis: Ptosis, chemosis,
proptosis, ophthalmoplegia (no movement of the
eye and no accommodation) and papilloedema.
Treatment
-Antibiotics.
-Mastoidectomy and removal of the thrombus
after exploring the sinus till free blood is
obtained proximally and distally. The affected
sinus is dull grayish, covered with granulations,
pulsating and firm. The healthy sinus is blue,
glistening, non-pulsating and easily
compressed.
-Anticoagulants (heparin) given after evacuation
of the thrombus.
-Ligation of the internal jugular vein if thrombosis
affects it to prevent further spread.
 Otogenic brain abscess

Stages and symptoms:

1. Stage of encephalitis:
Fever, headache and
drowsiness.
2. Stage of localization
or latent stage:
Minimal or no
symptoms.
3- Manifest stage ; The abscess enlarges gradually and causes ;
A) Increased intracranial tension (ICT):
1. Headache, projectile vomiting (not related to meals, not preceded by
nausea) and papilloedema.
2. Subnormal temperature, slow pulse and slow respiration due to
pressure on the medulla.

B) Localizing signs:
Temporal lobe abscess:
-Nominal aphasia (inability to name objects) due to pressure on the
speech centre.
- Hemianopia (vertical loss of vision on the opposite side of lesion) due to
pressure on the optic radiation.
-Hemiplegia on the other side due to pressure on the internal capsule.
-Hemianaesthesia on the other side due to pressure on the sensory area if
it extends to the parietal lobe.
-Uncinate fits: Hallucination of smell or taste followed by convulsive fits.
Hemianopia

Hemianopias occur because the right half of the brain has

visual pathways for the left hemifield of both eyes, and the
left half of the brain has visual pathways for the right
hemifield of both eyes.
Cerebellar abscess:

-Ataxia: lack of voluntary coordination of muscle movements.

-Positive Rombergism (tendency to fall to the diseased side).
-Intention tremors: missing the targeted object because of
the tremors
-Past pointing : inability to perform finger to nose test.
-Hypotonia and muscle weakness on the same side.
-Vertigo, nystagmus.
-Staccato speech: abnormal speech in which there are
pauses between words.
- Dysdiachokinesis: inability to perform rapid repetitive
movements. Rapid pronation and supination of the forearm
shows slow and irregular movements on the affected side.

4. Terminal stage: Rupture of the abscess leading to diffuse

encephalitis : coma and death.
Rombergism
Intention tremors

Dysdiadochokinesis

Past pointing

nystagmus
 Investigations ;
- C.T. and M.R.I for brain.

Rt temporal lobe abscess Dihesent tegmen tympani

Treatment:
-Antibiotics which crosses B.B.B..
-Reduce I.C.T by mannitol, no lumber
puncture (conization).
-Aspiration of the abscess through
burr holes.
-Mastoidectomy to eradicate M.E
and mastoid disease.
Extracranial Complications
1- Otitis Externa .
2- Jugular Vein Thrombosis .
3- Bezold’s Abscess .
4- Retropharyngeal Abscess .
 THANK YOU
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