The Laryngoscope Lippincott Williams & Wilkins, Inc.© 2007 The American Laryngological, Rhinological and Otological Society, Inc. Complications of Chronic Suppurative Otitis Media and Their Management Siba P. Dubey, MS; Varqa Larawin, MMed Objective: The objective of this is to determine the incidence of otogenic complications of chronic suppurative otitis media (CSOM) and its management. Study Design: The authors conducted a retrospective study. Methods: The study was conducted at the tertiary referral and teaching hospital. An analysis was made about the clinical and operative findings, surgical techniques and approaches, the overall management and recovery of the patients. The data were then compared with the relevant and available literature. Results: Of the 70 cases, 47 (67%) had a single complication, of which eight (11%) had intracranial and 39 (56%) had extracranial complications. Twenty-three (33%) had two or more complications. The commonly encountered intracranial complications were otitic meningitis, lateral sinus thrombosis, and cerebellar abscess, which were seen in 13 (19%), 10 (14%), and 6 (9%) cases, respectively. Among the extracranial complications, mastoid abscess, postauricular fistula, and facial palsy were encountered in 26 (37%), 17 (24%) and 10 (14%) patients, respectively. Surgeries were the main mode of treatment for these conditions. According to severity, we found four different types of the lateral sinus involvement. Three patients with otitic facial palsy failed to regain full facial function despite surgery. A total of nine patients with the diagnosis of otitic meningitis, lateral sinus thrombosis and interhemispheric abscess expired. It constituted the mortality rate of 13% in our study. Conclusion: CSOM complications, despite its reduced incidence, still pose a great challenge in developing countries as the disease present in the advanced stage leading to difficulty in management and consequently higher morbidity and mortality. Key Words: Otitis media, suppurative, complications, cholesteatoma, facial paralysis, meningitis, brain abscess, surgery, mastoidectomy, lateral sinus, thrombosis. Laryngoscope, 117:264 –267, 2007 From the Department of Ear, Nose and Throat (S.P.D., V.L.), Port Moresby General Hospital, Papua, New Guinea; and the Department of Otorhinolaryngology (S.P.D.), School of Medicine and Health Sciences, University of Papua, Papua, New Guinea. Editor’s Note: This Manuscript was accepted for publication September 29, 2006. Send correspondence to Siba P. Dubey, MS, Post Box 3265, Boroko, National Capital District, Papua New Guinea. E-mail:
[email protected] DOI: 10.1097/01.mlg.0000249728.48588.22 INTRODUCTION The occurrence of chronic suppurative otitis media (CSOM) and its complications have reduced considerably with the use of better antibiotics. However, in the developing countries, these infections still are major challenges with respect to diagnosis and management.1 The complications of CSOM are classified as intracranial and extracranial (intratemporal) or meningeal and nonmeningeal.2,3 Nevertheless, very little has changed as to their pathogenesis.2,3 The objective of our study was to determine the 1) various types of otogenic complications affecting both the pediatric and adult population in our institution, and 2) efficacy of various clinical measures involved in their identification and management. MATERIALS AND METHODS We were able to locate the complete clinical and operative records of 70 patients who presented with the complications of CSOM to the Department of Otorhinolaryngology of Port Moresby General Hospital during the period from January 1993 to May 2006. All the relevant data were taken from the patients’ medical records and analyzed. All patients with complications underwent canal wall down mastoidectomy (CDM) by postauricular incision. In patients who required lateral sinus exploration, those with mastoid abscess, the incision was made three to four fingers breadth behind the postauricular groove. The postauricular fistula was closed at the same stage by bucket handle flaps or at second stage by inferior based parieto-occipital flaps. During the CDM, an extended neck incision was made from the mastoid tip down over the anterior border of the upper one-third of the sternocleidomastoid muscle for drainage of Bezold’s abscess concomitantly. The sinus was opened up and explored when there was a negative aspirate. The infected thrombus in the sinus was evacuated using gentle suction or arterial thromboembolectomy balloon catheter until a free sinus blood flow was encountered. At this point, proximal and distal ends of the lateral sinus were blocked using a Surgicel (oxidized regenerated cellulose; Ethicon Inc, Somerville, NJ). The internal jugular veins (IJ) were also explored through separate incisions in the neck to remove the infected clot and/or pus from it. The tympanic and the mastoid segment of the facial nerve was decompressed during CDM in the patients who had facial palsy. Luc’s abscess was made by an incision into the temporal space. The cerebellar abscess was drained with the brain cannula either through the mastoid bowl (pre- and retrosigmoid locations) and through the suboccipital burr hole through a separate inci- Laryngoscope 117: February 2007 Dubey and Larawin: Otogenic Complications 264 1). which was encountered in 14 (20%) patients. Of these. Of the 70 patients. and eighth. metronidazole. 8 (11%) had only intracranial complications. and perisinus abscesses were also drained. This Fig. 17 (24%) in second. and ceftazidime. Pattern of different complications of CSOM affecting patients. The age ranged from 4 months to 73 years with an average age of 21 years. and seizures in 5 (7%). The temporal lobe abscess was drained through a burr hole in the temporal bone. The clinical features of the patients were otorrhea in 63 (90%). seventh.sion depending on the lateral or medial location of it. 21 (30%) in third. loss of equilibrium in 6 (9%). 1. which was accessed through a small extension of the anterosuperior aspect of the mastoid incision. mastoid abscess in 26 (37%). RESULTS Twenty-two (31%) patients were in the first decade. All the patients were treated with intravenous antibiotic in various combinations consisting of chloramphenicol. The male to female ratio was 3:1. neck stiffness in 21 (30%). facial palsy in 10 (14%). crystalline penicillin. ceftriaxone. epidural. vomiting in 15 (21%). Thirty (43%) of the patients were 16 years and less. 39 (56%) had exclusive extracranial complications. postauricular fistula in 17 (24%). The subdural. 5 (7%) in fourth. Abscess cavity was washed with gentamicin and an infant feeding tube was left within the abscess cavity to aspirate further accumulation of pus and to irrigate during the postoperative period. fever in 27 (39%). 2 (2. and 23 (33%) had both (Fig. meningism in 14 (20%). Laryngoscope 117: February 2007 Dubey and Larawin: Otogenic Complications 265 .9%) in fifth. and one (1%) each in sixth. otitic meningitis was the most common intracranial complication. Types of Intraoperative Lateral Sinus Conditions. Bezold abscess in 5 (7%). temporal lobe abscess in one (1%). neck stiffness. a combination of cholesteatoma and granulation tissue were seen in 22 (31%).5 Otitic meningitis is the most common intracranial complication. a pedicled calvarial bone graft was used for closure. four (29%) patients died. Of the 13 patients in whom the lateral sinus was exposed and/or explored. There were six (9%) patients with cerebellar abscess in our series. Cholesteatoma were encountered in the middle ear and the mastoid cavity in 31 (44%) patients. postauricular fistula in 17 (24%).4.5 The probable reason why these complications are still encountered may be related to the ignorance about the seriousness of persistent and sometimes offensive ear discharge.8 –10 This high rate may also be the result of 1) late arrival of patients and 2) lack of stronger intravenous antibiotic in peripheral hospitals and health centers. One abscess was drained through a presigmoid and two through retrosigmoid locations within the mastoid bowl and another two by a separate suboccipital burr hole.2. perisinus abscess in 3 (4%). Otitic facial nerve palsy was encountered in 10 (14%) patients. 12– 45 mL).6 Facial nerve palsy as a result of chronic otitis media is associated with dehiscence or destruction of the bony facial canal by cholesteatoma. II. interhemispheric abscess in 2 (3%).5. 10 (14%) had established lateral sinus complications. Fifteen (88%) underwent parieto-occipital bucket handle flap to close the postauricular defect after excision and debridement of necrosed postauricular skin and subcutaneous tissue during mastoidectomy. Two postauricular fistulae were seen in 5 (7%) patients. with or without scanty intrasinus pus. Although only 21% of patients in our series had otitic facial palsy. sinus outline indistinguishable. The last two also had intracranial complications and succumbed to these infections. 6 (46%) had type III. Postauricular fistula was seen in 17 (24%) patients who presented with this condition. Among the patients who died. Six had an intact fallopian canal and had recovered to House-Brackmann grade I postoperatively. Depending on the surgical findings. and subdural abscess in another one (1%) patient. cerebellar abscess in 6 (9%). we found younger patients frequently develop mastoid abscess and postaural fistula than intracranial complications. blood flow can be established with balloon catheter at the transverse sinus end Extensive perisinus granulation with perisinus abscess. The mastoid antrum is shallower in younger people. All five patients had successful recovery. III. sinus outline was apparent proximally and distally. blood could not be aspirated by syringe and needle. which in turn reduces the chances of infection spreading intracranially.3. Consequently.5 Lateral sinus thrombosis in our series had a higher mortality rate compared with others. One patient who also had coexistent tuberculous otitis media developed a large postauricular bony defect postoperatively. Among the extracranial complications. Three had erosion of the fallopian canal with evidence of granulation tissue over and around the facial nerve. were Pott’s puffy tumor. based on this classification. three were found to have type III and two had type IV intraoperative findings. Therefore. Gradenigo syndrome in 2 (3%). Other complications.was followed by lateral sinus thrombosis in 10 (14%). epidural abscess in 4 (6%). The facial nerves were decompressed in these nine cases. osteitic bone all around the sinus. lateral sinus conditions from normal to most severe pathology were classified as type I.7 Therefore. pneumonia.5 Males seem to have a higher preponderance for otogenic complications compared with females.6 Various explanation were given as to the exact cause of it. serous labyrinthitis in 2 (3%) and Luc’s abscess in one (1%). The classic spiking (picket fence) pattern of temperature was noticed in all patients. resulting in the Dubey and Larawin: Otogenic Complications TABLE I. It was similar to other study. soft infected thrombus found in the sinus lumen after opening it. 2 (15%) had type II. the lateral sinus were exposed and/or explored in 13 (19%) patients. Only one patient in this group left our hospital early to have successful treatment elsewhere.5 Otitic meningitis is often associated with other intracranial complications. sinus blood flow encountered after removal of clot Thick sinus wall with perisinus granulation. 3 (24%) had type I. On the basis of clinical and radiologic finding. These are more common in the first 3 decades of life in our series as well as in others. and 2 (15%) had type IV. DISCUSSION Despite the advent of antibiotics and advancement in our knowledge and skills in managing otitis media. mastoid abscess was seen in 26 (37%) cases. and fever are the most important clinical features of otitic meningitis. difficult to establish proximal blood flow with balloon catheter Laryngoscope 117: February 2007 266 . its incidence is variable. blood flow in sinus was verified by aspiration with syringe and needle Dull lusterless sinus wall.1. Nine underwent operation and one was lost in the follow up before operation. no intrasinus blood flow resulting from thrombotic occlusion. These factors contribute to perpetuation and propagation of infection. and paravertebral abscess in one patient each and septicemia in two. computed tomography scan is necessary to rule out other intracranial complications. Among the 14 (20%) patients with otitic meningitis. internal jugular vein thrombosis in 5 (7%). involvement of transverse sinus proximally and internal jugular vein distally.4. serious complications still exist. These three patients failed to regain full facial nerve function postoperatively and their final facial nerve status was House-Brackmann grade III. which were found in our series.7 The mortality rate from otitic meningitis in our series was 29%. or IV as shown in Table I . facial nerve palsy in 10 (14%). Sixteen (23%) patients had exuberant granulation tissue alone.5. Hence. The average amount of pus drained was 27 mL (range. The development of subperiosteal abscess with or without fistula leads to reduction of pressure of pus within the middle ear cleft.5 Headache. The overall mortality of the intracranial complications was seen in nine (13%) patients. Type Intraoperative Finding I II III IV Normal blue sinus wall. Two (12%) underwent an inferiorly based flap in similar situation. It reaches adult thickness by the age of 16 years. Wetmore RF.262:847– 851. others have used conservative treatments in this situation. Dubey SP. Fernandes CMC. None of the patients in our series received any thrombolytics because of the risk of dissemination of infected thrombus and its consequences. 7. Therefore. Eur Arch Otorhinolaryngol 2005.96:272–278. Coskun BU. Steinberg JL. 4.33:107–110. Yurttas V. It also shows how far the infection can spread.development of this serious complication. It is in such a situation that early diagnosis and prompt surgical interventions are most important for the survival of these patients. Sertac Y. once the patients have spiky temperatures in the preoperative period. Laryngoscope 1999. Seven H. BIBLIOGRAPHY 1. Mustafa K. 3rd ed. Turgut S. The systemic one should include those resulting from metastatic infections from the temporomastoid bone and the lateral sinus. it may follow an irreversible downhill clinical course. we used to use computed tomography scan. CONCLUSION Otogenic complications of CSOM still pose a great challenge to developing countries despite its declining incidence. Hence. Shambaugh GE Jr. Management of lateral sinus thrombosis. Am J Otol 1995. Intracranial otogenic complications: a persisting problem. J Laryngol Otol 2000. 5. Laryngoscope 117: February 2007 Dubey and Larawin: Otogenic Complications 267 . Hosoglu S. Sayin I.9 It is possible for them to treat this condition conservatively because they can follow up the lateral sinus condition radiologically by magnetic resonance. Meningeal complications of otitis media. Canal-down mastoidectomy: experience in 81 cases.23:580 –588. The former can be subdivided into intracranial and extracranial or meningeal and nonmeningeal. we used to remove the infected material from the lateral sinuses and the internal jugular veins. When can lateral sinus thrombosis be treated conservatively? J Otolaryngol 2004. Osma U. 9. Unal O. Holtel MR. Samuel J. We do not have magnetic resonance in our country. Complications of otitis media. Kiroglu AF. Fuat T.29:637– 646.109:1616 –1620. We hope that this gradation will help in uniform surgical intervention and its reporting. its unusual location makes it difficult to manage surgically. 3. Otol Neurotol 2002. Syms MJ. Moreover. Tsai PD. Intracranial abscesses associated with chronic suppurative otitis media.16:104 –109. Otol Neurotol 2001.8 The occurrence of interhemispheric abscess in two patients in our series is a clear manifestation of delayed diagnosis from reasons explained previously. Laryngoscope 1986. Pediatr Ann 2000.114: 97–100. Philadelphia: WB Saunders Co. we proposed a gradation of severity of involvement of the lateral sinus by otogenic infections. Fooanant S. Once these systemic complications sets in the patient.9 We also suggest that the complications of CSOM should be categorized as regional and systemic. On the contrary. Kutluhan A. 8. Kangsanarak J. On the basis of our experiences. Facial nerve paralysis due to chronic otitis media. Hence. Navacharoen N. 1980:289 –315. Cureoglu S.22:451– 456. Garap JP. Intracranial complications of suppurative otitis media: 13 years’ experience. in these complicated cases. In: Surgery of the Ear. It happened in three of our cases. Calis AB. Glasscock ME III. Ruckphaopunt K. we prefer to expose the lateral sinus in anticipation of an infected thrombus in it. 2. The complications of chronic otitis media: Report of 93 cases. 6. 10. This can be attributed to lack of public health awareness and inadequate healthcare delivery system. Kiris M.