Extra-cranial complications of CSOM

Dr. Aarthi G
2nd Year PG
Dept. of ENT
Chronic otitis media
• Persistent infection or inflammation of the middle ear and
mastoid air cells.

• Typically involves a tympanic membrane perforation with

intermittent or continuous otorrhea .

• Acute otitis media and its complications are more

common in young children

• Complications secondary to COM with or without

cholesteatoma are more common in older children and
adults ,
 Complications of AOM and COM

Extracranial Intracranial

Extratemporal Intratemporal

1. Subperiosteal abscess 1. Mastoiditis

2. Bezold’s abscess 2. Petrositis
3. Postauricular abscess 3. Labrynthine Fistula
4. Luc’s abscess 4. Acute Suppurative labrynthitis
5. Citelli abscess 5. Facial nerve Paralysis
Mastoiditis
• Mastoiditis, defined as mucosal thickening or a
mastoid effusion,
• Types :
• Acute mastoiditis
• Chronic mastoiditis
• Masked mastoiditis
• Coalescent mastoiditis
Acute Mastoiditis
• Acute mastoiditis can develop when AOM fails
to resolve.

• Acute mastoiditis is present when signs of

AOM are found on otoscopy and local
inflammation over the mastoid process is
evident (e.g., pain, erythema, tenderness,
auricular protrusion), or when the mastoid
inflammatory changes coexist with radiographic
or surgical findings of mastoiditis with or
without evidence of AOM.
• Causative Organisms : Streptococcus pneumoniae
Streptococcus pyogenes, Staphylococcus
aureus, and Haemophilus influenzae
• Management : CT scan

• Appropriate iv antibiotics for 3 to 6 weeks till

the CT scans show normally aerated middle
ear
Chronic Mastoiditis
• Chronic mastoiditis can occur in association
with a long-standing tympanic membrane
perforation, with cholesteatoma or as a
complication from an infection after placement
of a middle ear ventilating tube.

• Chronic mastoiditis requires surgical

intervention to heal,

• Infected cholesteatoma requires surgical

ablation regardless of duration .
Masked Mastoiditis
• Chronic otitis with granulation tissue formation
and bone erosion can occur without otorrhea. It
can persist despite a normal or near-normal
tympanic membrane. This condition has been
referred to as masked mastoiditis

• Patients who have received numerous courses

of antibiotics.

• Focal area of persistent infection

Mastoiditis
• Anaerobic organisms : Peptococcus spp.,
Bacteroides low virulence
• C/F: chronic but not severe auricular and
postauricular pain, mild mastoid tenderness

• CT scan shows a localized area of

opacification in an otherwise normal mastoid.

• Surgical excision eliminates the symptoms.

Coalescent Mastoiditis
• Pathophysiology :

• A mild form of mastoiditis regularly accompanies an

AOM , limited to the mucoperiosteum =
tympanomastoiditis(inflammation of the middle ear cleft )

• Aditus is blocked by inflammatory tissue 

mucopurulent material gets loculated in the antrum and
contiguous air cells in the temporal bone  persistent
infection leads to retrograde thrombhophebitis  edema
and cellulitis of soft tissue overlying the mastoid  if the
pus is not drained  necrosis and demineralisation of
the bony trabeculae  coalescent mastoiditis
Coalescent Mastoiditis

Gradenigo syndrome

Subperiosteal abscess

Bezold’s Abscess

Epidural Abscess
Management
• Complete blood picture

• CT scan

• Cortical mastoidectomy with ventilating tube

placement + appropriate antibiotic therapy

• Pneumatization has not progressed to

incorporate the mastoid tip in children younger
than 2 years, so a risk of surgical injury to the
facial nerve is present.
Subperiosteal abscess
• Most common extratemporal complication

• Occurs over the mastoid cortex when the

infectious process within the mastoid air cells
extends into the subperiosteal space.
Postauricular abscess
• m.c. complication of mastoiditis.

• Affects young children

• The infection extends from the mastoid to the

subperiosteal space; this usually occurs by
direct extension subsequent to bone
destruction or by phlebitis and periphlebitis of
mastoid veins.

• The surrounding soft tissue exhibits thickening,

inflammation, erythema, tenderness, and
fluctuation.
Bezold’s Abscess :
• Bezold abscess as a condition “caused by a
perforation in the bony plate forming the inner
surface of the tip of the mastoid.

• the tip cells – large and in which the bony plate

forming the inner or medial wall of the tip is
very thin

• Pus escaping through such a perforation

burrows downward in the neck beneath the
sternomastoid, or may be confined between
layers of the deep cervical fascia.”
• Seen in older children in whom pneumatization
has extended into the mastoid tip and in adults
who have either chronic mastoiditis or
cholesteatoma.
Abscess :

• Luc’s abscess: Through the bony wall between

the antrum and external osseous meatus.
Swelling is seen in deep part of bony meatus.
Abscess may burst into the meatus.
Petrositis
• Petrous apicitis is an extension of infection
from the mastoid air cell tract into a
pneumatized anterior or posterior petrous
apex.
 Pathophysiology :
• Petrous Apex can be pneumatic / diploeic / sclerotic
• Petrous apicitis = mastoiditis that occurs in the petrous apex.

• Petrositis develops by direct extension of a mastoid infection,

but the mastoid may respond to medical or surgical treatment
without apical resolution. Just as there can be disjunction
between the state of infection in the middle ear and the
mastoid.
 Pathophysiology :
• Pressure within the petrous apex usually results in pain
referred to the retroorbital area or deep within the skull.

• The most common symptoms are deep or retroorbital pain from

irritation of the contiguous trigeminal ganglion in the Meckel
cave;

• Paralysis of cranial nerve VI as it passes through the Dorello

canal, (under the Guber’s ligament )which abuts the petrous
apex;

• dysfunction of cranial nerves VII and VIII; or labyrinthitis.

• In 1904, Gradenigo described the triad of retroorbital pain, sixth

cranial nerve paralysis, and otorrhea, which has since become
known as Gradenigo syndrome.
 Petrositis

Acute Chronic

Gradenigo Syndrome Gradenigo syndrome +

new bone formation and resorption
 Management :
• CT scan shows the bony details of the septa of the air
cells and the size and contour of the entire apex

• MRI differentiates marrow from mucus or CSF.

 Treatment
• Difficult surgical approach (otic capsule and
carotid artery)

• First-line treatment of petrous apicitis : IV

antibiotics require a long duration of treatment.

• Serial C-reactive protein levels and erythrocyte

sedimentation rates have been used to monitor
for response of bony infections to medical
management
 Treatment
• In the presence of abscess, necrotic bone, or
persistent infection despite medical
therapy,surgical drainage is required.

• Several possibilities for surgical approach

including: infracochlear,infralabyrinthine,
retrolabyrinthine, subarcuate, and even middle
fossa .

• In a nonhearing ear, the translabyrinthine or

transcochlear approaches are used .
Labrynthitis
3 types :
• Serous labrynthtis

• Otogenic suppurative labrynthitis

• Meningitic suppurative labrynthitis

• Serous Labrynthitis :

• Bacterial toxins – via OW/ RW / Labrynthine fistula

• Diagnosis is retrospective

• Vestibular and auditory functions are partially or

completely retained .

• Antibiotics + corticosteroid therapy

Acute (otogenic) Suppurative Labrynthitis

• Route of transmission :
– dehiscent OWM ,(Mondini deformity )

– Enlarged vestibular aqueducts,

– Stapes surgery.

– The foramina of the internal auditory canal that opens into

the medial aspects of the labyrinth may also be weak or
dehiscent,

– cochlear aqueduct can permit bacterial infection to

progress from the labyrinth to the meninges or vice versa.

– Direct bacterial invasion of the labyrinth through a

cholesteatomatous lateral semicircular canal fistula.
• The diagnosis of acute suppurative labyrinthitis
is clinical.

• Tinnitus and dizziness  whirling vertigo with

nystagmus to opposite side

• pallor, diaphoresis, nausea, and vomiting.

• It is not possible to reverse the clinical course,

appropriate antibiotic treatment for 10 days

• Labyrinthectomy is unnecessary in labyrinthitis

secondary to AOM.
Labrynthine Fistula
• Labyrinthine fistula represents an erosive loss
of the endochondral bone that overlies the
semicircular canals without loss of perilymph.

• Most common complications of chronic otitis

with associated cholesteatoma, and have been
reported in approximately 7% of cases

• Horizontal semicircular canal (location near the

antrum) – m.c. (90%)
Pathophysiology
• Erosion of the bone of the otic :In the presence
of a cholesteatoma  activated mediators from
the matrix, or pressure from the cholesteatoma
itself  osteolysis and uncovering of the
labyrinth

• In the absence of cholesteatoma resorption

of the otic capsule due to inflammatory
mediators.
Classification :
• Dornhoffer
and Milewski

• Type 1: Fistulae with bony erosion and intact

endosteum
• Type IIa. If the endosteum is violated, but the
perilymphatic space is preserved,
• Type II b : When the perilymph is violated by
disease or inadvertently suctioned
• Type III :Membranous labyrinth and endolymph
have been disrupted by disease or surgical
intervention
Labrynthine Fistula
• C/F : Periodic vertigo – 62 % to 64 %

• Fistula test : positive in 32% to 50 %

• Preoperative CT : 57% to 60 %

• Definitive diagnosis can be made intraoperatively

• Treatment : Canal wall down mastoidectomy

• Use of corticosteroids at the time of cholesteatoma may

have protective measure on hearing
Labrynthine Fistula
Identifies the blue line of the actual fistula and the adjacent
thinned layer of bone on either side of it

The plane that separates the matrix and the endosteum is

developed,

A small piece of tissue or a shaped cap of bone is placed

over the site and secured in place with fibrin glue or
packing.

Large fistulae, it may be best to perform a canal-wall-down

procedure and leave the fistula covered by matrix, which
later forms the mastoid cavity lining
 Facial nerve paralysis

• Otogenic causes of Facial nerve paralysis :

– Acute otitis media

– Chronic otitis media without cholesteatoma

– Chronic otitis media with cholesteatoma

 Pathophysiology
• Route of spread :
• Via natural dehiscence (congenital )in the fallopian canal
, most often the tympanic segment

• Via natural pathways that connect the middle ear and the
lumen of the fallopian canal, neurovascular connections
and mastoid air cells in close contact with the fallopian
canal

• Via direct infection of bone around the fallopian canal

(localized osteitis)

• Via erosion with granulation tissue or cholesteatoma .

Inflammatory pressure or suppurative neuropraxia

Facial nerve paralysis in AOM
• Young children and infants

• Congenital dehiscence of the fallopian canal

• Incomplete paresis

• Rarely lasts longer than 3 weeks

• Acute onset palsy

• Management :

• Atleast 10 days of appropriate antibiotic therapy

• Myringotomy

• Tymapanostomy tube insertion

• Recovery - > 95% of cases

Chronic otitis media
• Chronic otitis media without cholesteatoma - Affects the
horizontal part of facial nerve

• Chronic otitis media with cholesteatoma Affects the

horizontal segment of the fallopian canal part of facial
nerve

• Gradual progression ,Stays after surgery

• Mastoidectomy. The nerve sheath does not have to be

incised unless the cholesteatoma has invaded the nerve
itself .

• The tympanic segment and second genu are involved

most commonly
Thank You