1. COMPLICATIONS
C.S.O.M.
Dr. Mohammad Aslam Chaudhry
Professor E.N.T (BBH)

2. Anatomical review

3. “Medial wall of middle ear”

4. Surgeon’s view

5. Complications of CSOM
• classification
1. Cranial (Intra-temporal )
2. Extra-cranial complications
3. Intra-cranial complications

7. Pre-disposing factors
• Age
• Virulent organisms
• Cholesteatoma or Bone erosion
• Presence of a congenital dehiscence
• Obstruction of drainage e.g polyp
• Low resistance of the patient
• Poor socio-economic status

8. Routes of spread

9. Pathways of infections
• The commonest way for extension of
infection is by bone erosion due to a
cholesteatoma.
• Vascular extension (retrograde
thrombophlebitis).
• Extension along preformed pathways as
– Congenital dehiscences, fracture lines, round
window membrane, the labyrinth,
– Dehiscences due to previous surgery.

10. COMPLICATIONS OF CSOM
Routs of spread

11. Cranial complications
(Intratemporal )
1. Mastoiditis
2. Petrositis
3. Labyrinthitis
4. Facial paralysis
5. Perilymphatic fistula

12. Mastoiditis
• Inflammation of mastoid air cells
• Acute vs Chronic
• Fever
• 2 weeks after OM
• Earache
• Irritability

14. Labyrinthitis
• • Infection of the inner ear
• • SNHL
• • Vertigo
• • Nausea and vomiting

15. labyrinthitis

16. Tympanosclerosis
• Asymptomatic
• Indicator of OM
• Ear drum stiffness
• Ossicular fixation

17. Tympanosclerosis

18. • 56 yr
• Earache
• Chronic Discharge

19. Facial Paralysis
• Slow – chronic expansion of disease
• Rapid – infected cholesteatoma
• With cholesteatoma requires immediate
surgery
• CT localizes involved portion

20. Facial Paralysis
Management
• Mastoidectomy, Remove cholesteatoma and
infected debris
• IV antibiotics and
+/- steroids.

21. Petrositis
• Only in pneumatised petrous pyramids
• Infected petrous cells
• Poor drainage
• Bony coalescence → symptoms

22. • GRADENIGO
• Retro-orbital pain
• Abducent→
Diplopia
• Discharge

23. Extra-cranial complications
• Otitis externa
• Cervical lymphadenitis
• Retropharyngeal &
• Parapharyngeal abscesses

24. Impending sign @ symptoms
• Decreased mental status
• Stiff neck
• Ataxia
• Visual changes
• Seizures
• Other
Headache, lethargy, fever.

25. INTRACRANIAL COMLICATIONS
• Barriers penetration
1. Bone
→ Epidural Abscess
→ LST
2. Dura Mater
→ Subdural Abscess
3. Arachnoid
→Meningitis
4. Pia Mater
→ Brain Abscess

26. COMPLICATIONS OF CSOM

28. Lateral Sinus Thrombosis (sigmoid sinus)
Spread of infection by direct extension or
via mastoid emissary vein
↓
Pus and granulation adjacent to sigmoid
sinus
↓
Reactive thrombophlebitis
↓
intraluminal thrombus
↓
CSF obstruction

29. Signs of LST
• Picket-fence fever 􀃆
• Papilledema
• Torticollis
• Greisinger sign →

30. LST
• LST is rare complication
• CT
• Angiography
• MRI- MRV

31. LST ……Treatment
• Empiric broad coverage until C&S
• antibiotic with good CSF penetration
• Surgery
– Mastoidectomy
– Decompression
– Thrombus evacuation

32. Intracranial Epidural Abscess
• Localized between dura
and bone
• dural adherence to bone
at suture lines
• Focal osteomyelitis
• Management and
etiology same as
subdural empyema

33. Subdural Abscess
• Between the dura and
the arachnoid.
• Potential space
• Lack of anatomical
boundaries
→ spread rapidly
• Ear 14%
• (paranasal sinusitis
75%)

34. Subdural Abscess - clinical
• Fever
• Focal neurological deficit
• Headache
• Seizures
• Forehead or eye swelling from
emissary vein thrombosis
• Vomiting

35. Subdural Abscess - evaluation
• CT of head both with and without contrast
• LP - hazardous - risk of transtentorial
herniation

36. Meningitis

37. Meningitis: Clinical Manifestations
• Headache
• Nuchal rigidity
• Fever and chills
• Photophobia
• Vomiting
• Seizures
• Focal neurologic symptoms
• Altered sensorium (confusion, delirium, or
declining level of consciousness)

38. Physical Examination
Kernig & Brudzinski signs have low sensitivity but high specificity

39. Brain Abscess - Clinical
Presentation
• non-specific Symptoms for abscess
• increased intracranial pressure
• –Headache,
• –Nausea/Vomiting
• – Lethargy.
• – Seizures.

40. Otic hydrocephalus
Symptoms
• Non-specific
• Headache
• Tinnitus
• Nausea / vomiting
• Visual disturbance
• Others – lethargy, dizziness, mood change

41. TX
• Decrease the IC pressure
– Corticosteriods
– Acetazolamide
– Lumbar pucture
• I/V Antibiotics
• Mastoidectomy

42. THANK YOU