Intracranial complication of chronic suppurative otitis media
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Transcript of Intracranial complication of chronic suppurative otitis media
INTRACRANIAL COMPL.- CSOM
• EXTRADURAL ABSCESS• SUBDURAL ABSCESS• MENINGITIS• OTOGENIC BRAIN ABSCESS• LATERAL SINUS THROMBOPHLEBITIS• OTITIC HYDROCEPHALUS
EXTRADURAL ABSCESS
PATHOLOGY• Coll. of pus b/w bone & dura-middle or post. Cranial
fossa• Affected dura- covered i granulation & discoloured.• a/c- bone over dura-destroyed by hyperaemic
decalcification.• c/c-destroyed by cholesteatoma• Spread
– destruc. Of bone– venous thrombophlebitis- bone over dura remains
intact
• C/Fmostly asymp.- discovered CM or MRMpresence suspected when
persistent headache on side of otitis mediasevere ear achepulsatile purulent ear d/sdisapp. Of headache- i flow of pus from eargeneral malaise i low grade fever
• DIAGNOSISContrast enhanced CT or MRI
• Rxabscesss- evacuated by removing overlying bone till healthy dura are reached.Causative d/s- CM broad spectrum antibiotics
SUBDURAL ABSCESS• PATHOLOGY
Spread- erosion of bone & duraor thrombophlebitic process- bone intact.
pus lie against surface of cerebral hemisphere causing pr. Symp and pus get loculated.
•
C/FMENINGEAL IRRITATION
fever(102F or more)Headachemalaise, drowsinessneck rigidity+ve kernig’s sign
THROMBOPHLEBITIS-CORTICAL VEINS OF CEREBRUM
aphasia, hemianopia, hemiplegiajacksonian type of epileptic fits
RAISED ICT III nerve- Papilloedema, ptosis, dilated pupil
• DIAGNOSISCT scan or MRI
• RxSeries of burr hole ORCraniotomyBSAonce infection subsides- CM
LP- cause herniation of cerebellar tonsils.
MENINGITIS
• Inflm. Of Leptomeninges.(piamater and arachnoid )+ bact. Invasion of CSF in subarachnoid space.
• Most common intracranial complication• 2nd most compl. Of OM.• Infants & children- a/c- blood borne
adults-c/c - bone erosion or thrombophlebitis- asso Extradural abs. or granulation tissue
C/fInfectionRaised ICTmeningeal or cerebral irritation.
• Fever 102-104F+ chills & rigor• Headache• Neck rigidity• Photophobia & mental irritability• N, V(projectile)• Drowsiness• CN palsies & hemiplegia
EXMN
Tendon reflexes -exaggerated during initial stage, later – sluggish or absent
Papilloedema – late stages
Diagnosis:examination of CSF-culture and antibiotic sesitivity
lumbar puncture• Turbid• increased cell count-polymorphs.• Protein level- increased• reduced glucose levels (1.7-3 mmol/l )• Chloride content - fall from 120 mmol/l to 80mmol/l.
CT or MRI
Rx• Med
-systemic antibiotics-BSACorticosteroids
• Surgical– a/c- CM– c/c- MRM or RM
OTOGENIC BRAIN ABSCESS• always develop in the temporal lobe or the cerebellum of the same
side of the infected ear. Temporal lobe abscess is twice as common as cerebellar abscess.
• In children -25% of brain abscesses are otogenic – a/c• In adults -50% of brain abscess are otogenic- c/c
TEMPORAL LOBE ABSCESS CEREBELLAR ABSCESS
Spread direct extension -eroded tegmen plate. Retrograde thrombophlebitis
direct extension -Trautmann's triangle.Retrograde thrombophlebitis
Asso- EDA EDA, perisinus abs, SST or labtrinythitis
• PATHOLOGY
• C/FRAISED ICT TEMPORAL LOBE ABSCESS CEREBELLAR ABSCESS
HEADACHE- generalised, worse in mrng.
N,V(proj.)
DROWSINESS, CONFUSION, STUPOR, COMA
PAPPILLOEDEMA- late, early in cerebellar abscess
Slow pulse
Subnl temp
NOMINAL APHASIA- pt fails to tell name but can demonstrate their use
HOMONYMOUS HEMIANOPIA- visual field oppo to side of lesion is lostDue to pr on optic radiations.
CONTRALATERAL MOTOR PARALYSISUpward-face, arm leg
EPILEPTIC FITSUncinate gyrus-taste hallucination, mvmt lips & tongue, generalised fits
PUPILLARY CHANGES & OCCULOMOTOR PALSY-transtentorial herniation
HEADACHE-subocci. Asso i neck rigidity
SPONT. NYSTAGMUS- irreg, side of lesion
IPSILAT. HYPOTONIA & WEAKNESS
IPSILAT. ATAXIA
PAST-POINTING & INTENTION TREMOR- finger nose test
DYSDIADOKOKINESIA- rapid pronation & supination of forearm show slow irreg mvmt on affected side.
• INVESTIGATIONSKULL X- RAY To see midline shift,
if pineal gland is calcified, gas in abscess cavity
X-RAY MASTOID Evaluating asso ear d/s
CT SCAN & MRI To find the site & size of abscess cavityAsso compl- EDA,SST,
LP danger because of the risk of coning.CSF- rise in pr, turbid raised WBC- polymorphs 0r lymphocytes raised protein level nl glucose level
TREATMENT:MEDICAL High dose iv antibiotics- Chloramphenicol+3rd gen
Cephalosporin bacteroides- Metronidazole pseudomonas , proteus- aminoglycoside- gentamicinRaised ICT- Dexamethasone- 4mg iv 6th hrly or mannitol 20% - 0.5 g/kg body wt.Ear discharge- suction clearence & topical ear drops
NEUROSURGICAL -drained by placement of burr holes, -excision of the necrotic tissue along with the capsule.--Open incision of abscess and pus evacuation
-If abscess is treated by aspiration- repeat CT or MRI to see if it diminish in size. Penicillin is instilled into abscess after aspiration
OTOLOGIC a/c- may resolve i antibioticsC/c- RM
LATERAL SINUS THROMBOPHLEBITIS
FORMATION OF PERISINUS ABSCESSENDOPHLEBITIS AND MURAL THROMBUS FORMATIONOBLITERATION OF SINUS LUMEN AND INTRASINUS ABSCESSEXTENSION OF THROMBUS- prox- sup sagittal sinus dist- mastoid emissary vein, to jugular bulb or jugular vein
C/FHECTIC PICKET- FENCE TYPE OF FEVER I RIGOR Irregular fever-1 or > peaks/day, in b/w bouts
of fever- sense of well being. profuse sweating follows fall of temp. Due to septicaemia-release of septic emboli
HEADACHE Early- perisinus abscessLate- raised ICT
ANAEMIA progressive
GRIESINGER’S SIGN Edema over post part of mastoid Due to thrombosis of mastoid emissary veins
PAPILLOEDEMA Seen when rt sinus is thrombosed or when clot extends to sup sagittal sinus
TOBEY- AYER TEST
CROWE- BECK TEST Pr on jugular vein of healthy side produce engorgement of retinal veins & supraorbital veins
TENDERNESS ALONG JUGULAR VEIN Asso i enlarge & inflmm of jugular LN & torticollis
INVESTIGATIONBLOOD SMEAR To rule out malaria
BLOOD CULTURE To find causative organismBlood-taken at the time of chills
CSF EXMN Normal except for rise in pr,To exclude meningitis
X-RAY MASTOID Asso ear d/s
CONTRAST ENHANCED CT SCAN Sinus thrombosis by typical delta sign or empty triangle sign- rim show enhancement on post cranial fossa central low density area on axial cut
MRI CONTRAST ENHANCED- Delta signMR venography- progression or resolution of thrombus
CULTURE & ANTIBIOTIC SENSITIVITY Ear swab
TREATMENTIV ANTIBIOTICS BSA- continued at least for a week after operation
MASTOIDECTOMY & EXPOSURE OF SINUS
CM-a/c or MRM-c/cSinus bony plate is removed to expose dura- perisinus abscess is drainedIntrasinus abscess of infected clots- dura is incised & infected clot & abscess drained
IJV- LIGATION When above 2 therapy fail- to control embolic phenomena & rigors OR tenderness & swelling- JV spreading
ANTICOAGULANT THERAPY If thrombus extend to cavernous sinus
SUPPORTIVE TREATMENT Anaemia- repeated blood transfusion
OTITIC HYDROCEPHALUS• It is a syndrome of raised intracranial pressure during or following
middle ear infection. • also known as Pseudotumorcerebri.• Pathogenesis:
– lateral sinus thrombosis -affects cerebral venous outflow, – or the extension of the thrombus into the superior sagittal sinus impedes CSF
resorption by arachnoid villi
C/FSYMPTOMS
headache Severe
diplopia Paralysis of VI CN
blurred vision Papilloedema or optic atrophy
SIGNS
papilloedema.
Nystagmus Due to raised ICT
LP Pr- >300mm of water (70-120mm water)All other normal
TREATMENT• ACETAZOLAMIDE• CORTICOSTERIODS• REPEATED LP OR PLACEMENT OF LUMBAR DRAIN• LUMPOPERITONEAL SHUNT • ASSO EAR INFECTION
THANK YOU