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Original Paper

ORL 2009;71:8792 DOI: 10.1159/000191472

Complications of Suppurative Otitis Media: Still a Problem in the 21st Century

Badr Eldin Mostafa Lobna M. El Fiky Mohammed M. El Sharnouby

Department of Otorhinolaryngology, Faculty of Medicine, Ain-Shams University, Cairo , Egypt

Although there was a significant decline of infectious problems during the twentieth century, complications of suppurative otitis media persist and may even increase [1, 2] . The incidence of complications varies widely between communities depending on the level of health care [35] . However, this is changing dramatically with easier air travel, massive internal and external migration and the emergence of multidrug resistance in patients with im-mune deficiencies. Moreover, diminished awareness in developed communities and changes from the classical clinical pictures may lead to undue delay in diagnosis and mismanagement with subsequent significant morbidity and mortality [3, 68] . This is a review of cases presenting with complicated suppurative otitis media in a tertiary-care university hospital.

Patients and Methods

This is a retrospective study including all cases presenting with suppurative otitis media presenting to the Ain-Shams Uni-versity Hospitals, Cairo, Egypt, Department of ENT-HNS, from January 1998 to January 2008. Review of the charts of the patients was performed to determine their presentations, duration of the disease, previous therapies and the presence of complications. Available investigations (audiological and radiological) were also included.

Key Words Suppurative otitis media, complications Brain abscess Mastoiditis

Abstract The purpose of this study was to review the incidence of complicated suppurative otitis media in 10 years at a tertiary referral university hospital. During this period, 3,364 pa-tients with suppurative otitis media (acute and chronic) were admitted to the department. The number of patients pre-senting with complications was 422 (12.54%). The ratio of ex-tracranial to intracranial complications was nearly 1: 1. The most frequent extracranial complication was mastoiditis while the most frequent intracranial one was lateral sinus thrombophlebitis. Multiple complications may present in the same patient. The onset of complications was insidious and 96% of the patients were already aware of their disease. There were 6 mortalities (1.42%), and additional morbidity was recorded in 16 patients (3.79%). Changes in the clinical picture should always alert the physician to the onset of a complication. Complications tended to occur in young pa-tients from a lower socioeconomic class and without sex pre-ponderance. Physicians should be aware of the continuing incidence of complications and the subtleness of their onset and investigate patients for the presence of more than one complication. Copyright 2009 S. Karger AG, Basel

Received: July 6, 2008 Accepted after revision: November 3, 2008 Published online: January 15, 2009

Prof. Badr Eldin Mostafa 48 Ibn El Nafees Street 11341 Nasr City, Cairo (Egypt) E-Mail bemostafa@yahoo.com

2009 S. Karger AG, Basel03011569/09/07120087$26.00/0

Accessible online at:www.karger.com/orl

Mostafa/El Fiky/El Sharnouby ORL 2009;71:879388

Results

During this period 3,364 patients with suppurative otitis media (acute and chronic) were admitted to the de-partment. There were 1,952 males (58.026%) and 1,412 females (41.973%). Their ages ranged between 3 and 65 years (mean 36.8). As regards the type of otitis media, 2,376 had chronic otitis media without cholesteatoma, 950 had cholesteatomas and 38 with acute suppurative otitis media. The duration of disease ranged between 3 months and 25 years. There were 724 diabetic patients (21.52%), 16 under chemotherapy for malignancies, 12 with rheumatoid arthritis, 4 with systemic lupus erythe-matosus and 1 with AIDS.

The number of patients presenting with complications was 422 (12.54%). There were 201 males and 212 females. Their ages ranged between 2 and 56 years (mean 21.5 years). Four hundred and two patients were diagnosed as

having cholesteatoma while 10 had chronic otitis media without cholesteatoma and 8 with acute suppurative oti-tis media. The duration of disease in the group with chronic suppurative otitis media (CSOM) was 4 months to 20 years with a mean of 3.4 years. Systemic problems (diabetes, chemotherapy, chronic steroids...) were present in 81 patients (19%).

Most of these patients (396, 96.1%) were already diag-nosed as having CSOM and received medical treatment for their disease prior to presentation. All patients with acute otitis media were already under treatment prior to presentation (mean duration of therapy 112 days).

Three hundred and fifty patients were from rural ar-eas, 40 were immigrants (Sudan, Somalia, Gaza strip, Tchad), and 22 came from slum areas in the greater Cai-ro region and 10 from the middle social classes.

All patients were admitted to hospital and underwent full audiological evaluation and radiological studies in-cluding at least a contrast-enhanced CT and when need-ed a contrast MRI. Bacteriological studies were per-formed in 375 patients. Infection was usually mixed. The commonest combinations were: Streptococcus pneumo-niae, Haemophilus influenzae and Streptococcus pyo-genes; Pseudomonas aeruginosa, Proteus mirabilis and Streptococcus faecalis; Escherichia coli, Moraxella catarrh-alis and anaerobes. In 10% of cases, cultures were negative due to previous antibiotic therapy.

The ratio of extracranial to intracranial complications was nearly 1: 1. The most frequent extracranial complica-tion was mastoiditis ( fig. 1 ) while the most frequent in-tracranial complication was lateral sinus thrombophlebi-tis (LST; tables 1 , 2 ). Multiple complications may present in the same patient ( fig. 2 ). Two combined complications occurred in 228 patients (54%) while 3 or more complica-tions occurred simultaneously in 187 patients (44.7%). The commonest combinations were: mastoiditis and ex-

Fig. 1. One-year-old child presenting with a 3-week history of otalgia and fever. Diag-nosed by her pediatrician as ASOM and treated by 3 daily intramuscular ceftriax-one injections. Fever responded but a non-tender firm postauricular swelling ap-peared. Examination revealed a bulging opaque drum with sagging of the postero-superior meatal wall. Coronal CT scans showing cortical erosion (black arrow) and subperiosteal collection (white ar-row).

Table 1. List of complications

Complication Number Percent

Mastoiditis 386 91.6Facial palsy 122 29Extratemporal abscesses 121 29Lateral sinus thrombosis 120 29Brain abscess 88 21Cerebellar abscess 70 16.5Labyrinthitis 69 16.5Labyrinthine fistula 54 12.5Meningitis 53 12.5Extradural abscess 53 12.5Cochlear erosion 34 8Subdural empyema 17 4Petrositis 16 4

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ORL 2009;71:8793 89

tracranial abscess; labyrinthine fistula and facial paraly-sis ( fig. 3 ); mastoiditis and LST. Other combinations may also be present ( fig. 4 ).

It seems that some complications are more prone to oc-cur in certain age groups ( table 3 ). For example of the 121 patients with an extracranial abscess, 102 (84.29%) were below the median age of 21.5 years. On the other hand of the 122 patients with facial paralysis, only 13 (10.65%) were of the younger group. The commonest complication below the age of 21.5 was extradural abscesses, and in the older patients facial paralysis was the commonest.

In patients with CSOM, different complications tend-ed to occur in a variable time scale. Labyrinthitis, extra-cranial abscesses, subdural and cerebellar abscesses could develop very early in the course of the disease, whereas other complications could appear after a very long dura-tion such as extradural abscesses, LST, brain abscesses and cochlear erosion ( table 4 ).

All patients received parenteral combination antibi-otic therapy: a third-generation cephalosporin and met-ronidazole or a quinolone with metronidazole depending on the results of culture and sensitivity. Surgery was per-formed once the general condition of the patient was sta-

bilized. The extent of surgery was tailored according to the pathological findings. This ranged from myringoto-my only in 5 patients with acute suppurative otitis media to radical mastoidectomy. Complications were managed simultaneously or sequentially. Temporal lobe abscesses, LST, perisinus abscesses, extradural and subdural collec-tions and extracranial abscesses were managed in the same session. On the other hand, cerebellar abscesses were excised by the neurosurgeons followed 1 week later by otosurgical management. Patients with meningitis were treated with antibiotics and repeated lumbar drain-age until they were stable and then operated upon.

Table 2. Extracranial versus intracranial complications

Extracranial Percent Intracranial Percent

Mastoiditis 92 LST 29Facial palsy 29 Temporal lobe abscess 21Extratemporal abscesses 29 Cerebellar abscess 16.5Labyrinthitis 16.5 Meningitis 12.5Labyrinthine fistula 12.5 Extradural abscess 12.5Petrositis 4 Subdural empyema 4

Fig. 2. Fourteen-year-old girl with a 10-year history of CSOM. Rapid onset of fe-ver, rigors and deterioration of the level of consciousness. Contrast-enhanced CT shows LST (white arrow) with absent con-trast uptake and cerebellar abscess (black arrow).

Gg

Lateral SCC

Fig. 3. Forty-five-year-old male patient with bilateral cholesteato-mas since childhood. Progressive hearing loss and sudden onset of facial paralysis. Intraoperative photograph showing a lateral canal fistula and exposure of the geniculate ganglion (Gg). SCC = Semicircular canal.

Mostafa/El Fiky/El Sharnouby ORL 2009;71:879390

There were 6 mortalities (1.42%). Two patients with temporal lobe abscesses ( fig. 5 ), both adults, 2 with cere-bellar abscesses, 1 adult and a 5-year-old girl, one 32-year-old male with LST and systemic pyemia and one 10-year-old boy with meningitis. Additional morbidity was recorded in 16 adult patients (3.79%). Eight patients suf-fered additional sensorineural hearing loss and 4 had fa-cial paralysis. Three patients had residual otitic hydro-cephalus necessitating a shunt. One patient had a recur-rent brain abscess.

Discussion

Complications of CSOM carried up to 75% mortality in the preantibiotic era [9] . However, with the advent of antibiotics and microsurgical techniques in the manage-ment of ear disease, this incidence declined dramatically

[1, 3, 4] . Unfortunately these complications did not disap-pear completely, and occasional resurgences occur. In the past couple of decades, the incidence of infectious diseas-es increased steadily. Many factors are responsible [10] with massive deterioration of health services in underde-veloped countries, and migration problems and diseases are exported around the world [1014] . Five factors have been associated with the spread of infection. In this study, we reviewed the incidence of complicated suppurative oti-tis media in patients presenting to a tertiary-care univer-sity center. The incidence of complications is 12.54%. This is a relatively high incidence compared to other studies [3, 4, 15, 16] but this is due to a referral bias. The commonest complications were mastoiditis and LST. Other studies re-port variable proportions of complications [1, 6, 8, 17] . However, intratemporal and intracranial complications coexisted in a high proportion of patients [1, 5, 6, 1618] . In our series more than half the patients had multiple

Fig. 4. Mastoiditis and Bezolds abscess. The white arrow shows the collection of pus within the sternomastoid sheath and the connection to the mastoid cavity. Thir-ty-two-year-old diabetic male with 5-year history of CSOM. Sudden onset of neck pain and swelling and torticollis.

Fig. 5. Temporal lobe encephalitis and periventricular abscess. Forty-two-year-old female with leukemia treated with che-motherapy. One-year history of bilateral CSOM. Rapid deterioration of conscious-ness and fits.

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ORL 2009;71:8793 91

complications. There are differences in the infecting or-ganisms in different series but in most cultures they are mixed with a high incidence of negative cultures [3, 7, 8] . Most patients were either under treatment or at least aware of their ear problems, and this did not present a safeguard against complications [3, 7, 8, 17] . In our series, most of the patients had been aware of their ear problem for a long time (mean 3.4 years) and presented to their physician with each exacerbation. Most received occasional medica-tions which reduced the discharge and pain, and then they did not follow up until the moment of presentation. Al-though most patients with acute suppurative otitis media

are treated by antibiotics on an outpatient basis, this is not always a safeguard against complications. Although com-plicated acute otitis media represented only 1.8% of all cases, among hospitalized patients with acute otitis media 21% had a complication compared to 12.4% for CSOM. Our mortality rate is relatively low (1.42%) compared to other studies [2, 5, 15, 18, 19] . The male:female ratio was 1: 1 with an older mean age of presentation [6, 15, 20] . The type of complications seems to vary with age. Younger patients were more prone to extradural abscesses, labyrin-thitis, LST and meningitis. In the older age group, the commonest were facial paralysis followed by LST, brain abscess and finally extradural abscess. Similarly certain complications appeared quite early during the course of the disease such as labyrinthitis and extracranial abscess-es. Other complications could appear a very long time af-ter the diagnosis of CSOM such as brain abscesses, extra-dural abscesses and LST.

Patients with otitis media should be properly managed whenever diagnosed and followed up quite closely. Un-fortunately most patients do not seek medical advice ex-cept when pain occurs, when discharge increases or when a complication becomes established. This problem is multifaceted: poor physician and patient education and increasing health care cost and inadequate availability es-pecially in marginalized and illiterate communities [1013] . The key point here should be increasing physician awareness of the problems inherent in otitis media, espe-cially pediatricians, family doctors and general practitio-ners as well as encouraging early referral to specialized centers for the proper management of these cases.

Complications Numbertotal

21.5 years p value

n % n %

Facial paralysis 122 13 10.6 109 89.4

Mostafa/El Fiky/El Sharnouby ORL 2009;71:879392

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