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. Editors 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: dubeysp@datec.net.pg 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 Bezolds 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. Lucs 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-

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sion depending on the lateral or medial location of it. 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. The temporal lobe abscess was drained through a burr hole in the temporal bone, which was accessed through a small extension of the anterosuperior aspect of the mastoid incision. The subdural, epidural, and perisinus abscesses were also drained. All the patients were treated with intravenous antibiotic in various combinations consisting of chloramphenicol, crystalline penicillin, metronidazole, ceftriaxone, and ceftazidime.

RESULTS
Twenty-two (31%) patients were in the first decade, 17 (24%) in second, 21 (30%) in third, 5 (7%) in fourth, 2

(2.9%) in fifth, and one (1%) each in sixth, seventh, and eighth. The age ranged from 4 months to 73 years with an average age of 21 years. Thirty (43%) of the patients were 16 years and less. The male to female ratio was 3:1. The clinical features of the patients were otorrhea in 63 (90%), fever in 27 (39%), mastoid abscess in 26 (37%), neck stiffness in 21 (30%), postauricular fistula in 17 (24%), vomiting in 15 (21%), meningism in 14 (20%), facial palsy in 10 (14%), loss of equilibrium in 6 (9%), and seizures in 5 (7%). Of the 70 patients, 39 (56%) had exclusive extracranial complications, 8 (11%) had only intracranial complications, and 23 (33%) had both (Fig. 1). Of these, otitic meningitis was the most common intracranial complication, which was encountered in 14 (20%) patients. This

Fig. 1. Pattern of different complications of CSOM affecting patients.

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was followed by lateral sinus thrombosis in 10 (14%), cerebellar abscess in 6 (9%), epidural abscess in 4 (6%), perisinus abscess in 3 (4%), interhemispheric abscess in 2 (3%), temporal lobe abscess in one (1%), and subdural abscess in another one (1%) patient. Among the extracranial complications, mastoid abscess was seen in 26 (37%) cases, postauricular fistula in 17 (24%), facial nerve palsy in 10 (14%), Bezold abscess in 5 (7%), internal jugular vein thrombosis in 5 (7%), Gradenigo syndrome in 2 (3%), serous labyrinthitis in 2 (3%) and Lucs abscess in one (1%). Two postauricular fistulae were seen in 5 (7%) patients. Other complications, which were found in our series, were Potts puffy tumor, pneumonia, and paravertebral abscess in one patient each and septicemia in two. The last two also had intracranial complications and succumbed to these infections. Cholesteatoma were encountered in the middle ear and the mastoid cavity in 31 (44%) patients, a combination of cholesteatoma and granulation tissue were seen in 22 (31%). Sixteen (23%) patients had exuberant granulation tissue alone. On the basis of clinical and radiologic finding, the lateral sinus were exposed and/or explored in 13 (19%) patients. The classic spiking (picket fence) pattern of temperature was noticed in all patients. Depending on the surgical findings, lateral sinus conditions from normal to most severe pathology were classified as type I, II, III, or IV as shown in Table I . Of the 13 patients in whom the lateral sinus was exposed and/or explored, 3 (24%) had type I, 2 (15%) had type II, 6 (46%) had type III, and 2 (15%) had type IV. Therefore, based on this classification, 10 (14%) had established lateral sinus complications. Among the patients who died, three were found to have type III and two had type IV intraoperative findings. There were six (9%) patients with cerebellar abscess in our series. Only one patient in this group left our hospital early to have successful treatment elsewhere. 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. The average amount of pus drained was 27 mL (range, 12 45 mL). All five patients had successful recovery. Among the

14 (20%) patients with otitic meningitis, four (29%) patients died. The overall mortality of the intracranial complications was seen in nine (13%) patients. Otitic facial nerve palsy was encountered in 10 (14%) patients. Nine underwent operation and one was lost in the follow up before operation. The facial nerves were decompressed in these nine cases. Six had an intact fallopian canal and had recovered to House-Brackmann grade I postoperatively. Three had erosion of the fallopian canal with evidence of granulation tissue over and around the facial nerve. These three patients failed to regain full facial nerve function postoperatively and their final facial nerve status was House-Brackmann grade III. Postauricular fistula was seen in 17 (24%) patients who presented with this condition. 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 (12%) underwent an inferiorly based flap in similar situation. One patient who also had coexistent tuberculous otitis media developed a large postauricular bony defect postoperatively. Hence, a pedicled calvarial bone graft was used for closure.

DISCUSSION
Despite the advent of antibiotics and advancement in our knowledge and skills in managing otitis media, serious complications still exist. These are more common in the first 3 decades of life in our series as well as in others.4,5 Males seem to have a higher preponderance for otogenic complications compared with females.1,5 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. The development of subperiosteal abscess with or without fistula leads to reduction of pressure of pus within the middle ear cleft, which in turn reduces the chances of infection spreading intracranially. The mastoid antrum is shallower in younger people. It reaches adult thickness by the age of 16 years. Consequently, we found younger patients frequently develop mastoid abscess and postaural fistula than intracranial complications. Although only 21% of patients in our series had otitic facial palsy, its incidence is variable.5,6 Facial nerve palsy as a result of chronic otitis media is associated with dehiscence or destruction of the bony facial canal by cholesteatoma.6 Various explanation were given as to the exact cause of it.2,3,5 Otitic meningitis is the most common intracranial complication.5 Headache, neck stiffness, and fever are the most important clinical features of otitic meningitis.5 Otitic meningitis is often associated with other intracranial complications.5,7 Therefore, computed tomography scan is necessary to rule out other intracranial complications.7 The mortality rate from otitic meningitis in our series was 29%. It was similar to other study.5 Lateral sinus thrombosis in our series had a higher mortality rate compared with others.4,8 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. These factors contribute to perpetuation and propagation of infection, resulting in the Dubey and Larawin: Otogenic Complications

TABLE I. Types of Intraoperative Lateral Sinus Conditions.

Type Intraoperative Finding

I II

III

IV

Normal blue sinus wall, blood flow in sinus was verified by aspiration with syringe and needle Dull lusterless sinus wall; blood could not be aspirated by syringe and needle; soft infected thrombus found in the sinus lumen after opening it; sinus blood flow encountered after removal of clot Thick sinus wall with perisinus granulation; sinus outline was apparent proximally and distally; with or without scanty intrasinus pus; no intrasinus blood flow resulting from thrombotic occlusion; blood flow can be established with balloon catheter at the transverse sinus end Extensive perisinus granulation with perisinus abscess; osteitic bone all around the sinus; sinus outline indistinguishable; involvement of transverse sinus proximally and internal jugular vein distally; difficult to establish proximal blood flow with balloon catheter

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development of this serious complication. None of the patients in our series received any thrombolytics because of the risk of dissemination of infected thrombus and its consequences.8 The occurrence of interhemispheric abscess in two patients in our series is a clear manifestation of delayed diagnosis from reasons explained previously. It also shows how far the infection can spread. Moreover, its unusual location makes it difficult to manage surgically. On the basis of our experiences, we proposed a gradation of severity of involvement of the lateral sinus by otogenic infections. We hope that this gradation will help in uniform surgical intervention and its reporting. We do not have magnetic resonance in our country. Hence, in these complicated cases, we used to use computed tomography scan. Therefore, once the patients have spiky temperatures in the preoperative period, we prefer to expose the lateral sinus in anticipation of an infected thrombus in it. On the contrary, others have used conservative treatments in this situation.9 It is possible for them to treat this condition conservatively because they can follow up the lateral sinus condition radiologically by magnetic resonance.9 We also suggest that the complications of CSOM should be categorized as regional and systemic. The former can be subdivided into intracranial and extracranial or meningeal and nonmeningeal. The systemic one should include those resulting from metastatic infections from the temporomastoid bone and the lateral sinus. Once these systemic complications sets in the patient, it may follow an irreversible downhill clinical course. It happened in three of our cases. Hence, we used to remove the infected material from the lateral sinuses and the internal jugular veins.

CONCLUSION
Otogenic complications of CSOM still pose a great challenge to developing countries despite its declining incidence. This can be attributed to lack of public health awareness and inadequate healthcare delivery system. It is in such a situation that early diagnosis and prompt surgical interventions are most important for the survival of these patients.

BIBLIOGRAPHY
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