Abstract
Objective
The aim of the study was to review the pathogenesis and the result of management of the intracranial complications of chronic middle ear suppuration.
Methods
This was a retrospective review of charts of 32 cases with intracranial complications due to chronic middle ear infection managed between 1993 and 2007. The symptoms, clinical findings, and medical and surgical management were reviewed and analyzed.
Results
There were 10 (31.2%) patients in the age group of 0 to 10 years, 9 (28.1%) patients in the age group of 11 to 18 years, and 13 (40.6%) patients older than 18 years. Males were involved twice as much as females. Among the 32 patients, 18 (56.3%) had a single intracranial complication, whereas 14 (43.7%) had multiple intracranial complications. Among all the intracranial complications in the 32 patients, otitic meningitis was the commonest intracranial complication and was seen in 14 (43.7%) patients; it was followed by lateral sinus thrombosis in 10 (31.2%), cerebellar abscess in 6 (18.7%), epidural abscess in 7 (21.8%), and perisinus abscess in 5 (15.6%). Other less common but serious intracranial complications encountered were cerebral abscess and interhemispheric abscess in 2 (6.2%) each, and subdural abscess, otitic hydrocephalus, and otogenic cavernous sinus thrombosis in 1 (3.1%) each. Upon admission, all patients received a combination of parenteral antibiotics. Canal wall down mastoidectomy was performed in all but 1 patient. In addition, lateral sinus was explored in 13 (40.6%) and cerebellar abscesses were drained in 5 (15.6%) patients. The overall mortality rate of 31.2% was found in our series.
Conclusion
The prognosis was worse with delayed presentation because of overwhelming intracranial infection due to multiple pathways of extension from chronic otitis media. Infected thrombus in the dural venous sinus should be removed to prevent dissemination of septic emboli.
1
Introduction
Intracranial complications used to arise as a result of untreated chronic middle ear infection . The overall mortality has decreased over the years . This is true for the developed world where there is better socioeconomic condition and health care delivery system. However, in the developing countries, this condition is still a matter of grave concern . In this article, we reviewed the mechanism of intracranial spread and the result of management of the patients with intracranial complications from chronic suppurative otitis media.
2
Materials and methods
The medical and surgical records of 32 patients with intracranial complications were investigated retrospectively. All patients were admitted to our hospital and were managed between 1993 and 2007. The surgical interventions were determined by the clinical, pathologic, and radiologic findings. All patients underwent canal wall down mastoidectomy. Additional procedures were mandated by their underlying diagnosis. Parenteral antibiotics consisting of metronidazole, chloramphenicol, crystalline penicillin, and third-generation cephalosporins in different combinations were administered to patients immediately upon admission. The timing of operations was determined by the general and neurologic conditions of these patients. During the same period, we managed 5 cases of intracranial complications from patients with acute otitis media who primarily presented to the otolaryngologist.
2
Materials and methods
The medical and surgical records of 32 patients with intracranial complications were investigated retrospectively. All patients were admitted to our hospital and were managed between 1993 and 2007. The surgical interventions were determined by the clinical, pathologic, and radiologic findings. All patients underwent canal wall down mastoidectomy. Additional procedures were mandated by their underlying diagnosis. Parenteral antibiotics consisting of metronidazole, chloramphenicol, crystalline penicillin, and third-generation cephalosporins in different combinations were administered to patients immediately upon admission. The timing of operations was determined by the general and neurologic conditions of these patients. During the same period, we managed 5 cases of intracranial complications from patients with acute otitis media who primarily presented to the otolaryngologist.
3
Results
There were 10 (31.2%) patients in the age group 0 to 10 years, 9 (28.1%) patients in the age group 11 to 18 years, and 13 (40.6%) patients older than 18 years. The oldest patient was 31 years old. The male-to-female ratio was 2:1.
Among the 32 patients, 18 (56.2%) had a single intracranial complication, whereas 14 (43.7%) had multiple intracranial complications. Of those 18 with single intracranial complication, otitic meningitis were seen in 10 (31.2%) patients and lateral sinus thrombosis (LST), subdural abscess, and cerebellar abscess in 2 (6.2%) patients each, and temporal lobe abscess and interhemispheric abscess in 1 (3.1%) patient each. Of the 14 patients with multiple intracranial complications, 4 (12.5%) patients had combination of more than 2 complications; those were LST, cerebellar abscess with otitic hydrocephalus, epidural abscess, LST, perisinus abscess with meningitis, epidural abscess, cerebellar abscess with meningitis and LST, and interhemispheric abscess with meningitis in 1 (3.1%) case each. Ten (31.2%) patients had combination of 2 intracranial complications. Those were LST with perisinus abscess in 3 (9.4%) cases and epidural abscess with cerebellar abscess in 2 (6.2%) cases, and LST with epidural abscess, LST with cavernous sinus thrombosis, epidural abscess with meningitis, perisinus abscess with epidural abscess, and parietal lobe abscess with epidural abscess in 1 (3.1%) case each.
All patients presented with offensive ear discharge. This was found in the right ear as much as in the left. Intermittent fever and headache were seen in 32 (100%) and 16 (50%) patients, respectively. Cerebellar symptoms such as falling sensation, ataxia, and disequilibrium were seen in 6 (18.7%) patients each. Seizures were also encountered as presenting compliant in 4 (12.5%) patients. On admission, 32 (100%) patients were noted to have high-grade fevers; this was followed by neck stiffness in 26 (81.2%), meningism in 15 (46.8%), irritability in 13 (40.6%), positive cerebellar signs in 6 (18.7%), altered mental status in 3 (9.3%), and Griesinger sign in 1 (3.1%). Positive signs of cavernous sinus thrombosis, namely, ipsilateral ptosis, conjunctival chemosis, ophthalmoplegia, and 6th nerve palsy were seen in 1 (3.1%). Contrast-enhanced computed tomographic scans were performed routinely to plan a more definitive course of management.
Canal wall down mastoidectomy was the baseline surgical procedure performed in 31 (96.8%) patients. One (3.1%) was conservatively managed as the patient was too sick to undergo operation. The patient had lateral sinus, internal jugular vein, and cavernous sinus thrombosis. The patient ultimately died of the infection. Cholesteatoma with or without granulation tissue was found in the tympanic cavity of all the 31 (96.8%) patients who underwent surgical exploration. Lateral sinus infection was suspected in 13 (40.6%) patients. Of these, 3 (9.3%) had type I, 2 (6.2%) had type II, 6 (18.7%) had type III, and 2 (6.2%) had type IV lateral sinus condition according to the Dubey-Larawin classification ( Table 1 ). Drainage of cerebral and cerebellar abscesses was done in 2 (6.2%) and 5 (15.6%) patients, respectively ( Fig. 1 ). One (3.1%) patient with cerebellar abscess left the hospital to seek treatment elsewhere. Ten (31.2%) patients in our series died as a result of their underlying intracranial as well as other associated complications ( Table 2 ).
