Intratemporal and Intracranial Complications of Otitis Media

Intratemporal and Intracranial Complications of Otitis Media

Alexander H. Arts

Meredith E. Adams

Otitis media (OM) is a heterogeneous disease with a wide spectrum of presentations and natural histories. The etiology, presentation, natural history, and management of acute and chronic otitis media (AOM and COM) are discussed in detail in other chapters. In this chapter, we discuss the complications, both intratemporal and intracranial, of AOM and COM and cholesteatoma, and their management. These complications are summarized in Table 149.1.

AOM is a common infection, estimated to represent up to 5.8% of all patient visits to physicians (1, 2). In the vast majority of cases, the pathologic process is self-limited, or resolves with antibiotic therapy. Indeed, although not universally agreed upon, some have recently considered observation alone for straightforward cases of AOM, with antibiotics reserved for refractory cases, or for prevention of complications in higher risk patients (3). AOM may resolve completely, resolve and recur, or evolve into one of many manifestations of COM. Complications of OM can occur directly from AOM or arise from COM. Although these complications are rare today, they occur in developed countries at approximately the same frequency as in underdeveloped countries, and are associated with high rates of serious morbidity and mortality (4). Prompt diagnosis and rapid, effective therapy are critical to minimizing these sequelae.


Complications of OM tend to present in predictable patterns (Table 149.3). With the exception of meningitis in children and some cases of facial paralysis, which are usually associated with AOM, most complications tend to be associated with COM. Typically, mastoiditis is the initial complication, with more severe complications developing secondarily. Petrositis (petrous apicitis), for example, almost never occurs without preceding mastoiditis. Labyrinthine fistulae virtually always develop secondary to cholesteatoma. Granulation tissue in air cells adjacent to the sigmoid sinus can result in erosion of the bone overlying the sinus, with resultant sigmoid sinus exposure and possible sigmoid sinus thrombophlebitis. If the sigmoid becomes obstructed with thrombus, intracranial hypertension, that is, otitic hydrocephalus, can result (11). Retrograde thrombophlebitis may extend intracerebrally, resulting in a brain abscess. Subdural empyema rarely occurs due to COM, but is a more typical complication of meningitis in infants.


Origin of complication

Acute infection

Meningitis—infants and young children

Meningitis—adults or children with occult CSF leaks

Facial paralysis—children more commonly


Subdural abscess—infants more commonly

Subacute or chronic infection



Facial paralysis


Extradural abscess and granulations

Sigmoid sinus thrombophlebitis

Brain abscess

Otitic hydrocephalus


Subdural abscess

Patterns of associated diseases and usual sequence

Mastoiditis or petrositis

Extradural granulation tissue and/or abscess

Sigmoid sinus thrombophlebitis

Brain abscess or otitic hydrocephalus


Subdural abscess—infants more commonly

Without a high index of suspicion, early evidence of an impending complication will be missed. Early symptoms and signs of complication are summarized in Table 149.4. Because antibiotic therapy may have a masking effect on the significant signs and symptoms of complications, a high level of clinical awareness is important for early diagnosis. Persistence of acute symptoms for 2 weeks or more or recurrence of symptoms or infection within 2 weeks is often the first sign of a potential complication. In chronically draining ears, acute exacerbation of pain or the new development of fetid drainage should be evaluated. Foulsmelling drainage that fails to respond to conservative treatment (debridement and topical antibiotics) portends an impending complication.

Once a complication has begun, signs and symptoms typically progress rapidly. Fever associated with COM
implies some degree of extracranial cellulitis or intracranial infection. Postauricular edema/erythema, edema of the posterior-superior external auditory canal (EAC) wall, or anterolateral displacement of the pinna indicates mastoiditis associated with subperiosteal abscess. Retro-orbital pain in an infected ear is highly suggestive of petrositis (petrous apicitis). Vertigo and nystagmus in a patient with OM may indicate serous or suppurative labyrinthitis, or possibly a labyrinthine fistula. Facial paralysis ipsilateral to an infected ear may complicate AOM, or COM with cholesteatoma. Papilledema is an obvious sign of elevated intracranial pressure, but will go undetected without a fundoscopic examination. Headache and lethargy usually accompany an intracranial infectious complication. Meningismus is associated with meningitis, and focal neurologic signs or seizures are seen in brain abscess.


Impending complication

Persistence of acute infection for 2 weeks or more

Recurrence of symptoms within 2 weeks after initial resolution

Acute exacerbation of chronic infection, especially if foul-smelling

Foul-smelling discharge during treatment

Haemophilus influenza type B or anaerobes

Complication (associated complication)

Fever associated with a chronic perforation (intracranial infection or extracranial cellulitis)

Pinna displaced inferolaterally and/or edema of the posterosuperior ear canal wall skin (subperiosteal abscess)

Retro-orbital pain (petrositis)

Vertigo in a patient with an infected ear (labyrinthitis or labyrinthine fistula)

Facial paralysis ipsilateral to an infected ear (facial paralysis)

Headache and lethargy (intracranial complication of any sort)

Meningismus (meningitis or subdural abscess)

Focal neurologic signs or seizure (brain abscess)

Global neurologic signs (subdural abscess or meningitis)

May 24, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Intratemporal and Intracranial Complications of Otitis Media

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