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7) complications of active com

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1. Complications of active COM Classification of complications Extracranial complications are postauricular abscess,facial palsy, petrous apicitis, Bezold’s…
  • 1. Complications of active COM Classification of complications Extracranial complications are postauricular abscess,facial palsy, petrous apicitis, Bezold’s abscess(neck abscess as a result of direct extension from suppuration in the mastoid tip). Intracranial complications are meningitis, brain abscess, extradural abscess, subdural abscess,lateral sinus thrombosis & otitic hydrocephalus. Relative incidence of complications in active mucosal & squamous COM Extracranial Intracranial Postauricular abscess 75% Brain abscess 51% Facial palsy 6% Subdural abscess 20% Bezold’s abscess 2% Extradural abscess 10% Petrous apicitis .2% Lateral sinus thrombosis 20% Meningitis 12% Extracranial complications 1) Sensorineural hearing loss: it has been suggested that toxins in COM can damage the cochlea. The risk of sensorineural hearing loss may increase with age. Sensorineural hearing loss may result from the treatment of active COM with potentially ototoxic eardrops. 2) Sudden sensorineural hearing loss may also occur. 3) Labyrinthine complications: chronic low grade imbalance with or without detectable nystagmus, implies the development of a labyrinthine fistula(almost invariable lateral semicircular canal). Erosion of the bone overlying the lateral canal arises in both mucosal & squamous epithelial disease, particularly if there is extensive granulation tissue formation. The mechanism likely to be the inflammatory reaction provoking osteitis in the labyrinthine bone with osteoclastic & osteablastic activity(osteaclastic activity predominant). When the inflammatyory process is eliminated by surgery, bone regeneration may occur over such a fistula. 4) Facial nerve complications: it is usually associated with dehiscence of the fallopian canal, present in around 10% of ears. Erosion of fallopian canal can occur in both active mucosal & squamousal disease, particularly in the presence of granulation tissue. Granulation tissue may form on the nerve sheath itself, is extremely hazardous to the nerve& should be carried out under direct vision.
  • 2. Management of extracranial complications 1. Labyrinthine complications: acute labyrinthitis should be managed medically with bed rest, intravenous antibiotics, labyrinthine sedatives such as prochlorperazine. When the general conditions has improved,usually after several days, middle ear& mastoid should be explored & appropriate surgery carried out. Most surgeon recommoned a canal wall down mastoidectomy. The cholesteatoma matrix should be left undisturbed over the semicircular canals until all other disease is removed & all other aspect of the procedure such as meatoplasty are completed. The matrix should then be carefully lifted& the fistula identified. It is then peel off the membranous labyrinth & fistula is immediately sealed with fascia & bone dust. The fascia graft for the tympanic membrane provides a further layer of closure. The risk of loss of cochlear function are higher in large fistula(>2mm). 2. Facial nerve complications: In the presence of a facial nerve palsy, active COM should be treated urgently, appropriate intravenous antibiotic & almost always surgically. Active mucosal COM should be managed by cortical mastoidectomy & exploration of middle ear with careful removal of granulation tissue from the fallopian canal. Some surgeons believe that the canal should be widely decompressed & nerve sheath opened. Others think that removal of disease is adequate & opening of the nerve sheath increases the risk of surgical trauma to the facial nerve. Complete recovery can be expected in most cases after careful surgical management. Intracranial complications There are several route by which sepsis may spread to the cranial cavity from an inected ear. 1. The most common route by direct erosion of osteitis bone by the inflammatory process. 2. via infected thromobophlebitis of the emissary vein traversing bone & dura. 3. Via fractures & surgical defect. 4. Normal anatomical weak points such as oval & round window. Meningitis : meningitis usually presents as an acute illness with severe headache, neck stiffness & in the later stage drowsiness. The suspicion of meningitis should be raised in fit with severe acute pyrexia illness with headache who has a history of a discharging ear, particularly if there is neck stiffness. The diagnosis is confirmed by lumber puncture & culture of CSF fluid will identify the organism. Intracranial abscess : the presentation is often much more insidious with mild headache, low grade fever, later stages weakness, lethargy &drowsiness. The most common sites for otitic intracranial abscess are temporal lobe & cerebellum. Brain abscess may be accompanied by fit with focal neurological signs. Diagnosis is made by CT scanning.
  • 3. Lateral sinus thrombosis: infection spread to the venous sinus directly from the mastoid or via any of the venous channels draining the middle ear & mastoid. Initially mural thrombus forms in the sinus which progagates & organizes. Development of infection in the thrombus, there may be abscess formation in close vicinity of the vein. The clinical features will frequently modified by antibiotic therapy but pyrexia, otalgia, mastoid & neck tenderness in systemically ill patient are suggestive. The disease is frequently complicated by other intracranial septic complications such as meningitis or brain abscess. Papilloedema is frequently present & highly suggestive of the diagnosis. The investigation usually undertaken first is CT scanning but MRI may add further information particularly about venous flow in the sinus. Otitic hydrocephalus: otitic hydrocephalus(benign intracranial hypertension) is the rarest of the intracranial complications of the ear & may occur after an episode of acute otitis media as well as complicating COM. Lateral sinus thrombosis with comcomitant obstruction of other intracranial venous sinuses. The presence of papilloedema is suggestive. Early CT scanning is necessary to make the diagnosis & rule out other intracranial septic complications. Management of intracranial complications The basic principles of management of intracranial sepsis resulting from COM are: 1. Broad spectrum intravenous antibiotics in effective dose should be started. A bacteriological swab should be taken from ear for culture & sensitive. 2. Full neurological observations; 3. Neurosurgical managements; 4. Management of the ear disease. Meningitis : treatment is intravenous antibiotic & observation. Management of ear should be deferred for a few day until the patient’s condition does not improves. However,if patient’s condition does not improve after 48 hours, or if it deteriorates, then immediate exploration of the ear is indicated. Intracranial abscess: abscess require drainage, otogenic extradural abscesses usually lie adjacent to the temporal bone. The most appropriate surgical approach to the abscess is through the mastoid, therefore, the ear disease should be managed at the same time. Subdural & intracranial abscess are managed by the neurosurgeon, 1. Aspiration through a Burrhole, which may be required repeatedly or 2. By craniotomy,excision of abscess. Management of ear is usually delayed untill the patient’s condition improves.
  • 4. Lateral venous sinus thrombosis: early surgical management is important. Surgical access to the lateral sinus is through mastoid. After clearing the disease from mastoid, bone covering the lateral wall is removed. The sinus is opened & infected clot is removed. Bleeding is controlled by placing packing between the walls of the sinus & bone. It is occasionally necessary to ligate the internal jugular vein. Otitic hydrocephalus: management is reduction of the raised intracranial pressure by steroids, diuretics & hyperosmolar dehydration agents. Treatment may need to be continued for many weeks. Occasionally a ventriculoperitoneal shunt may be required. Best clinical practice 1. Complication should be suspected in any patient with COM who is generally unwell, pyrexia & headache. 2. Early & effective management of complications is important. 3. Management of the ear.
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