Extracranial Complications of CSOM

🦻 Extracranial Complications of CSOM

Extracranial complications, which are further divided into:

• Intratemporal complications
• Extratemporal complications

🔬 Intratemporal Complications

1️⃣ Mastoiditis

Mastoiditis refers to the inflammation and infection of the mastoid air cell system, which can extend from mucosal involvement to the bony walls of the mastoid.

🔸 Types of Mastoiditis

• Acute Mastoiditis
• Masked (Latent) Mastoiditis

🦠 Acute Mastoiditis

Definition:

Extension of infection from the mucosa lining the mastoid air cells to the bony septa and walls of the mastoid system.

What are the causes of Acute Mastoiditis?

⚕️ Clinical Features

• Mastoid tenderness
• Fever and ear discharge
• Sagging of posterior superior meatal wall
• Ironed-out mastoid
• Obliterated post-auricular sulcus
• Tympanic membrane perforation

What is Ironed-out mastoid? Why does it happen?

💊 Treatment

• Immediate hospitalization
• IV antibiotics and analgesics
• Myringotomy if TM is bulging (AOM cases)
• Cortical Mastoidectomy in chronic or refractory cases

😷 Masked (Latent) Mastoiditis

Definition:

A slowly destructive form of mastoiditis without the overt acute symptoms seen in the acute type.

What are the causes of Masked Mastoiditis?

⚕️ Clinical Features

• Minimal or no pain behind ear
• No discharge, fever, or mastoid swelling
• Thickened, non-translucent tympanic membrane (no perforation)

💊 Treatment

• Full course of IV antibiotics
• Cortical Mastoidectomy

2️⃣ Petrositis

Definition:

Spread of infection from the middle ear or mastoid to the petrous part of the temporal bone.

Association:

• Commonly occurs with acute mastoiditis or cholesteatoma
• Seen in pneumatized petrous apex (present in ~30% individuals)

What is the pathophysiology of Petrositis?

⚠️ Classical Presentation — Gradenigo’s Syndrome

What is the triad seen in Gradenigo’s Syndrom?

💊 Treatment

• IV antibiotics
• Cortical, Radical, or Modified Radical Mastoidectomy (based on extent)

3️⃣ Facial Nerve Paralysis

Facial nerve palsy can occur in both AOM and COM.

🧩 In Acute Otitis Media

Pathogenesis:

• Dehiscence of facial canal → facial nerve exposed beneath middle ear mucosa
• Inflammation spreads to epineurium and perineurium

Timeline:

• Palsy within 10 days → due to inflammation
• Palsy after 2 weeks → due to bony erosion

Treatment

• Systemic antibiotics and myringotomy
• Occasionally corticosteroids
• Cortical mastoidectomy if unresponsive

🧩 In Chronic Otitis Media

Cause:

• Cholesteatoma or granulation tissue eroding the bony facial canal

Clinical Course:

• Slow, insidious onset
• Progressive facial weakness

Investigation:

• HRCT temporal bone to assess disease and facial canal erosion

Treatment:

• Urgent Radical or Modified Radical Mastoidectomy
• Explore facial canal
• Remove granulations gently; preserve uninvolved nerve sheath
• Resect damaged segment and perform nerve grafting

4️⃣ Labyrinthitis

Inflammation of the inner ear (labyrinth), commonly secondary to middle ear infection.

🔸 Types of Labyrinthitis

1. Circumscribed (Localized)
2. Diffuse Serous
3. Diffuse Suppurative (Purulent)

🔹 Circumscribed Labyrinthitis (Labyrinthine Fistula)

Definition:

Abnormal communication between inner ear and middle ear due to erosion of bony labyrinth.

What are the causes of Circumscribed Labyrinthitis?

Clinical Features:

• Intermittent vertigo with normal equilibrium between attacks
• Positive fistula test

What is Fistula test?

How do you perform fistula test?

What are some causes of False positive Fistula test?

What are some causes of False negative Fistula test?

Treatment:

• Systemic antibiotics
• Surgical management to remove source of erosion

🔹 Diffuse Serous Labyrinthitis

Definition:

Diffuse inflammatory reaction of the labyrinth without pus formation — reversible stage.

What are the causes of Diffuse Serous Labyrinthitis?

Clinical Features:

• Spontaneous vertigo
• Irritative nystagmus
• Positive fistula test (if fistula present)
• Mild SNHL

Treatment:

• Head immobilization (affected ear up)
• IV antibiotics
• Labyrinthine sedatives
• Myringotomy if due to AOM
• Cortical mastoidectomy if indicated

🔹 Diffuse Purulent Labyrinthitis

Definition:

Diffuse pyogenic infection of the labyrinth with irreversible cochlear and vestibular damage.

Causes:

• Usually follows serous labyrinthitis

Treatment:

• Same as serous form + occasionally labyrinth drainage

🌐 Extratemporal Complications

There are six main abscesses associated with the mastoid that form the extratemporal complications.

1️⃣ Post Auricular Abscess

Definition:

Collection of pus in the post-auricular region, typically following acute mastoiditis.

Clinical Features:

• Swelling behind ear
• Tenderness and warmth
• Obliterated post auricular groove
• Sagging posterior superior canal wall

Treatment:

• IV antibiotics
• Cortical Mastoidectomy

2️⃣ Zygomatic Abscess

Definition:

Pus collection above and in front of the pinna (temporal fossa over zygomatic arch).

Features:

• Swelling in temporal region
• Upper eyelid edema

Treatment:

• IV antibiotics
• Surgical drainage / Mastoidectomy

3️⃣ Bezold’s Abscess

Definition:

Deep neck abscess due to erosion of the mastoid tip, with pus tracking along SCM sheath.

Clinical Features:

• Painful upper neck swelling
• Torticollis

Treatment:

• IV antibiotics
• Neck abscess drainage
• Mastoidectomy

4️⃣ Luc’s Abscess

Definition:

Subperiosteal abscess within the external auditory canal, without bony mastoid destruction.

Features:

• Localized swelling in posterior superior canal wall

Treatment:

• IV antibiotics
• Drainage as needed

5️⃣ Citelli’s Abscess

Definition:

Posteriorly tracking pus collection from acute mastoiditis into the occipital region.

Features:

• Swelling in occipital region
• Tracks via Citelli’s tract and posterior digastric groove

Treatment:

• IV antibiotics
• Surgical drainage / Mastoidectomy

6️⃣ Parapharyngeal / Retropharyngeal Abscess

Cause:

Spread from peritubal cell infection or acute coalescent mastoiditis.

Treatment:

• IV antibiotics
• Drainage procedure
• Address underlying mastoiditis