--- title: "Signs in Complications of Otitis Media" description: "ENT notes on signs seen in complications of Otitis Media." source: "The ENT Resident" author: "Dr. Mausumi Das" canonical_url: "https://www.theentresident.com/ent-notes-lectures/otitis-media-complications-signs" categories: ["Signs, Syndromes, Triads, and Compilation Lists in ENT", "Otology"] video: "https://www.youtube.com/watch?v=dBojdjB13KE" image: "https://media.theentresident.com/og-images/otitis-media-complications-signs.png" --- # Signs in Complications of Otitis Media ENT notes on signs seen in complications of Otitis Media. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=dBojdjB13KE Several classical signs are seen in the complications of otitis media. In this post, we will discuss: * Delta Sign * Griesinger Sign * Ring Sign * Kernig Sign * Brudzinski Sign * Ironed Out Appearance of Mastoid * Lighthouse Sign * Reservoir Sign --- ### Delta Sign #### 📌 Type of Sign 👉 Radiological Sign seen on: * Contrast enhanced CT (CECT) * MRI > What is the other name of Empty Triangle Sign? #### 🔍 What is the Sign? Delta Sign refers to a **triangular filling defect within the dural venous sinus, surrounded by contrast enhancement**. Described radiologically as: 👉 **Central low density with rim enhancement** Seen in **Lateral (Sigmoid) Sinus Thrombosis**, a complication of otitis media. > Which section of CT Scan shows the Delta sign? > What does Central low density with rim enhancement indicate? #### 🔺 Why is it Called Delta Sign? The appearance resembles a **triangle (delta)**, hence the name **Delta Sign**. > What is the most common ENT cause of lateral sinus thrombosis? --- ### Griesinger Sign #### 📌 Type of Sign 👉 Clinical Sign elicited during **Mastoid examination**. #### 🔍 What is the Sign? Griesinger Sign refers to **edema of the post auricular soft tissues overlying the mastoid process**, due to **thrombosis of the mastoid emissary vein**. Seen in **Lateral Sinus Thrombosis**. > What is the pathogenesis behind Griesinger Sign? #### 👨‍⚕️ Eponym Named after Griesinger, who described mastoid region edema due to mastoid emissary vein thrombosis in lateral sinus thrombosis. > Which is the vein involved in Griesinger Sign? --- ### Ring Sign #### 📌 Type of Sign 👉 Radiological Sign Seen on **Contrast enhanced CT or MRI Brain**. #### 🔍 What is the Sign? Ring Sign refers to a **ring enhancing lesion, with a central necrotic or hypodense area surrounded by an enhancing capsule**. Seen in **Brain Abscess**, a complication of otitis media. > What is the pathogenesis behind Ring sign? > What are the stages of Brain abscess? > What is the most common ENT cause of brain abscess? > What is the most common site of otogenic brain abscess? > What is the most common intracranial complication of CSOM? > What are the intracranial complications of CSOM? > What is the Differential Diagnosis of Ring Enhancing Lesion seen on CT? --- ### Kernig Sign #### 📌 Type of Sign 👉 Clinical Sign A sign of **Meningeal irritation**. #### 🔍 What is the Sign? Kernig Sign refers to **pain or resistance on extending the knee when the hip is flexed**. Seen in **Meningitis**, the most common intracranial complication of CSOM. #### 🩺 How is it Elicited? 1- The **hip is flexed** 2- With the hip flexed, the **knee is extended** A **positive sign** is: ✅ Pain in the lower back ✅ Resistance to extension of the knee ✅ Complete inability to extend the knee ⭐ In a normal patient, the knee can be fully extended. #### 🧠 Why Does it Occur? Knee extension stretches the **sciatic nerve and the inflamed meninges**, resulting in pain and spasm, preventing full knee extension. #### 👨‍⚕️ Eponym Named after Vladimir Kernig, who described this sign in patients with meningitis. #### 💡 Mnemonic **KE** from **KE**rnig 👉 **K**nee **E**xtension is painful > What are the CSF findings in bacterial meningitis? --- ### Brudzinski Sign #### 📌 Type of Sign 👉 Clinical Sign A sign of **Meningeal irritation**. #### 🔍 What is the Sign? Brudzinski Sign refers to **involuntary flexion of the hip and knee on flexing the neck**. Seen in **Meningitis**. #### 🩺 How is it Elicited? 1- The patient lies in the **supine position** 2- The examiner gently **flexes the neck forward** A **positive sign** is: ✅ Involuntary hip and knee flexion #### 🧠 Why Does it Occur? Flexion of the neck **stretches the inflamed meninges**. To reduce the stretch and the pain, the patient reflexly **flexes the hip and knee**. #### 👨‍⚕️ Eponym Named after Josef Brudzinski, a Polish paediatrician, who first described this sign. #### 💡 Mnemonic **B** from **B**rudzinski 👉 On **B**ending the neck, hip and knee are flexed --- ### Ironed Out Appearance of Mastoid #### 📌 Type of Sign 👉 Clinical Sign seen during **Examination of the mastoid region**. #### 🔍 What is the Sign? Ironed Out Appearance refers to a **smooth, shiny, flattened appearance of the skin over the mastoid region**, with loss of the normal bony contour. Seen in **Acute Mastoiditis**. ⭐ A normal mastoid feels **irregular**, not smooth, on palpation. #### 🧠 Why Does it Occur? Infection spreads from the middle ear to the mastoid air cells → Breaks through the **mastoid cortex** → **Periostitis** with **subperiosteal pus collection** → Thickened periosteum → Skin over the mastoid becomes **stretched, shiny and swollen** #### 👔 Why is it Called Ironed Out Appearance? The post-auricular swelling destroys the normal mastoid appearance, leaving it flat and smooth like ironed cloth, hence the name **Ironed Out Appearance**. > What are all the other Signs in seen Acute Mastoiditis? --- ### Lighthouse Sign #### 📌 Type of Sign 👉 Clinical Sign seen during **Otoscopy**. #### 📌 Also Known As 👉 Pulsatile Otorrhea #### 🔍 What is the Sign? Lighthouse Sign refers to **pus coming out under pressure through a small pinhole perforation of the tympanic membrane**, synchronizing with each arterial pulse. > Which stage of ASOM do you see Lighthouse sign in? > What are the stages of ASOM? > What is the sign seen in the stage of presuppuration of ASOM? #### 🧠 Why Does it Occur? * Pus collects in the middle ear and mastoid * Pus escapes under pressure through the pinhole perforation * **Transmitted vascular pulsations** from the middle ear make the discharge appear pulsatile * The pulsatile discharge **reflects the light intermittently** during otoscopy #### 🚨 Why is it Called Lighthouse Sign? The intermittently reflecting pulsatile discharge resembles **a lighthouse beam flashing intermittently**, hence the name **Lighthouse Sign**. --- ### Reservoir Sign #### 📌 Type of Sign 👉 Clinical Sign seen during **Otoscopy**. #### 🔍 What is the Sign? Reservoir Sign refers to **rapid refilling of the external auditory canal with pus or discharge within minutes of suctioning it clear**. Seen in **Acute Mastoiditis**. #### 🧠 Why Does it Occur? * **Continuous pus production** in the mastoid air cells and middle ear cleft * Pus keeps draining into the external auditory canal as soon as it is cleared #### 🪣 Why is it Called Reservoir Sign? The mastoid and middle ear act as a **reservoir of pus**, refilling the external auditory canal rapidly each time it is cleaned, hence the name **Reservoir Sign**. --- ### ⭐ High Yield Rapid Revision Table | Sign | Type | Finding | Seen In | | --- | --- | --- | --- | | Delta Sign | Radiological | Triangular filling defect with rim enhancement | Lateral sinus thrombosis | | Griesinger Sign | Clinical | Edema of post auricular soft tissue over the mastoid | Lateral sinus thrombosis | | Ring Sign | Radiological | Ring enhancing lesion with central hypodense core | Brain abscess | | Kernig Sign | Clinical | Pain or resistance on knee extension with hip flexed | Meningitis | | Brudzinski Sign | Clinical | Involuntary hip and knee flexion on neck flexion | Meningitis | | Ironed Out Mastoid | Clinical | Smooth, shiny, flattened skin over the mastoid | Acute mastoiditis | | Lighthouse Sign | Clinical | Pulsatile pus through a pinhole perforation | ASOM, Acute mastoiditis | | Reservoir Sign | Clinical | Rapid refilling of the external auditory canal with pus | Acute mastoiditis | --- ### 🧠 Viva Pearls * Griesinger Sign is due to thrombosis of the mastoid emissary vein. * Ring Sign is seen in brain abscess. * Kernig Sign and Brudzinski Sign are signs of meningeal irritation. * Kernig Sign is pain or resistance on knee extension with the hip flexed. * Brudzinski Sign is involuntary hip and knee flexion on flexing the neck. * Ironed Out Appearance of the mastoid is due to periostitis and subperiosteal pus collection. * Lighthouse Sign is also known as pulsatile otorrhea. * Reservoir Sign is due to continuous pus production in the mastoid and middle ear. --- ## About This Note This free ENT note on Signs in Complications of Otitis Media was written by Dr. Mausumi Das and is paired with a corresponding video lecture. 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