Chronic suppurative otitis media

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    • a long-standing infection of a part or whole of the middle ear cleft characterised by ear discharge and a permanent perforation.
    • Permanent perforation
      • A perforation becomes permanent when its edges are covered by squamous epithelium
      • it does not heal spontaneously.
    • Single most important cause of hearing impairment in rural population
    • Types of CSOM
      • Tubotympanic
        • Also called the safe or benign type
        • it involves anteroinferior part of middle ear cleft, i.e. eustachian tube and mesotympanum
        • is associated with a central perforation.
        • There is no risk of serious complications.
      • Atticoantral
          • Also called unsafe or dangerous type
          • it involves posterosuperior part of the cleft (i.e. attic, antrum and mastoid)
          • it is associated with an attic or a marginal perforation.
          • The disease is often associated with a bone-eroding process such as cholesteatoma, granulations or osteitis.
          • Risk of complications is high in this variety.

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        • Tubotympanic Type CSOM
                            • Ear discharge
              • It is non-offensive, mucoid or mucopurulent, constant or intermittent.
              • The discharge appears mostly
                • at time of upper respiratory tract infection
                • on accidental entry of water into the ear.
            • Hearing loss
              • It is conductive type
              • severity varies but rarely exceeds 50 dB.
              • What is round window shielding effect
                • Sometimes, the patient reports of a paradoxical effect, i.e. hears better in the presence of discharge than when the ear is dry.
                • This is due to "round window shielding effect" produced by discharge which helps to maintain phase differential.
                • In the dry ear with perforation, sound waves strike both the oval and round windows simultaneously, thus cancelling each other’s effect
              • In long standing cases, cochlea may suffer damage , hearing loss becomes mixed type.
            • Perforation
              • Always central
            • Middle ear mucosa
              • It is seen when the perforation is large.
              • Normally, it is pale pink and moist
            • Treatment
              • Aural toilet
              • Ear drops
                • Antibiotic ear drops containing neomycin, polymyxin, chloromycetin or gentamicin are used.
                • They are combined with steroids which have local anti-inflammatory effect.
                • Acid pH helps to eliminate pseudomonas infection, and irrigations with 1.5% acetic acid are useful.
              • Precautions
                • Patients are instructed to keep water out of the ear during bathing, swimming and hair wash.
                • Hard nose-blowing can also push the infection from nasopharynx to middle ear and should be avoided.
              • Surgical treatment
                • Aural polyp or granulations, if present, should be removed before local treatment with antibiotics.
                • An aural polyp should never be avulsed as it may be arising from the stapes, facial nerve or horizontal canal and thus lead to facial paralysis or labyrinthitis.
              • Reconstructive surgery
                • Once ear is dry, myringoplasty with or without ossicular reconstruction can be done to restore hearing. (MCQ)
        • Atticoantral Type CSOM
          • It involves posterosuperior part of middle ear cleft (attic, antrum and posterior tympanum and mastoid)
          • associated with cholesteatoma
          • the disease is also called unsafe or dangerous type.
          • Atticoantral diseases is associated with the following pathological processes:
            • Cholesteatoma
            • Osteitis and granulation tissue
              • Osteitis involves outer attic wall and posterosuperior margin of the tympanic ring.
              • A mass of granulation tissue surrounds the area of osteitis
              • A fleshy red polypus may be seen filling the meatus.
            • Ossicular necrosis
              • It is common in atticoantral disease.
              • hearing loss is always greater than in disease of tubotympanic type.
            • Cholesterol granuloma
              • It is a mass of granulation tissue with foreign body giant cells surrounding the cholesterol crystals.
              • It is a reaction to long-standing retention of secretions or haemorrhage
              • When present in the mesotympanum, behind an intact drum, the latter appears blue.
            • Who is cholesteatoma hearer
              • Occasionally, the cholesteatoma bridges the gap caused by the destroyed ossicles, and hearing loss is not apparent (cholesteatoma hearer).
        • Symptoms
            • Ear discharge
              • Usually scanty, but always foul-smelling due to bone destruction.
              • Total cessation of discharge from an ear which has been active till recently should be viewed seriously, because
                • perforation in these cases might be sealed by crusted discharge
                • inflammatory mucosa or a polyp, obstructing the free flow of discharge.
                • Pus, in these cases, may find its way internally and cause complications.
          • Hearing loss
            • Hearing is normal when
              • ossicular chain is intact
              • when cholesteatoma, having destroyed the ossicles, bridges the gap caused by destroyed ossicles (cholesteatoma hearer).
            • Hearing loss is mostly conductive but sensorineural element may be added.
          • Bleeding
            • It may occur from granulations or the polyp when cleaning the ear.
        • Signs
          • Perforation
            • It is either attic or posterosuperior marginal type.
          • Retraction pocket
            • An invagination of tympanic membrane is seen in the attic or posterosuperior area of pars tensa.
          • Cholesteatoma
        • . Investigations
          • X-ray mastoids
              • They are useful to indicate a low-lying dura or an anteposed sigmoid sinus.
              • Cholesteatoma causes destruction in the area of attic and antrum (key area), better seen in lateral view.
            • CT scan temporal bone
              • CT scan of temporal bone gives more information and is preferred to X-ray mastoids.
            • Features Indicating Complications in CSOM
              • Pain
                • Pain is uncommon in uncomplicated CSOM.
                • Its presence is considered serious as it may indicate
                  • extradural, perisinus or brain abscess.
                  • otitis externa associated with a discharging ear.
              • Vertigo
                • It indicates erosion of lateral semicircular canal which may progress to labyrinthitis or meningitis.
                • Fistula test should be performed in all cases.
              • Persistent headache
                • It is suggestive of an intracranial complication.
                • Facial weakness
                • indicates erosion of facial canal.
                • A listless child refusing to take feeds and easily going to sleep indicate extradural abscess
                • Fever, nausea and vomiting –intracranial infection
                • Irritability and neck rigidity — meningitis
                • Diplopia – Gradenigo’s syndrome
                • Ataxia – labyrinthitis or cerebellar abscess
                • Abscess round the ear — mastoiditis
            • Treatment
              • Surgical
                • It is the mainstay of treatment.
              • Canal wall down procedures.
                • They leave the mastoid cavity open into the external auditory canal so that the diseased area is fully exteriorised.
                • The commonly performed operations for atticoantral disease are
                  • Atticotomy
                  • modified radical mastoidectomy
                  • radical mastoidectomy
              • Canal wall up procedures.
                • Here disease is removed by combined approach through the meatus and mastoid but retaining the posterior bony meatal wall intact
                • an open mastoid cavity is avoided
                • It gives dry ear
                • It permits easy reconstruction of hearing mechanism.
                • However, there is danger of leaving some cholesteatoma behind. Incidence of residual or recurrent cholesteatoma in these cases is very high
                • long-term follow-up is essential.
                • Some surgeon’s even advise routine re-exploration in all cases after 6 months or so.
                • Canal wall up procedures are advised only in selected cases
                  • Combined-approach or intact canal wall mastoidectomy
                    • disease is removed both permeatally, and through cortical mastoidectomy
                  • Posterior tympanotomy approach,
                    • a window is created between the mastoid and middle ear, through the facial recess, to reach sinus tympani
            • Hearing can be restored by myringoplasty or tympanoplast

            Complications of Suppurative Otitis Media

              • Classification
                • Intratemporal (Within the Confines of Temporal Bone)
                  • Mastoiditis
                  • Petrositis
                  • Facial paralysis
                  • Labyrinthitis.
                • Intracranial
                  • Extradural abscess
                  • Subdural abscess
                  • Meningitis
                  • Brain abscess
                  • Lateral sinus thrombophlebitis
                  • Otitic hydrocephalus.
              • Sequelae of Otitis Media – direct result of middle ear infection
                • Perforation of tympanic membrane
                • Ossicular erosion
                • Atelectasis and adhesive otitis media
                • Tympanosclerosis
                • Cholesteatoma formation
                • Conductive hearing loss due to ossicular erosion or fixation
                • Sensorineural hearing loss
                • Speech impairment
                • Learning disabilities
              • Acute Mastoiditis
                • Inflammation of mucosal lining of antrum and mastoid air cell system
              • Aetiology
                • Acute mastoiditis usually accompanies or follows acute suppurative otitis media
                • the determining factors
                  • high virulence of organisms
                  • lowered resistance of the patient due to measles, exanthematous fevers, poor nutrition
                  • diabetes
                  • Acute mastoiditis is often seen in mastoids with well-developed air cell system.
                  • Children are affected more.
                  • Beta-haemolytic streptococcus is the most common causative organism
                • Pathology
                  • Two main pathological processes are responsible:
                    • Production of pus under tension.
                    • Hyperaemic decalcification and osteoclastic resorption of bony walls.
                • Clinical Features
                  • Symptoms
                    • They are similar to that of acute suppurative otitis media.
                    • In a case of acute middle ear infection, it is the change in the character of these symptoms which is significant and a pointer to the development of acute mastoiditis.
                    • Pain behind the ear.
                      • Pain is seen in acute otitis media but it subsides with establishment of perforation or treatment with antibiotics.
                      • It is the persistence of pain, increase in its intensity or recurrence of pain, once it had subsided. These are significant pointers of pain.
                    • Fever.
                      • It is the persistence or recurrence of fever in a case of acute otitis media, in spite of adequate antibiotic treatment that points to the development of mastoiditis.
                  • Ear discharge.
                      • In mastoiditis, discharge becomes profuse and increases in purulence
                      • Any persistence of discharge beyond three weeks, in a case of acute otitis media, points to mastoiditis.
                  • Signs
                    • Mastoid tenderness.
                      • This is an important sign.
                      • Tenderness is elicited by pressure over the middle of mastoid process, at its tip, posterior border or the root of zygoma.
                      • Tenderness elicited over the suprameatal triangle may not be diagnostic of acute mastoiditis as it is seen even in cases of the acute otitis media due to inflammation of mastoid antrum (antritis).
                  • Ear discharge.
                      • Mucopurulent or purulent discharge
                      • often pulsatile (light-house effect),
                      • seen coming through a central perforation of pars tensa.
                  • Sagging of posterosuperior meatal wall.
                      • It is due to periosteitis of bony party wall between the antrum and deeper posterosuperior part of bony canal.
                  • Perforation of tympanic membrane.
                    • Usually, a small perforation is seen in pars tensa with congestion of the rest of tympanic membrane.
                    • Perforation may sometimes appear as a nipple-like protrusion
                    • An absolutely normal looking tympanic membrane excludes possibility of acute mastoiditis
                  • Swelling over the mastoid.
                    • Initially, there is oedema of periosteum, imparting a smooth "ironed out" feel over the mastoid.
                    • Later retroauricular sulcus becomes obliterated
                    • pinna is pushed forward and downwards.
                    • When pus bursts through bony cortex, a subperiosteal fluctuant abscess is formed
                  • Hearing loss.
                    • Conductive type of hearing loss is always present.
                  • General findings.
                    • Patient appears ill and toxic with low-grade fever.
                    • In children, fever is high with a rise in pulse rate.
                • Investigations
                  • X-ray mastoid
                    • There is clouding of air cells due to collection of exudate in them.
                    • Bony partitions between air cells become indistinct, but the sinus plate is seen as a distinct outline.
                • Treatment
                  • Myringotomy
                    • Early cases of acute mastoiditis respond to conservative treatment with antibiotics alone or combined with myringotomy.
                • Cortical mastoidectomy(MCQ)
                  • It is indicated when there is:
                    • Subperiosteal abscess.
                    • Sagging of posterosuperior meatal wall.
                    • Positive reservoir sign, i.e. meatus immediately fills with pus after it has been mopped out.
                    • No change in condition of patient or it worsens in spite of adequate medical treatment for 48 hours.
                    • Mastoiditis, leading to complications, e.g. facial paralysis, labyrinthitis, intracranial complications, etc.
                  • Aim of cortical mastoidectomy is to exenterate all the mastoid air cells and remove any pockets of pus.
                  • Adequate antibiotic treatment must be continued at least for 5 days following mastoidectomy.
              • Complications of Acute Mastoiditis
                • Subperiosteal abscess
                • Labyrinthitis
                • Facial paralysis
                • Petrositis
                • Extradural abscess
                • Subdural abscess
                • Meningitis
                • Brain abscess
                • Lateral sinus thrombophlebitis
                • Otitic hydrocephalous.(MCQ)
              • Abscesses in Relation to Mastoid Infection
                • Postauricular abscess
                  • This is the commonest abscess that forms over the mastoid. (MCQ)
                  • Pinna is displaced forwards, outwards and downwards.
                  • In infants and children, abscess forms over the MacEwen’s triangle; pus in these cases travels along the vascular channels of lamina cribrosa.
                • Zygomatic abscess
                  • It occurs due to infection of zygomatic air cells situated at the posterior root of zygoma.
                  • Swelling appears in front of and above the pinna
                  • There is associated oedema of the upper eyelid.
                  • In these cases, pus collects either superficial or deep to the temporalis muscle.
                • Bezold abscess (MCQ)
                  • It can occur following acute coalescent mastoiditis when pus breaks through the thin medial side of the tip of the mastoid
                  • presents as a swelling in the upper part of neck.
                  • The abscess may
                    • lie deep to sternocleidomastoid, pushing the muscle outwards
                    • follow the posterior belly of digastric and present as a swelling between the tip of mastoid and angle of jaw,
                    • be present in upper part of posterior triangle,
                    • reach the parapharyngeal space
                    • track down along the carotid vessels
                  • Clinical features
                    • Onset is sudden.
                    • There is pain, fever, a tender swelling in the neck and torticollis.
                    • Patient gives history of purulent otorrhoea.
                    • A Bezold abscess should be differentiated from:
                      • acute upper jugular lymphadenitis.
                      • abscess or a mass in the lower part of the parotid gland.
                      • an infected branchial cyst.
                      • parapharyngeal abscess.
                      • jugular vein thrombosis.
                  • A CT scan of the mastoid and swelling of the neck may establish the diagnosis.
                  • Treatment
                    • Cortical mastoidectomy for coalescent mastoiditis
                    • exploration of the tip for a fistulous opening into the soft tissues of the neck.
                    • Drainage of the neck abscess through a separate incision and putting a drain in the dependent part.
                    • Administration of intravenous antibiotics
                • Meatal abscess (Luc’s abscess) (MCQ)
                  • In this case, pus breaks through the bony wall between the antrum and external osseous meatus.
                  • Swelling is seen in deep part of bony meatus.
                  • Abscess may burst into the meatus.
                • Behind the mastoid (Citelli’s abscess) (MCQ)
                  • Abscess is formed behind the mastoid more towards the occipital bone unlike postauricular mastoid abscess which forms over the mastoid
                  • Some authors consider Citelli’s abscess.as abscess of the digastric triangle, which is formed by tracking of pus from the mastoid tip,
                • Parapharyngeal or retropharyngeal abscess
                  • This results from infection of the peritubal cells due to acute coalescent mastoiditis.

               

                    • Petrositis
                      • Spread of infection from middle ear and mastoid to the petrous part of temporal bone is called petrositis.
                      • It may be associated with
                        • acute coalescent mastoiditis
                        • latent mastoiditis
                        • chronic middle ear infections.
                      • Clinical Features
                        • Gradenigo’s syndrome consists of a triad of (MCQ)
                          • external rectus palsy (VIth nerve palsy)
                          • deep-seated ear or retro-orbital pain (Vth nerve involvement)
                          • persistent ear discharge.
                      • Persistent ear discharge with or without deep-seated pain in spite of an adequate cortical or modified radical mastoidectomy also points to petrositis.
                      • Fever, headache, vomiting and sometimes neck rigidity may also be associated.
                      • Some patients may get facial paralysis and recurrent vertigo due to involvement of facial and statoacoustic nerves.
                    • Diagnosis of petrous apicitis requires both CT scan and MRI.
                      • CT scan of temporal bone will show bony details of the petrous apex and the air cells
                      • MRI helps to differentiate diploic marrow containing apex from fluid or pus.
                    • Treatment
                      • Cortical, modified radical or radical mastoidectomy is often required if not already done.
                      • The fistulous tract should be found out, which is then curetted and enlarged to provide free drainage.
                        • Tract of posterosuperior cells starts in the Trautmann’s triangle or the attic.
                        • Tract of anterior cells is situated near the tympanic opening of eustachian tube
                      • Most cases of acute petrositis can now be cured with antibacterial therapy alone.
                • Facial Paralysis
                  • It can occur as a complication of both acute and chronic otitis media.
                  • Acute Otitis Media
                    • Facial nerve function fully recovers if acute otitis media is controlled with systemic antibiotics.
                    • Myringotomy or cortical mastoidectomy may sometimes be required.(MCQ)
                  • Chronic Otitis Media
                    • Facial paralysis in chronic otitis media either results from cholesteatoma or from penetrating granulation tissue.
                    • Treatment is urgent exploration of the middle ear and mastoid.
                • Labyrinthitis (MCQ)     
                  • There are three types of labyrinthitis:
                    • Circumscribed labyrinthitis
                    • Diffuse serous labyrinthitis
                    • Diffuse suppurative labyrinthitis
                  • Circumscribed Labyrinthitis (Fistula of Labyrinth)
                    • There is thinning or erosion of bony capsule of labyrinth, usually of the horizontal semicircular canal.
                    • The causes are:
                      • Chronic suppurative otitis media with cholesteatoma is the most common cause.
                      • Neoplasms of middle ear, e.g. carcinoma or glomus tumour.
                      • Surgical or accidental trauma to labyrinth.
                    • Clinical features
                      • A part of membranous labyrinth is exposed and becomes sensitive to pressure changes.
                      • Patient complains of transient vertigo
                      • often induced by pressure on tragus, cleaning the ear or while performing Valsalva manoeuvre.
                      • It is diagnosed by "fistula test" which can be performed in two ways.
                        • Pressure on tragus.
                          • Sudden inward pressure is applied on the tragus.
                          • Nystagmus may also be induced with quick component towards the ear under test.
                        • Siegle’s speculum.
                          • When positive pressure is applied to ear canal, patient complains of vertigo usually with nystagmus.
                          • The quick component of nystagmus would be towards the affected ear (ampullopetal displacement of cupula).
                      • Ampullopetal flow of endolymph (as also ampullopetal displacement of cupula) whether in rotation, caloric or fistula test causes nystagmus to same side.
                      • If negative pressure is applied, again it would induce vertigo and nystagmus but this time the quick component of nystagmus would be directed to the (opposite) healthy side due to ampullofugal displacement of cupula.
                    • Treatment
                      • In chronic suppurative otitis media or cholesteatoma, mastoid exploration is often required to eliminate the cause.
                      • Systemic antibiotic therapy
                    • Diffuse Serous Labyrinthitis
                      • It is diffuse intralabyrinthine inflammation without pus formation
                    • it is a reversible condition if treated early.
                    • Aetiology
                      • Most often it arises from pre-existing circumscribed labyrinthitis associated with chronic middle ear suppuration or cholesteatoma.
                      • In acute infections of middle ear
                      • It can follow stapedectomy or fenestration operation.
                    • Quick component of nystagmus is towards the affected ear.
                    • Myringotomy is done if labyrinthitis has followed acute otitis media and the drum is bulging
                    • Cortical mastoidectomy (in acute mastoiditis) or modified radical mastoidectomy (in chronic middle ear infection or cholesteatoma) will often be required to treat the source of infection. (MCQ)
                  • Diffuse Suppurative Labyrinthitis
                    • This is diffuse pyogenic infection of the labyrinth
                    • permanent loss of vestibular and cochlear functions.
                    • It usually follows serous labyrinthitis,
                    • Spontaneous nystagmus with its quick component towards the healthy side.
                    • Patient is markedly toxic.
                    • There is total loss of hearing.
                    • Relief from vertigo is seen after 3-6 weeks due to adaptation.

                Intracranial complications of otitis media

                  • Extradural Abscess
                      • It is collection of pus between the bone and dura.
                      • It may occur both in acute and chronic infections of middle ear.
                      • Presence is suspected when there is: (MCQ)
                        • Persistent headache on the side of otitis media.
                        • Severe pain in the ear.
                        • General malaise with low-grade fever.
                        • Pulsatile purulent ear discharge.
                        • Disappearance of headache with free flow of pus from the ear (spontaneous abscess drainage).
                      • Diagnosis is made on contrast-enhanced CT or MRI.
                      • Treatment – Cortical or modified radical or radical mastoidectomy
                  • Subdural Abscess
                  • This is collection of pus between dura and arachnoid.
                  • Signs and symptoms of subdural abscess are due to
                    • meningeal irritation
                    • thrombophlebitis of cortical veins of cerebrum
                      • aphasia, hemiplegia, hemianopia.
                    • raised intracranial tension.
                  • Treatment
                    • Lumbar puncture should not be done as it can cause herniation of the cerebellar tonsils.
                    • It is a neurological emergency.
                    • A series of burr holes or a craniotomy is done to drain subdural empyema. Intravenous antibiotics are administered to control infection.
                  • Meningitis
                    • Corticosteroids combined with antibiotic therapy further helps to reduce neurological or audiological complications.
                    • Meningitis following acute otitis media may require myringotomy or cortical mastoidectomy.
                    • Meningitis following chronic otitis media with cholesteatoma will require radical or modified radical mastoidectomy.
                  • Otogenic Brain Abscess (MCQ)
                    • Fifty percent of brain abscesses in adults and 25% in children are otogenic in origin.
                    • In adults, abscess usually follows chronic suppurative otitis media with cholesteatoma
                    • in children, it is usually the result of acute otitis media.
                    • Cerebral abscess is seen twice as frequently as cerebellar abscess.
                      • Cerebral abscess develops as a result of
                        • direct extension of middle ear infection through the tegmen
                        • by retrograde thrombophlebitis, in which case the tegmen will be intact.
                      • Often it is associated with extradural abscess.
                  • Cerebellar abscess
                    • develops
                      • as a direct extension through the Trautmann’s triangle
                      • by retrograde thrombophlebitis.
                    • This is often associated with extradural abscess, perisinus abscess, sigmoid sinus thrombophlebitis or labyrinthitis.
                  • Clinical Features
                    • Temporal lobe abscess
                      • Nominal aphasia.
                        • If abscess involves dominant hemisphere, i.e. left hemisphere in right-handed persons
                        • patient fails to tell the names of common objects such as key, pen, etc. but can demonstrate their use.
                      • Homonymous hemianopia.
                        • This is due to pressure on the optic radiations.
                        • The defect is usually in the upper, but sometimes in the lower quadrants.
                      • Contralateral motor paralysis.
                        • In the usual upward spread of abscess, face is involved first followed by the arm and leg.
                        • Inward spread, towards internal capsule, involves the leg first followed by the arm and the face.
                      • Epileptic fits.
                        • Involvement of uncinate gyrus causes hallucinations of taste, and small and involuntary smacking movements of lips and tongue
                      • Pupillary changes and oculomotor palsy.
                        • It indicates transtentorial herniation.
                    • Cerebellar abscess
                      • Headache involves suboccipital region and may be associated with neck rigidity.
                      • Spontaneous nystagmus is common and irregular and generally to the side of lesion.
                      • Ipsilateral hypotonia and weakness.
                      • Ipsilateral ataxia. Patient staggers to the side of lesion.
                      • Past-pointing and intention tremor can be elicited by finger nose test.
                      • Dysdiadokokinesia. Rapid pronation and supination of the forearm shows slow and irregular movements on the affected side.
                  • CT scan
                    • is the single most important means of investigation and helps to find the site and size of an abscess
                    • It also reveals associated complications such as extradural abscess, sigmoid sinus thrombosis, etc.
                  • Treatment
                      • Chloramphenicol and third generation cephalosporins are usually effective. Bacteroides fragilis, an obligate anaerobe, often seen in brain abscess, responds to metronidazole.
                      • Aminoglycoside antibiotics, e.g. gentamicin, may be required if infection suspected is pseudomonas or proteus.
                      • Raised intracranial tension can be lowered by dexamethasone  or mannitol 20%
                    • Lateral Sinus Thrombophlebitis (Syn. Sigmoid Sinus Thrombosis
                      • It is an inflammation of inner wall of lateral venous sinus with formation of a thrombus.
                      • Clinical Features
                        • Hectic Picket-fence type of fever with rigors
                          • This is due to septicaemia, often coinciding with release of septic emboli into blood stream.
                          • Clinical picture resembles malaria but lacks regularity.(MCQ)
                        • In between the bouts of fever, patient is alert with a sense of well-being.
                      • Headache
                        • In early stage, it may be due to perisinus abscess and is mild.
                        • Later, it may be severe when intracranial pressure rises due to venous obstruction.
                      • Progressive anaemia and emaciation
                      • Griesinger’s sign (MCQ)
                        • This is due to thrombosis of mastoid emissary vein.
                        • Oedema appears over the posterior part of mastoid.
                    • Papilloedema
                        • Its presence depends on obstruction to venous return.
                        • It is often seen when right sinus (which is larger than left) is thrombosed or when clot extends to superior sagittal sinus.
                    • Tobey-Ayer test (MCQ)
                        • This is to record CSF pressure by manometer and to see the effect of manual compression of one or both jugular veins.
                        • Compression of vein on the thrombosed side produces no effect while compression of vein on healthy side produces rapid rise in CSF pressure which will be equal to bilateral compression of jugular veins.
                    • Crowe-Beck test
                        • Pressure on jugular vein of healthy side produces engorgement of retinal veins (seen by ophthalmoscopy) and supraorbital veins.
                        • Engorgement of veins subside on release of pressure.
                    • Tenderness along jugular vein
                        • This is seen when thrombophlebitis extends along the jugular vein.
                        • There may be associated enlargement and inflammation of jugular chain of lymph nodes and torticollis.
                    • Investigations
                      • X-ray mastoids
                        • clouding of air cells (acute mastoiditis)
                        • destruction of bone (cholesteatoma).
                      • Contrast-enhanced CT scan can show sinus thrombosis by typical delta sign.
                        • It is a triangular area with rim enhancement, and central low density area is seen in posterior cranial fossa on axial cuts.
                      • MR imaging
                        • better delineates thrombus.
                        • "Delta sign" may also be seen on contrast-enhanced MRI.
                        • MR venography is useful to assess progression or resolution of thrombus.
                  • Complications
                      • Septicaemia and pyaemic abscesses in lung, bone, joints or subcutaneous tissue.
                      • Meningitis and subdural abscess.
                      • Cerebellar abscess.
                      • Thrombosis of jugular bulb and jugular vein with involvement of IXth, Xth and XIth cranial nerves.
                      • Cavernous sinus thrombosis. There would be chemosis, proptosis, fixation of eyeball and papilloedema.
                      • Otitic hydrocephalus, when thrombus extends to sagittal sinus via confluens of sinuses.
                  • Treatment
                      • Mastoidectomy and exposure of sinus
                      • Ligation of internal jugular vein
                      • Anticoagulant therapy
                  • Otitic Hydrocephalus
                    • It is characterised by raised intracranial pressure with normal CSF findings. It is seen in children and adolescents with acute or chronic middle ear infections.
                      • Mechanism
                      • Lateral sinus thrombosis accompanying middle ear infection causes obstruction to venous return.
                      • If thrombosis extends to superior sagittal sinus, it will also impede the function of arachnoid villi to absorb CSF
                    • Clinical Features
                      • Severe headache, sometimes intermittent, is the presenting feature. It may be accompanied by nausea and vomiting.
                      • Diplopia due to paralysis of VIth cranial nerve.
                      • Blurring of vision due to papilloedema or optic atrophy.
                      • Papilloedema may be 5-6 diopters, sometimes with patches of exudates and haemorrhages.
                      • Nystagmus due to raised intracranial tension.
                    • Lumbar puncture.
                      • CSF pressure exceeds 300 mm of water (normal 70-120 mm H2O).
                      • It is otherwise normal in cell, protein and sugar content and is bacteriologically sterile.
                    • Treatment
                      • The aim is to reduce CSF pressure to prevent optic atrophy and blindness. This is achieved medically by acetazolamide and corticosteroids and repeated lumbar puncture or placement of a lumbar drain.
                      • Sometimes, draining CSF into the peritoneal cavity (lumboperitoneal shunt) is necessary.
                  • TUBERCULAR OTITIS MEDIA
                    • In most of the cases, infection is secondary to pulmonary tuberculosis
                    • infection reaches the middle ear through eustachian tube.
                    • Disease is mostly seen in children and young adults.
                    • Clinical Features (MCQ)
                      • Painless ear discharge
                      • Earache is characteristically absent in cases of tubercular otitis media. (MCQ)
                      • Discharge is often foul-smelling because of the underlying bone destruction.
                    • Perforation
                      • Multiple perforations, 2 or 3 in number, are seen in pars tensa and form a classical sign of disease.
                    • Hearing loss
                      • There is severe hearing loss, out of proportion to symptoms.
                      • Mostly conductive
                    • Facial paralysis (MCQ)
                      • It is a common complication

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                  UntitledHigh yield MCQ topic for USMLE AIBM DNB CET AIPGMEE AIIMS PGIMER JIPMER COMEDK FMGE MCI Screening test WBPGMAT TNPG APPG MBBS exams
                  CHRONIC SUPPURATIVE OTITIS MEDIA DR FOHEID ALSOBEI
                  CHRONIC SUPPURATIVE OTITIS MEDIA DR FOHEID ALSOBEI
                  Ottitis Media Pathology
                  Ottitis Media Pathology
                  atlas of otology chronic suppurative otitis media tubo tympanic perforation
                  atlas of otology
                  CHRONIC SUPPURATIVE OTITIS MEDIA WITH ATTIC PERFORATION
                  Chronic Suppurative Otits Media
                  Purulent bilateral otitis media, with followup one week later
                  Complications of CSOM
                  CSOM video otoscopy.wmv
                  Short video otoscope view of chronic serous otitis media, using two different tips.
                  COMLEX USMLE Board Review Lectures Acute Suppurative Otitis Media
                  Acute Suppurative Otitis Media
                  Pulsating Air Bubble in Active Stage of Chronic Suppurative Otitis Media
                  This video shows pulsating air bubble in the presence of ear discharge in chronic suppurative otitis media (CSOM). In reflects the transmission of soft tissue compression surrounding the eustachian tube as the the carotid artery course is just nearby.