Chapter 17 95 17 Complications Jürgen Lautermann, Holger Sudhoff

Complications of infected and draining ears may arise from acute otitis media, cholesteatoma, and rarely from chronic suppurative otitis media. Bacteria and their toxins may spread by direct infective erosion, by preformed path- ways such as the oval and round windows and by passing along vascular chan- nels (osteo-thrombophlebitis). Anatomically, infective complications of the ear may be roughly divided into intratemporal, extradural and intradural complications. A high-resolution CT scan should be performed in every sus- pected complication supplemented by MRI if necessary. Rare causes are tuber- culosis, Wegener’s granulomatosis and malignant external otitis. Acute mastoiditis is the most common complication of an otitis media. It presents with retroauricular painful swelling, reddening, general sickness and an elevated erythrocyte sedimentation rate. The early stage of mastoiditis without signs of bone erosion in the CT scan may be treated with systemic antibiotics for a limited period of time. If symptoms progress or do not resolve within 24 h, a mastoidectomy in children simultaneously with myringotomy and/or grommet insertion and adenotomy should be performed to improve the tubal drainage to the epipharynx and to remove a source of inflammation. If uncontrolled the infection can spread into the surrounding tissues. Choles- teatoma can cause the similar complications.

Labyrinthitis and Facial Palsy Labyrinthitis and facial palsy are rare intratemporal complications. 1. If facial paralysis originates from a cholesteatoma or mastoiditis, an immediate operation is obligatory. The cholesteatoma must be removed, the facial nerve must be identified and decompressed and the neural sheath must be incised if necessary. 2. Sensorineural hearing loss, vertigo and tinnitus indicate inner ear involvement and require revision of the mastoid as well as antibiotic treat- ment. Purulent labyrinthitis requires opening of the labyrinth. 96 17 Complications

Extradural Complications 1.Asubperiostealabscessdevelopsifpusspreadsthroughvascularchannels in the suprameatal triangle and displaces the periosteum on the planum mastoideum. In these cases a protrusion of the posterosuperior meatal wall may be seen. 2. Bezold’s abscess results from a perforation of pus through the tip of the mastoid with concurrent swelling of the sternocleidomastoid muscle and the lateral neck. 3. If the zygoma is well pneumatized it may be involved in the infection (zygomaticitis) with preauricular reddening and swelling. 4. If the pus extends into the digastric fossa (Muret’s abscess), trismus may be observed. 5. Citelli’s abscess results form spread of infection from the retrosinous cells to the with osteomyelitis of the calvarium. 6. Infections of the petrous apex may involve the cavernous sinus and lead to paralysis of the abducens nerve and pain in the trigeminal nerve (Gra- denigo’s syndrome). If symptoms do not resolve after systemic antibiotics, surgical exenteration of the petrous apex may become necessary through an infracochlear, transmastoid-infralabyrinthine approach, a middle fossa approach or a translabyrinthine approach in a deaf ear. 7. In extradural (also called epidural) abscess pus collects between dura and bone. Further diagnosis should exclude intracanial involvement. 8. If the infection spreads towards the lateral sinus, an infected mural thrombus can develop which may cause septic emboli. The source of the sinus involvement must be eradicated; that is the acute or chronic mas- toiditis or the cholesteatoma must be operated on independently of the decision to treat the thrombosis of the sinus. The latter can be treated with anticoagulants as recommended today or by removing the thrombus surgically. During mastoidectomy the sinus should be checked from the outside for signs of inflammation such as granulations or pus. In addition the presence of clinical indications such as fever or septic symptoms necessitate removal of the thrombus and the lateral sinus should be ligated or packed. Before ligation the bone over the lateral sinus should be generously removed with a diamond drill. Before opening the sinus the patient must be placed in a “head down” position to prevent air embo- lism. Using a Deschamps’ ligature carrier sutures are brought around the sinus and the sinus is ligated. Intracranially the Deschamps’ carrier must be passed close to the sinus to prevent damage to the arachnoidal vessels. The sinus may be too rigid and may be attached to the surrounding dura 17 Complications 97

hence ligation may tear the vessel. Therefore it is often easier to pack the sinus with a muscle plug, which has to be sutured to the sinus in order to prevent emboli. If the MRI picture shows that the thrombosis has descended to the bulb or the upper jugular vein, we recommend ligation of the jugular vein to prevent septic emboli.

Intracranial Complications 1. Otogenic meningitis must be treated by immediate removal of the source of the infection, which means mastoidectomy and treatment of the com- plications mentioned above if present. Conservative treatment and/or delayed surgery is not justified. 2. Otologic brain abscesses most frequently develop in the temporal lobe and less frequently in the . This complication should be diag- nosed by CT scan or MRT. The operation should be performed together with the neurosurgeon. It is reasonable to open an abscess adjacent to the from its origin, that is from the mastoid and not through healthy brain tissue. This is the most dangerous complication of mastoid- itis and carries the highest lethality. Treatment consists of operating in the infected ear combined with drainage of the intracerebral abscess.