AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Otitis media is the most common bacterial infection in children. Approximately 70% of children are affected by the age of 3 years. Antibiotics have produced an overall decline in the frequency of complications of otitis media relative to the preantibiotic era. However, severe complications still occur and may be associated with high mortality.

Both intracranial and extracranial complications of acute and chronic otitis media are possible. A discussion of the diagnosis and management of these complications is the focus of this article. The complications of otitis media include the following:

• Chronic suppurative otitis media

  Postauricular abscess

• Facial nerve paresis
• Labyrinthitis

  Labyrinthine fistula

• Mastoiditis

  Temporal abscess

• Petrositis
• Intracranial abscess
• Meningitis
• Otitic hydrocephalus
• Sigmoid sinus thrombosis

  Encephalocele

  CSF leak

Pathophysiology

Spread of infection from the ear and temporal bone causes intracranial complications of otitis media. Spread of infection occurs through 3 routes, namely, direct extension, thrombophlebitis, and hematogenous dissemination. Extracranial complications are usually direct sequelae of localized acute or chronic inflammation.

Frequency

United States

Otitis media is most common in children between the neonatal period and age 7 years, with approximately 70% of children having 1 or more episodes by their third birthday.

The overall incidence of all complications of otitis media has decreased since the advent of effective antimicrobial treatment. For example, in the preantibiotic era, the incidence of mastoiditis requiring surgical treatment was 25-50%. In the 1980s, the incidence decreased to approximately 0.02%. In 1995, Kangsanarak et al conducted a review of 24,321 patients with otitis media.¹ This review revealed an intracranial complication rate of 0.36%.

The most common extracranial complication is postauricular abscess, and the most common intracranial complication is meningitis, though complications often occur together.

Mortality/Morbidity

In the preantibiotic era, the mortality rate from intracranial complications of otitis media was reported to be as high as 76.4%. A recent review of 24,321 patients (from 1978-1990) who had intracranial complications associated with otitis media identified a mortality rate of 18.4%.

Sex

No sex predilection exists.

Age

Otitis media occurs most commonly between the neonatal period and age 7 years, and complications of otitis media more commonly are observed in children. One large series of South African patients found that nearly 80% of extracranial complications and 70% of intracranial complications occurred in children in their first two decades of life.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The risk for complications associated with otitis media increases if an acute episode of otitis media persists longer than 2 weeks, or symptoms recur within a 2-to 3-week period. Headache and fever are the most frequently observed early manifestations of complications associated with otitis media. Other manifestations are as follows:

• Severe otalgia
• Vertigo
• Lethargy
• Nausea and vomiting
• Mental status changes
• Fetid otorrhea

Physical

A high index of suspicion is necessary in order to diagnose a complication of otitis media. The persistence or recurrence of acute infection within 2 weeks of treatment suggests impending complications.

• Complications typically are associated with subacute or chronic infections, but acute otitis media remains the most common cause of meningitis. Meningitis in the setting of acute suppurative otitis media in a child may suggest an anatomical abnormality such as a Mondini malformation. A Mondini deformity is a specific type of inner ear dysplasia, which may present as a spontaneous perilymphatic fistula due to a stapes footplate deficiency. This anatomical abnormality may predispose the patient to recurrent meningitis and profound sensorineural hearing loss.
• The following signs or symptoms are suggestive of intracranial complications:
• • Fever associated with a chronic perforation
  • Lethargy
  • Focal neurologic signs (eg, ataxia, oculomotor deficits, seizure)
  • Papilledema
  • Meningismus
  • Altered mental status
  • Severe headaches
• The following signs or symptoms are suggestive of extracranial complications:
• • Fever associated with a chronic perforation
  • Postauricular edema or erythema
• Facial nerve paresis or paralysis
• Fetid otorrhea
• Retro-orbital pain on the side of the infected ear
• Vertigo
• Spontaneous nystagmus associated with sensorineural hearing loss
• An infected ear
• Presentation of extracranial complications includes the following:
• • Labyrinthitis - Fever, nystagmus, serous or suppurative otitis media
  • Mastoiditis with subperiosteal abscess - Fever, fluctuance overlying the mastoid area, lateral displacement of pinna, otitis media
  • Petrositis - Retro-orbital pain, otorrhea, abducens paralysis, fever
• Presentation of intracranial complications includes the following:
• • Brain abscess - Fever, possibly seizures or focal neurologic signs, headache
  • Meningitis - Fever, meningismus
  • Otitic hydrocephalus - Headache, signs of increased intracranial pressure in setting of otitis media
  • Sigmoid sinus thrombosis - Spiking fever, otitis media, edema and tenderness over mastoid cortex, headache

Causes

• Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis are the most common pathogens that cause acute suppurative otitis media. An increasing incidence of penicillin-resistant S pneumoniae has been observed and may be responsible for an increasing rate of acute mastoiditis noted by some authors.
• Although less than 5% of otitis media is caused by H influenzae type B, this organism often is identified in pediatric patients with meningitis or other CNS infections occurring simultaneously with otitis media.
• Pseudomonas aeruginosa, Staphylococcus aureus, and other gram-negative organisms such as Proteus species, Klebsiella species, and Escherichia coli typically are cultured from uncomplicated chronic otorrhea.
• Bacteroides fragilis often is found in mastoiditis associated with chronic suppurative otitis media.
• Multiple organisms (average 3) are identified in 50-60% of chronically draining ears associated with cholesteatoma. Foul-smelling discharge tends to signify the presence of multiple organisms, including both anaerobes and aerobes.
• M catarrhalis, S aureus, H influenzae, and Bacteroides species are beta-lactamase–producing organisms, which also may protect other penicillin-susceptible pathogens from beta-lactam antibiotics. Resistant organisms, particularly S pneumoniae, also are becoming increasingly frequent.
• Intracranial abscesses typically are polymicrobial, with a predominance of anaerobic organisms such as Bacteroides species. Gram-negative organisms such as Proteus mirabilis and P aeruginosa are found often in intracranial complications. Streptococcus faecalis is a gram-positive organism that commonly is cultured from intracranial abscesses of otogenic origin.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Extracranial complications

Chronic suppurative otitis media is a form of chronic otomastoiditis, often with drainage due to P aeruginosa.

Facial nerve paralysis may be associated with acute or subacute/chronic infection.

Labyrinthitis may be serous or suppurative.

Mastoiditis with subperiosteal abscess may present as Bezold abscess, which represents extension of the abscess from the mastoid tip into the digastric groove. A temporal root abscess can also form by direct extension via bone erosion through the epitympanic temporal root cells.

Petrositis may present as a classic triad of retro-orbital pain, otorrhea, and abducens paralysis. This condition also is known as Gradenigo syndrome.

Intracranial complications

A brain abscess may occur in the temporal lobe or cerebellum, typically from chronic otitis media.

An epidural abscess may occur as a result of bony destruction and extension from coalescent mastoiditis or cholesteatoma.

Meningitis may be associated with acute or subacute/chronic infection. Acute otitis media is the most common cause of meningitis. Extradural granulation tissue or frank pus may be found.

In both adults and children, meningitis in the setting of chronic suppurative otitis media may be secondary to the direct extension of infection through the dura, through a previous stapedectomy site, or through a cholesteatoma-induced labyrinthine fistula.

Otitic hydrocephalus may occur as a result of increased intracranial pressure secondary to middle ear infection and complicated by sigmoid sinus thrombosis with total occlusion.

A sigmoid sinus thrombosis or subdural abscess/empyema may be associated with otitis media.

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Obtain cultures from the septic focus to guide therapy; however, they may fail to reveal the true pathogen in at least 25% of cases of otorrhea.
• CBC count and ESR may be helpful in monitoring response to therapy.

Imaging Studies

• CT scan
• • A fine-cut CT scan of the temporal bones will evaluate the integrity of the bone of the tegmen, otic capsule, posterior fossa, and facial canal. It will show soft tissue causing coalescence of mastoid air cells in mastoiditis, and may show destruction of the overlying cortex with overlying postauricular abscess formation. A frank subperiosteal abscess is found in only 48-49% of acute mastoiditis cases.
  • A contrasted CT scan will detect abscess formation or sigmoid sinus thrombosis. The delta sign is a triangular enhancement of the wall of the sigmoid sinus suggestive of thrombosis.
  • Meningitis, facial paralysis, brain abscess, otitic hydrocephalus, sigmoid sinus thrombophlebitis, and intracranial abscess may also occur without evidence of bone destruction as observed on CT scan.
• MRI with gadolinium
• • A contrasted MRI study of the head should be performed if intracranial abscess formation or sigmoid sinus thrombophlebitis is suspected.
  • MRI is superior to CT in the identification of intracranial suppurative lesions, meningeal inflammation, and extradural granulation tissue. The T2-weighted images can identify intraparenchymal edema and thus make an earlier diagnosis of impending intracranial complications than CT.
  • Acute suppurative labyrinthitis may present with enhancement of the cochlea, labyrinth, and/or internal auditory canal contents.
  • Enhanced MRI is sensitive for sigmoid sinus thrombosis. Additional imaging with MR venography demonstrates the degree of patency of the related venous sinuses.

Other Tests

• Always determine hearing status at some point during the course of treatment. Sensorineural, conductive, or mixed losses may be identified depending on the clinical scenario and must be monitored and addressed accordingly.
• Electrical excitability tests, such as electroneurography (ENOG), are appropriate in cases of acute otitis media accompanied by complete facial paralysis. Perform ENOG after the third day of complete facial paralysis associated with acute otitis media. Greater than 90% electrical degeneration of the involved side indicates that potentially irreversible nerve damage has occurred. Total facial nerve decompression may be warranted in cases of 90% or greater electrical degeneration.

Procedures

• Lumbar puncture is indicated in suspected meningitis. Avoid this procedure until imaging studies are performed to exclude a brain abscess. Brain herniation can result in the face of sudden release of intracranial pressure if a brain abscess is present.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Extracranial and intracranial complications (with the exception of uncomplicated cholesteatoma and chronic suppurative otitis media) usually require admission to the hospital.

• Initially, IV antibiotics are directed toward the most common pathogens, followed by culture-specific antibiotics. Due to an increasing incidence of penicillin-resistant S pneumoniae, consider the empiric use of vancomycin until culture results are finalized.
• Acute otitis media resulting in acute/subacute mastoiditis, meningitis, or intracranial complications is best treated with a third-generation cephalosporin.
• Complications of chronic disease generally require broader coverage to include pseudomonads and anaerobic organisms.
• Furosemide and mannitol initially are effective in lowering intracranial hypertension in otitic hydrocephalus; however, definitive treatment requires mastoidectomy with exposure and removal of extradural granulation tissue.
• Monitoring of visual acuity and visual fields is essential in otitic hydrocephalus. If deterioration is progressive, fenestration of the optic nerve sheath may be warranted.

Surgical Care

• Perform myringotomy with removal and culture of middle ear fluid/granulation tissue in cases of acute/subacute mastoiditis, facial paralysis or labyrinthitis, and meningitis (if clinically stable).
• Facial nerve paralysis may present as a complication of acute or chronic middle ear disease. In the setting of acute otitis media (within 7-10 days), facial nerve weakness is due to edema of the nerve within the bony canal and not due to bone erosion. Therefore, recovery can be expected with conservative treatment of acute otitis media. In the case of chronic otitis media or the delayed onset of facial paralysis, the paralysis likely is secondary to erosion of the osseous facial canal. In this case, immediate surgical intervention is indicated in the form of simple mastoidectomy without exposure of the nerve if the paralysis is incomplete. Incision of the nerve sheath is contraindicated in the treatment of facial paralysis associated with otitis media. Incision of the perineurium facilitates the spread of infection, which normally is prevented by this structure. In rare cases of complete paralysis with loss of electrical excitability, perform decompression of the nerve.
• Labyrinthitis may present as a serous or suppurative process. Serous labyrinthitis generally responds to conservative management consisting of myringotomy and antibiotics. Be sensitive to signs of progression of suppurative labyrinthitis, which consists of acute increase in vestibular symptoms and sudden hearing loss. The most important aspect of treatment of suppurative labyrinthitis is bed rest, IV antibiotics, and close observation for evidence of intracranial involvement. Surgical drainage of the labyrinth is indicated in cases with suspected intracranial involvement (on the basis of lumbar puncture results, meningismus, and other diagnostics and manifestations).
• Petrositis in its acute form usually can be cured with antibiotics. In chronic cases associated with otorrhea, retro-orbital pain, diplopia, and fever, surgical intervention is indicated. Multiple approaches to the infected petrous cells are possible following a traditional simple mastoidectomy. The safest surgical approach depends on the available air cell pathways leading there. Usually once the mastoidectomy is completed, the air cell track containing granulation tissue can be followed into the petrous apex and adequate drainage can be obtained. A middle cranial fossa approach may be necessary if there is limited access through the mastoid route.
• Perform drainage of a subperiosteal abscess of the mastoid with a simple mastoidectomy.
• Mastoidectomy with exposure of diseased dura is imperative in cases of extradural abscess or granulation tissue, sigmoid sinus thrombophlebitis, and otitic hydrocephalus.
• Treatment of lateral sinus thrombosis is controversial, but most authors recommend mastoidectomy with bony decompression of the sinus.
• • Following decompression, many authors recommend aspirating the sinus with an 18- or 20-gauge needle. Consider an attempt at thrombus removal if free blood return is absent and particularly if pus is encountered. Some surgeons recommend extending the exposure and clot evacuation until free bleeding occurs.
  • Anticoagulation is controversial. Recommendations for anticoagulation originate from neurology and hematology studies, in which patients have different etiologic factors and pathophysiology. Patients with thrombus confined to the sigmoid sinus should be considered for treatment without anticoagulation in order to avoid the associated risks. Serial imaging should be performed in those cases to assess for clot propagation. Patients with evidence of thrombus progression, extension to other sites (jugular vein, transverse sinus, cavernous sinus) on initial presentation, neurologic changes, persistent fevers, or embolic events should be considered for anticoagulation.

Consultations

• Obtain neurosurgical consultation in cases of intracranial complications.
• Consider infectious disease consultation in all cases.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Direct initial antibiotic therapy at commonly associated pathogens according to each complication.

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Give special consideration to the use of empiric vancomycin due to the increasing incidence of penicillin-resistant S pneumoniae.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Patients may be admitted for observation and administration of parenteral antibiotics.
• Neurosurgical consultation is indicated in cases of intracranial complications. Consider infectious disease consultation in all cases.
• Repeat CT scan and/or MRI studies may be necessary if little or no improvement occurs after the initial surgical and medical intervention.

Further Outpatient Care

• Careful monitoring of visual fields and visual acuity is necessary in patients with intracranial complications; visual changes usually signify an increase in intracranial pressure.
• Frequent neurological evaluation is imperative in cases of intracranial complications.
• Obtain follow-up audiograms during and after treatment.

In/Out Patient Meds

• Most infectious disease consultants recommend a total of 2-4 weeks of IV antibiotics for intracranial complications. A 7-10 day course of oral antibiotics (eg, cefuroxime, amoxicillin-clavulanate) directed towards cultured organism(s) may be prescribed on discharge depending on the type of complication.

Transfer

• For intracranial complications, transfer to a hospital where neurosurgical services are available.
• Transfer of pediatric patients, particularly with intracranial complications, to a hospital with intensive care facilities may be considered.

Complications

• Complications resulting from surgical intervention are unique to each operation. They include blood loss, brain herniation, facial nerve injury, hearing loss, and air embolism.
• Complications specific to mastoidectomy include hearing loss, vertigo, tinnitus, facial nerve injury, altered taste sensation, and the possible need for further surgery.

Prognosis

• Despite adequate treatment, approximately a third of patients with meningitis develop permanent neurological sequelae, including seizures and behavioral disorders.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to consider the diagnosis of a complication of otitis media in a patient with facial nerve paresis, or the failure to document the status of the middle ear in a patient with facial nerve weakness

Special Concerns

• Neurological sequelae

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. Kangsanarak J, Navacharoen N, Fooanant S, et al. Intracranial complications of suppurative otitis media: 13 years'' experience. Am J Otol. Jan 1995;16(1):104-9. [Medline].
2. Antonelli PJ, Dhanani N, Giannoni CM, et al. Impact of resistant pneumococcus on rates of acute mastoiditis. Otolaryngol Head Neck Surg. Sep 1999;121(3):190-4. [Medline].
3. Bradley DT, Hashisaki GT, Mason JC. Otogenic Sigmoid Sinus Thrombosis: What is the Role of Anticoagulation?. Laryngoscope. 2002;112:1726-1729.
4. Djeric DR, Schachern PA, Paparella MM, et al. Otitis media (silent): a potential cause of childhood meningitis. Laryngoscope. Dec 1994;104(12):1453-60. [Medline].
5. Dubey SP, Larawin V. Complications of chronic suppurative otitis media and their management. Laryngoscope. Feb 2007;117(2):264-7. [Medline].
6. Fliss DM, Leiberman A, Dagan R. Medical sequelae and complications of acute otitis media. Pediatr Infect Dis J. Jan 1994;13(1 Suppl 1):S34-40; discussion S50-4. [Medline].
7. Gaffney RJ, O''Dwyer TP, Maguire AJ. Bezold''s abscess. J Laryngol Otol. Sep 1991;105(9):765-6. [Medline].
8. Garcia RD, Baker AS, Cunningham MJ, et al. Lateral sinus thrombosis associated with otitis media and mastoiditis in children. Pediatr Infect Dis J. Jul 1995;14(7):617-23. [Medline].
9. Grafstein E, Fernandes CM, Samoyloff S. Lateral sinus thrombosis complicating mastoiditis. Ann Emerg Med. Mar 1995;25(3):420-3. [Medline].
10. Harker LA, Pignatari SS. Facial nerve paralysis secondary to chronic otitis media without cholesteatoma. Am J Otol. Jul 1992;13(4):372-4. [Medline].
11. Harker LA, Shelton C. Complications of Temporal Bone Infections. Cummings Otolaryngology Head and Neck Surgery Fourth Edition. 2005;4:3013-3039.
12. Kangsanarak J, Fooanant S, Ruckphaopunt K, et al. Extracranial and intracranial complications of suppurative otitis media. Report of 102 cases. J Laryngol Otol. Nov 1993;107(11):999-1004. [Medline].
13. Kuczkowski J, Narozny W, Stankiewicz C. Zygomatic abscess with temporal myositis - a rare extracranial complication of acute otitis media. Int J Pediatr Otorhinolaryngol. 2005;69:555-9.
14. Kutluhan A, Kiris M, Yurttas V. When can lateral sinus thrombosis be treated conservatively?. J Otolaryngol. 2004;33:107-110.
15. Magliulo G, Vingolo GM, Petti R, et al. Acute mastoiditis in pediatric age. Int J Pediatr Otorhinolaryngol. Mar 1995;31(2-3):147-51. [Medline].
16. Munz M, Farmer JP, Auger L, et al. Otitis media and CNS complications. J Otolaryngol. Jun 1992;21(3):224-6. [Medline].
17. Myer CM 3d. The diagnosis and management of mastoiditis in children. Pediatr Ann. Nov 1991;20(11):622-6. [Medline].
18. Neely JG. Intratemporal and intracranial complications of otitis media. In: Bailey BJ, ed. Head and Neck Surgery - Otolaryngology. Philadelphia, Pa:. Lippincott-Raven;1993:1607-22.
19. Penido NO, Borin A, Iha LC. Intracranial complications of otitis media: 15 years of experience in 33 patients. Otolaryngol Head Neck Surg. 2005;132:37-42.
20. Poole MD. Otitis media complications and treatment failures: implications of pneumococcal resistance. Pediatr Infect Dis J. Apr 1995;14(4 Suppl):S23-6. [Medline].
21. Popovtzer A, Raveh E, Bahar G. Facial palsy associated with acute otitis media. Otolaryngol Head Neck Surg. 2005;132:327-9.
22. Seven H, Ozbal AE, Turgut S. Management of otogenic lateral sinus thrombosis. Am J Otolaryngol. 2004;25:329-33.
23. Stein EH, Cunningham MJ, Weber AL. Noninvasive radiologic options in evaluating intracranial complications of otitis media. Ann Otol Rhinol Laryngol. Apr 1992;101(4):363-6. [Medline].

Article Last Updated: Aug 10, 2007