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Intracranial complications of chronic suppurative otitis media, attico -antral type: Experience at TUTH

The objective of this study is to find out the prevalence

and types of intracranial complications among 699 patients having attico-antral suppurative otitis media who underwent mastoid exploration from April 1997 to December 2003 at the Department of Otorhinolaryngology (ORL) and Head and Neck Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Of the 699 patients, 33 (4.72%) had intracranial complications. Out of these, 3 patients had both extra and intracranial complications. The age of the patients with intracranial complications ranges from 4 55 years (mean 17.23 years). Twenty-six (79%) patients were male, while 7 (21%) were female. Brain abscess was the commonest intracranial complication, found in 16 (48.48%) patients, followed by meningitis, found in 9 (27.27%) patients. Thirty-day mortality rate was 3.03%.

Key Words: abscess, complications, CSOM, meningitis

Existence of chronic suppurative otitis media (CSOM) has been documented since prehistoric times. The potential seriousness of this disease was appreciated by Hippocrates.1 Morgagni recognized the potential of suppurative otitis media to invade intracranium and also established a direct relationship between CSOM and brain abscess.3

Chronic suppurative otitis media is one of the commonest otolaryngologic problems especially in underdeveloped countries like Nepal. Its high incidence in low socio-economic status is associated with poor hygiene, overcrowding associated with the ignorance and lack of awareness of disease and its consequences amongst patients. In developed countries the incidence of complications of CSOM has come down to 0.04% of all cases of suppurative ear disease.6,11 In a rural area of India it was found to be 4.26%4 whereas in Thailand it varies from 6.45-7.60%.9,15 Similarly, the mortality rate due to intracranial complications of CSOM varies from country to country. A study in Thailand showed the mortality rate to be 18.4%7

whereas studies in Bangladesh and Egypt revealed it to be only 4% and 3% respectively.2,5

The aim of this study was to evaluate the prevalence and types of intracranial complications in patients with attico-antral type of CSOM who underwent mastoid exploration in Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal.

Materials and Methods

Six hundred and ninety nine patients with attico-antral

type of CSOM who underwent emergency or routine mastoid exploration in the Department of ORL and Head & Neck Surgery, TUTH, Maharajgunj, Kathmandu from April 1997 to December 2003 were enrolled in the study. Of these, 33 (4.72%) patients had intracranial complications. These patients constitute the basis of this study. Records of all these patients were reviewed regarding age, sex and types of complications, hospital course and short-term outcome at discharge.

Original article J Neuroscience 1:36-39, 2004

Naramaya Thapa, MS Department of Otorhinolaryngology and Head and Neck Surgery Tribhuvan University Teaching Hospital Kathmandu, Nepal Rakesh P. Shrivastav, MS Department of Otorhinolaryngology and Head and Neck Surgery Tribhuvan University Teaching Hospital Kathmandu, Nepal

Address for correspondence: Naramaya Thapa, MS Department of Otorhinolaryngology and Head and Neck Surgery Tribhuvan University Teaching Hospital Kathmandu, Nepal Email:

naramayat@yahoo.com

Received, December 12, 2003 Accepted, December 25, 2003

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All patients with proven or suspected CSOM were seen by the ORL team. Examination finding was confirmed by Examination Under Microscope (EUM) just prior to surgery. Pure tone audiogram and x-ray mastoids Townes and lateral oblique views were advised in each case. When the clinical features suggested possible intracranial complications, either a CT scan of the head or a lumbar puncture was performed. Those patients with brain abscess were treated surgically by neurosurgeons first and intravenous antibiotic was given for 6 weeks. Those with meningitis were treated conservatively with intravenous antibiotics at least for 2 weeks by a neurologist. These patients underwent mastoid exploration as soon as their general condition permitted general anesthesia. Those patients with complications other than brain abscess and meningitis underwent emergency mastoid exploration. In all cases, postauricular incision was given. After exposure of the suprameatal triangle, bone was drilled using cutting burrs. During surgery, the extent of the disease, the status of the dural plate, sinus plate and fallopian canal, and the status of the ossicles were evaluated. After removal of the disease, the mastoid cavity was covered either by the temporalis fascia or by the periostium. Meatoplasty was done to facilitate better drainage of the cavity. The wound was closed after packing with a Bismuth iodoform paraffin soaked pack.

Results

A total of 699 patients having attico-antral type of CSOM underwent either emergency or routine mastoid exploration. Of these, 33 (4.72%) patients had intracranial complications and out of these extra- and intracranial complication was present in 3 patients (Table 1).

Complication No. of patients

% of total intracranial

complications a. Brain abscess b. Meningitis c. Subdural empyema d. Perisinus abscess e. Extradural abscess f. Lateral sinus

thrombosis g. Brain abscess, acute

mastoiditis h. Subdural empyema,

facial nerve palsy i. Extradural abscess,

acute mastoiditis, Bezolds abscess

16 9 2 2 1 1 1 1 1

48.48 27.27 6.06 6.06 3.03 3.03 3.03 3.03 3.03

Table 1. Distribution of intracranial complications in

patients with CSOM attico-antral type (n = 33)

The age of the patients with intracranial complications ranged from 4 to 55 years with a mean age of 17.23 years. As shown in Table 2, the commonest age group to have intracranial complications was 11-20 years (14 (42.42%) patients). Twenty-six (79%) patients were male while 7 (21%) were female.

Age group (years) No. of patients % of

intracranial complications

0 10 10 20 21 30 31 40 41 50 51 - 60

11 14 6 1 0 1

38.38 42.42 18.18 3.03 0 3.03

Table 2. Age distribution of patients with intracranial

complications (n = 33)

Various intracranial complications of CSOM among 33 patients are shown in Table 1. Brain abscess was present in 16 (48.48%) and meningitis in 9 (27.27%) patients. Of 16 patients with brain abscess, 1 patient had acute mastoiditis also. Three (9.09%) patients had subdural empyema. Of these 3 patients, 1 patient had facial nerve palsy along with empyema. Two (6.06%) patients had perisinus abscess. Extradural abscess was found in 2 (6.06%) patients. One of these patients had acute mastoiditis and Bezolds abscess also. One (3.03%) patient who had lateral sinus thrombosis died. Two patients who had brain abscess had developed aphasia. However, both of them recovered completely after a few days. Figure 1 shows computerized tomography scan of head of a 12-year-old child with CSOM who presented with headache and irritability. A low-density lesion with a high-density peripheral rim (enhanced after contrast administration) in the left temporoparietal region highly suggestive of brain abscess is evident. As per the symptomatology all patients had a history of ear discharge and hearing impairment. Those patients with intracranial complications also complained of headache and fever. Of these patients, 11 (9 with meningitis, 1 with brain abscess and 1 with lateral sinus thrombosis) also had vomiting. Three patients with brain abscess and 2 with meningitis had altered sensorium.

Discussion

In the preantibiotic era the incidence of complications of CSOM was very high. Although the incidence has decreased with the development of antibiotics, it is still high in the underdeveloped countries like ours. In this study intracranial complication was found in 33 (4.72%) patients. This is in contrast to the study done by Osma et al. that revealed that, out of 2890 patients, 57 (1.97%) patients had intracranial complications. 10 This difference may be due to late presentation of our patients because of lack of awareness of disease and education, and poverty. We found that

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complications were more common in the age group, 11-20 years which is consistent with other studies.2,3,5,7,8,13,14,15 The reason behind this may be that this is socially the most active and health conscious age group. Most of our patients were male. The reason for this is not entirely clear, but it might be possible that males may have sought medical attention more frequently than females, as our part of the world is considered a male dominant society.

Figure 1. Contrast enhanced CT scan of head of a 12- year old by with headache and irritability. A low-density lesion with a high-density peripheral rim (enhanced after contrast administration) in the left temporoparietal region highly suggestive of brain abscess is evident.

In our study, brain abscess (16 (48.48%) patients) was

the commonest intracranial complication. The reason of this finding may be that most of our patients with intracranial complications were from out of the Kathmandu Valley. Because of ignorance, poverty and lack of transport facilities, they had presented to us quite late (only after development of abscess). The second most common intracranial complication was meningitis (9 (27.27%) patients). This finding is consistent with the studies done by Chotmongkol et al.2 and Rupa et al.13 However, studies of Chowdhury et al. and Kurien et al. revealed meningitis to be the commonest intracranial complication followed by brain abscess.3,9

Among the brain abscess patients, temporal lobe abscess (9 (27.27%)) was more common than cerebellar abscess (6 (18.18%)). This finding is consistent with the studies of Bluestone et al. and Lund. 1,10 As shown in table 1, multiple complications (more than one complication) were seen in only 3 (9.09%) patients. It could well be due to small sample size. However, Gupta et al. reported the incidence of multiple complications being 47.82%.5

Finally, limitations of our study deserve mention. This is a retrospective study with a small sample size and it was carried out in only one institution. So the introduction of bias cannot be ruled out. Further study with a large sample size is needed to verify the findings of this study.

Conclusions

Complications of attico-antral type of CSOM accounts for a high rate of morbidity and mortality in developing countries. Complications were more common in males and in the young age group (11-20 years). Brain abscess and meningitis were the commonest intracranial complications. Temporal lobe abscess was more common than cerebellar abscess. Family physicians, as well public at large, should be made aware of the seriousness of middle ear suppuration as this accounts for a high rate of morbidity and mortality in our country.

Acknowledgements

I would like to thank all the staffs of the Operation Theater, Department of Otorhinolaryngology and Head & Neck Surgery and the Record Section of TU Teaching Hospital for their valuable help.

References

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