COMPLICATIONS OF

CHAPTER 38 

OTITIS MEDIA
Jameson K. Mattingly, MD and Kenny H. Chan, MD

KEY PO I N T S
Pathophysiology of Complicated Otitis Media (OM)
1. Complications from OM can occur by different mechanisms.
2. Preformed pathways increase the risk of spread of infection from the middle ear and mastoid to
adjacent areas.
3. The three main routes of spread of OM are hematogenous, direct extension, and propagation of
thrombus.
4. The treatment of most complications will involve myringotomy and ventilation tube insertion,
usually for persistent effusion or infection.
5. Complicated OM (COM) is associated with infections by bacteria with increased resistance
including strains of S. aureus, P. aeruginosa, K. pneumoniae, and anaerobic bacteria.

Pearls
1. Most common pathogens associated with complications in AOM are S. pneumonia, H. influenzae,
and M. catarrhalis.
2. Initial antibiotic regimens should be broad-spectrum, and the degree of CSF penetration should be
considered.
3. Surgical intervention is warranted if there is no improvement on medical therapy, if complications
develop, or with intracranial complications.

QUESTIONS
1. Describe the pathophysiology of complications related to acute otitis media
(AOM).
The pathophysiology of complicated otitis media (OM) largely depends on whether it arises in the
setting of AOM or chronic suppurative otitis media (CSOM). AOM develops in previously healthy ears
and is characterized by mucosal edema with exudation of fluid, bacterial proliferation, and the
formation of byproducts of inflammation (pus). Infection then spreads contiguously into the mastoid.
Given the lack of granulation tissue and bony erosion with AOM, infection spreads either
hematogenously or through direct extension via preformed pathways.
2. Describe the pathophysiology of complications related to chronic suppurative
otitis media (CSOM).
CSOM is characterized by persistent mastoid and middle ear inflammation and infection. This can
occur with or without cholesteatoma, tympanic membrane perforation, or persistent otorrhea through
ventilation tubes. When infection and inflammation persist, mucosal edema blocks off the normal
pathways for drainage and aeration between the mastoid and middle ear. Continued inflammation
results in bony destruction and granulation tissue formation. Infection subsequently spreads through
direct extension via bony erosion from cholesteatoma or osteitis, or possibly through preformed
pathways (more commonly associated with AOM).
262
Downloaded for Carima Jatno (carimajatno.md@gmail.com) at Universitas Muslim Indonesia from ClinicalKey.com by
Elsevier on May 26, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All
rights reserved.
 38  Complications of Otitis Media  263

3. What are some examples of preformed pathways?

Examples of preformed pathways are congenital inner ear anomalies such as Mondini’s
malformation or an enlarged vestibular aqueduct, trauma from previous surgery, or prior temporal
bone fractures. These pathways increase the risk of direct extension of infection in the middle ear
and mastoid.
4. What are the three pathways that result in complicated OM?
The three main pathways that result in OM complications are hematogenous spread, direct
extension though bony erosion or preformed pathways, and thrombophlebitis of local perforating
(diploic) veins.
5. What is an example of hematogenous spread of infection with OM?
Meningitis is an example of hematogenous spread. Meningitis usually occurs as a result of AOM
rather than CSOM, and classic symptoms include headache, nausea, nuchal rigidity, photophobia,
altered mental status, and fever. Cerebrospinal fluid examination is critical, and many times
computed tomography (CT) is performed to rule out other intracranial complications and mass
lesions.
6. What are examples of direct extension?
Direct extension results in a variety of complications depending upon the area of spread.
Complications such as postauricular abscess, Bezold’s abscess, sigmoid sinus thrombosis, epidural
abscess, and subdural empyema all result from direct extension (see Figure 38-1).
7. What is a Bezold’s abscess?
A Bezold abscess is a complication of acute otomastoiditis where the infection erodes through the
mastoid cortex medial to the attachment of sternocleidomastoid, at the attachment site of the
posterior belly of the digastric muscle, and extends into the infratemporal fossa. Due to it being
deep to the cervical fascia that envelops the sternocleidomastoid muscle and trapezius muscle, it is
difficult to palpate.
8. What is the bacteriology of complicated OM?
Complicated otitis media characteristically has an increase in resistant organisms, and is often
polymicrobial. Frequently cultured organisms include P. aeruginosa, S. aureus including methicillin
resistant strains, K. pneumoniae, P. acnes, and Bacteroides species.

Figure 38-1.  Axial CT scan with contrast

demonstrating a postauricular abscess. (From
El-Kashlan H, Harker L, Shelton C, et al:
Complications of Temporal Bone Infections.
In Flint P, et al, editors: Cummings
Otolaryngology Head and Neck Surgery,
ed 5, Philadelphia, 2010, Mosby Elsevier,
pp 1979–1998.)

Downloaded for Carima Jatno (carimajatno.md@gmail.com) at Universitas Muslim Indonesia from ClinicalKey.com by
Elsevier on May 26, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All
rights reserved.
 264  IV  OTOLOGY AND AUDIOLOGY

Table 38-1. Classification Schema for Complications of OM

EXTRACRANIAL/INTRATEMPORAL INTRACRANIAL
Acute mastoiditis Meningitis
Coalescent mastoiditis Brain abscess
Chronic mastoiditis Subdural empyema
Postauricular abscess Epidural abscess
Bezold abscess Lateral sinus thrombosis
Temporal abscess Otitic hydrocephalus
Petrous apicitis
Labyrinthe fistula
Facial paralysis
Acute suppurative labyrinthitis
Encephalocele
CSF leak
Hearing loss (conductive and sensorineural)

9. What is the epidemiology of complications associated with OM?

The majority of complications associated with OM occur in children and young adults. Incidence
varies among studies, but 60% to 80% of complications occur in the first two decades of life.
10. What is the most common complication of OM?
The most common complication of OM is otitis media with effusion (OME). This entity is defined
as middle ear effusion without signs of acute infection or inflammation, and may contribute to
hearing loss.
11. What is the classification schema for complications of OM?
Complications can be divided into intracranial or extracranial/intratemporal (Table 38-1).
12. What are important presenting symptoms for complications of OM?
The signs and symptoms of OM and its associated complications can be quite broad, depending on
the structures affected. Symptoms typically will begin with otalgia, irritability, and fever in AOM.
CSOM may be initially more subtle, presenting with persistent purulent otorrhea. Patients may have
postauricular pain, edema, otorrhea, and erythema with mastoid infection or abscess. Additionally, a
patient’s level of consciousness may be altered from intracranial complications. The time period of
mental status change is variable based on the specific type of intracranial complication. The patient
may exhibit papilledema, cranial nerve palsies, nuchal rigidity, or other neurologic findings.
13. What is the role of imaging in the diagnosis of complicated OM?
A CT should be performed with contrast to assess for soft tissue and intracranial abscesses,
inflammation, and flow voids in vessels. CT also allows evaluation of the osteology of the temporal
bone specifically related to aeration of the middle ear and mastoid, bony dehiscence or erosions,
and evaluation of cholesteatoma. However, it should be noted that imaging for OM is not needed
unless there is worry about associated complications. Since the middle ear is connected to the
mastoid air cell system, imaging of any acute OM likely will show mastoid opacification and thus
may be interpreted as mastoiditis by the radiologist. Although CT offers excellent initial evaluation
of suspected complications of OM and is much faster, MRI is more sensitive for diagnosis of
intracranial complications. MRI detects subtle cerebral edema, dural enhancement, abscess, and
vessel lumen patency more sensitively than CT. Both modalities are complementary to one another
in diagnosis, management, and response to treatment. However, CT is a much quicker alternative
than magnetic resonance imaging (MRI) in patients who are unstable or with altered mental status.

Downloaded for Carima Jatno (carimajatno.md@gmail.com) at Universitas Muslim Indonesia from ClinicalKey.com by
Elsevier on May 26, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All
rights reserved.
 38  Complications of Otitis Media  265

14. What are important physical exam findings in complicated OM?

A complete head and neck examination as well as a neurologic exam should be completed
if there is any suspicion of complications of OM. The otologic exam may reveal signs of acute
infection such as an erythematous, bulging, and opaque tympanic membrane, or may show
perforation with purulent otorrhea, granulation tissue, or signs of a cholesteatoma. Postauricular
or temporal abscesses may exhibit pain with palpation, erythema, and fluctuance. Vestibular
symptoms may be present in certain cases with periods of imbalance, dysequilibirum,
and vertigo.
Intracranial complications may present with papilledema, abducens nerve palsy, nuchal rigidity,
positive Kernig or Brudzinski’s signs, and altered mental status. Posterior superior sagging of the
external auditory canal may be indicative of canal erosion from cholesteatoma. Facial nerve
paralysis is not an uncommon finding, especially with bony dehiscence within the middle ear and
resultant inflammation of the facial nerve. Petrous apicitis may present with abducens nerve palsy. It
is therefore important to conduct a thorough cranial nerve examination.

15. What are some eponyms that your attending might quiz you on?
• Queckenstedt’s sign is a test to determine whether cerebrospinal fluid (CSF) flow is obstructed in
the subarachnoid space of the spinal canal by applying bilateral pressure on the internal jugular
veins during lumbar puncture. No rise in pressure during this maneuver indicates obstruction of
CSF flow as seen in meningitis or lateral sinus thrombophlebitis.
• Gradenigo syndrome is the triad of symptoms associated with petrous apicitis including
retro-orbital pain, abducens nerve palsy, and otorrhea.
• Bezold’s abscess is a cervical infection on the medial side of the mastoid deep to the digastric
ridge that develops into an abscess.
• Citelli abscess is a cervical infection extending along the posterior belly of the digastric muscle
that develops into an abscess.

16. What is the general treatment for complications associated with AOM?
Determining the status of the middle ear prior to infection is crucial in development of a treatment
algorithm. Given that AOM develops in a previously normal ear without bony erosion and significant
mucosal edema to block access to the mastoid, medical treatment with antibiotics is usually
adequate to treat the otitis, and mastoidectomy is not needed. Sometimes myringotomy with or
without tube placement is recommended. Treatments regarding specific complications vary and are
discussed later in this chapter.

17. What is the general treatment for complications associated with COM?
As stated earlier, determining the status of the middle ear prior to infection is of the utmost
importance. In CSOM, complications occur secondary to bony erosion, granulation tissue formation,
or presence of cholesteatoma. In addition to bony erosion or cholesteatoma, infection can gain
access to local structures through direct extension, and less frequently from a congenital anomaly.
Infection may also propagate along vascular foramina from the mastoid to adjacent structures. Given
the different pathophysiology of CSOM compared to AOM, the use of antibiotics and surgery are
often complementary in management.

18. What is the role of medical therapy in treating complications of OM?

In almost all cases, intravenous (IV) antibiotics are the mainstay of therapy with initial broad-
spectrum activity against aerobes and anaerobes. Until culture directed treatment can be obtained,
initial regimens are meant to be broad and involve a combination of antibiotics such as vancomycin,
a β-lactam antibiotic with a β-lactamase inhibitor (e.g., ampicillin-sulbactam), cephalosporins (e.g.,
ceftriaxone, cefepime, cefotaxime), and/or metronidazole. There may be significant institutional
variability among antibiotics of choice depending on local patterns of resistance. Cerebrospinal fluid
penetration should also be considered when intracranial complications are suspected. Treatment
should be tailored once culture results are available.

19. What is the role of anticoagulation with sigmoid sinus thrombosis due to OM?
Sigmoid sinus thrombosis is an intracranial complication of OM. Mastoidectomy and antibiotics are
well-established treatments with anticoagulation as a possible adjunct. Anticoagulation, though
controversial, is thought to be beneficial in preventing clot extension and embolization, but current
literature continues to be inconclusive regarding its use.

Downloaded for Carima Jatno (carimajatno.md@gmail.com) at Universitas Muslim Indonesia from ClinicalKey.com by
Elsevier on May 26, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All
rights reserved.
 266  IV  OTOLOGY AND AUDIOLOGY

Table 38-2. General Treatment Strategies for Complications of OM Including

Surgical Options
General Treatment Strategies for Complications of OM
COMPLICATION
Acute mastoiditis
Coalescent mastoiditis
Postauricular abscess
Bezold abscess
Temporal abscess
Petrous apicitis
Labyrinthe fistula
Facial nerve paralysis
Acute suppurative
labyrinthitis
Encephalocele, CSF
leak
Meningitis
Intraparenchymal brain
abscess
Subdural empyema
Epidural abscess
Sigmoid sinus
thrombosis
Otitic hydrocephalus
MEDICAL TREATMENT SURGICAL TREATMENT
IV antibiotics ± Tympanocentesis, ± mastoidectomy
IV antibiotics Mastoidectomy
IV antibiotics Incision and drainage, mastoidectomy
IV antibiotics Incision and drainage, mastoidectomy
IV antibiotics Incision and drainage, mastoidectomy
IV antibiotics, ± steroids ± Mastoidectomy, ± petrous apex
drainage
± IV antibiotics removal of cholesteatoma, ±fistula repair
± IV antibiotics, ± steroids ± Tympanocentesis, ± facial nerve
decompression, ± removal of
cholesteatoma
IV antibiotics, ± steroids +± Mastoidectomy
No antibiotics Mastoid or middle fossa approach repair*
IV antibiotics, steroids Tympanocentesis, ± mastoidectomy
IV antibiotics ± Incision and drainage*, mastoidectomy
IV antibiotics Incision and drainage*, mastoidectomy
IV antibiotics Incision and drainage, mastoidectomy
IV antibiotics, Mastoidectomy, ± clot removal, ± ligation
± anticoagulation, of internal jugular vein
± steroids
IV antibiotics, ± steroids, Mastoidectomy, ± clot removal, ± serial
± diuretics, lumbar punctures
± anticoagulation

*Neurosurgical consultation.

20. What is the role of surgical intervention?

Table 38-2 depicts general treatment guidelines for complications of OM. Medical therapy without
surgery may be warranted initially, especially in uncomplicated cases of acute mastoiditis. Surgery
is usually recommended if there is failure to improve on medical therapy, development of
complications, or presentation with intracranial complications. Surgery may range from myringotomy
and tube insertion to mastoidectomy with intracranial decompression.
Special consideration must be given for complications associated with cholesteatoma because
the removal of the cholesteatoma is required for adequate long-term treatment. IV antibiotics are
usually warranted and neurosurgery consultation may be sought in both medical and surgical
management of intracranial complications.

BIBLIOGRAPHY
Casselbrant M, Mandel E: Acute otitis media and otitis media with effusion. In Flint P, et al, editors: Cummings
Otolaryngology Head and Neck Surgery, ed 5, Philadelphia, 2010, Mosby Elsevier, pp 2761–2777.
Chole R, Sudhoff H: Chronic otitis media, mastoiditis, and petrositis. In Flint P, et al, editors: Cummings Otolaryngology
Head and Neck Surgery, ed 5, Philadelphia, 2010, Mosby Elsevier, pp 1963–1978.

Downloaded for Carima Jatno (carimajatno.md@gmail.com) at Universitas Muslim Indonesia from ClinicalKey.com by
Elsevier on May 26, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All
rights reserved.
 38  Complications of Otitis Media  267

El-Kashlan H, Harker L, Shelton C, et al: Complications of temporal bone infections. In Flint P, et al, editors: Cummings
Otolaryngology Head and Neck Surgery, ed 5, Philadelphia, 2010, Mosby Elsevier, pp 1979–1998.
Friedland DR, Pensak ML, Kveton JF: Cranial and intracranial complications of acute and chronic otitis media. In Snow J,
Wackym P, editors: Ballenger’s Otorhinolaryngology Head and Neck Surgery, ed 17, Ontario, 2009, BC Decker,
pp 229–238.
Isaccson B, Mirabal C, Kutz W, et al: Pediatric otogenic intra-cranial abscesses, Otolaryngol Head Neck Surg 142:
434–437, 2010.
Osma U, Cureoglu S, Hosgoglu S: The complications of chronic otitis media: report of 93 cases, J Laryngol Otol
114:97–100, 2000.
Psarommatis IM, Voudouris C, Douros K, et al: Algorithmic management of pediatric acute mastoiditis, Intl J Pediatr
Otorhinolaryngol 76(6):791–796, 2012.
Singh B, Maharaj TJ: Radical mastoidectomy: its place in otitic intracranial complications, J Laryngol Otol 107:
1113–1118, 1993.
Sitton MS, Chun R: Pediatric otogenic lateral sinus thrombosis: role of anti-coagulation and surgery, Intl J Pediatr
Otorhinolaryngol 76:428–432, 2012.
Yorgancilar E, Yildrum M, Gun R, et al: Complications of chronic suppurative otitis media: a retrospective review, Eur
Arch Otorhinolaryngol 270:69–76, 2013.

Downloaded for Carima Jatno (carimajatno.md@gmail.com) at Universitas Muslim Indonesia from ClinicalKey.com by
Elsevier on May 26, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All
rights reserved.