Scholars Journal of Applied Medical Sciences (SJAMS) ISSN 2320-6691 (Online)

Abbreviated Key Title: Sch. J. App. Med. Sci. ISSN 2347-954X (Print)
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A Unit of Scholars Academic and Scientific Society, India ENT
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Clinicopathological Profile and Outcome of Patients with Intracranical

Complication Secondary to Otitis Media: 4 Year Retrospective Analysis
Devdatt P. Kotnis*
Associate professor, Department of ENT, DVVPF's medical college, Ahmednagar, Maharashtra, India

Abstract: Chronic suppurative otitis media (csom) is, defined as a chronic

Original Research Article inflammation of the middle ear and mastoid cavity. India falls in category of highest
prevalence of CSOM requiring urgent attention. The reported overall extra- and
*Corresponding author intracranial complication rate in CSOM varies from 0.7% to 3.2%; extracranial
Devdatt P. Kotnis complications alone from 0.5% to 1.4% and intracranial complications from 0.3% to
2.0%. Present study is undertaken to study demographic, clinical profile and treatment
Article History outcome of patients of otitis media associated with intracranial complications (ICC).
Received: 14.06.2018 This retrospective observational study was carried out in department of ENT, DVVPF's
Accepted: 27.06.2018 medical college & Hospital from May 2014 till April 2018. Clinical profile and
Published: 30.06.2018 outcome of treatment were analysed in patients of otitis media with associated
intracranial complications. During study period 24 patients of otitis media with
DOI: intracranial complication were included in study. The mean age of presentation of these
10.21276/sjams.2018.6.6.50 patients with icc in present study is about 22 years. Extradural abscess was the most
common ICC (n=9, 31%) followed by brain abscess in 6 patients (20.7%). 9 (31%)
patients had meningitis with or without associated intracranial abscess. We saw 3
(10.4%) patients with lateral sinus thrombosis. The mean duration of hospital stay in
this patient were 51 days. Satisfactory recovery was seen in most of the patients (82%)
with no neurological sequele. 3 patients developed deafness. Neurological deficit was
more common in patients with cerabral abscess (p< 0.05). Otitis media is disease of
childhood, if not treated adequately can lead to serious complication in early adulthood
causing permanent deafness & neurological deficit. Patients with intracranial
complications have longer hospital stay. A multidisciplinary approach is required to
maximize recovery once complication occurs.
Keywords: acute otitis media, cerebral abscess, chronic suppurative otitis media,
intracranial complications, meningitis.

INTRODUCTION prevalence requiring urgent attention [4]. CSOM is

Chronic suppurative otitis media (CSOM) is, associated with serious extracranial and intracranial
defined as a chronic inflammation of the middle ear and complications. The reported overall extra- and
mastoid cavity, which presents with recurrent ear intracranial complication rate in CSOM varies from
discharges or otorrhoea through a tympanic 0.7% to 3.2%; extracranial complications alone from
perforation[1]. The disease usually begins in childhood 0.5% to 1.4% and intracranial complications from 0.3%
as a spontaneous tympanic perforation due to an acute to 2.0%. The most frequent extracranial complications
infection of the middle ear, known as acute otitis media are facial paralysis, subperiosteal abscess, mastoiditis,
(AOM), or as a sequel of less severe forms of otitis and labyrinthitis, with reported incidences of 13–58%,
media [2]. The point in time when AOM becomes 40–68%, 14–74%, 7–34% of all extracranial
CSOM is not clear. Generally, patients with tympanic complications, respectively. The most common
perforations which continue to discharge mucoid intracranial complications of CSOM are meningitis,
material for periods of from 6 weeks to 3 months, cerebral abscess, lateral sinus thrombosis, extradural
despite medical treatment, are recognized as CSOM abscess, otic hydrocephalus, and encephalitis, with
cases. The WHO definition requires only 2 weeks of reported incidences of 21–72%, 18–42%, 2–26%, 7–
otorrhoea, but otolaryngologists tend to adopt a longer 16%, 5–11%, and 2% of all intracranial complications,
duration, e.g. more than 3 months of active disease [3] respectively[5]. In 1990, about 28 000 deaths all over
the prevalence of CSOM varies widely. Across the the world and largely among developing countries were
globe countries with CSOM prevalence rates of less due to otitis media. Mortality and disabilities due to
than 1% are classified as lowest prevalence & more otitis media are primarily related to the complications of
than 4% are highest. India falls in category of highest CSOM, particularly brain abscess[6]. The frequency of
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Devdatt P. Kotnis., Sch. J. App. Med. Sci., Jun 2018; 6(6): 2563-2566
life-threatening complications from CSOM has been Following parameters were analysed in each patient.
dramatically reduced by more than 10-fold with the  Demographic profile: age at presentation, gender
modern antibiotics.Acute exacerbations usually lead to  Clinical profile: Type of otitis media, age of
rapid intracranialextension of disease[7]. Routes to diagnosis, duration of disease, type of intracranial
cranial spread include direct erosion of bone, blood complication, treatment received
borne infection and diffusion, through anatomical or  Outcome: Mortality, permanent sequele, total
traumatic pathways[8]. hospital stay.

Present study is retrospective analysis of Results were tabulated and OPEN EPi
patients admitted with us with intracranial software was used for statistical analysis.
complications secondary to chronic otitis media.
OBSERVATIONS
MATERIALS & METHODS During study period total 751 patients with
This retrospective observational study was otitis media presented to ENT OPD. 439 patients had
carried out in department of ENT, DVVPF's medical acute otitis media, while remaining 312 were suffering
college & Hospital from May 2014 till April 2018 after from CSOM. 24 patients were having associated
getting institutional ethical committee clearance. intracranial complications. 4 patients had intracranial
complication secondary to acute otitis media, while 20
A total of 751 patients with otitis media (OM) patients suffered from CSOM with intracranial
presented in OPD, of which 24 patients had associated complications. Thus incidence of ICC was 0.9% in
intracranial complications. All these 24 patients were acute otitis mrdia and 6.41% in patients with CSOM.
included in present study. Detailed clinical history, Such high incidence in present study is attributed to
examination and investigations such as complete many referred patients to our institute.
haemogram, X-ray were carried out. Computerized
tomography (CT) scan, magnetic resonance imaging The mean age of presentation of these patients
(MRI), magnetic resonance (MR) angiography and with ICC in present study is about 22 years(Table: 1)
lumbar puncture were advised as per patient The mean age of diagnosis of otitis media in these
presentation. patients is about 5-7 years. Thus there is lag of about 15
years between diagnosis of otitis media and
All patients recieved IV antibiotics, steroids development of ICC. 17 (71%) Patients in our study
and antiepileptic drug if necessary. Surgical were male, 7 (29%) were female.
management was needed in some patients.

Table-1: Demographic profile of patients

No. of cases %
Age at presentation with ICC
< 10 years 3 12.5
10-20 years 8 33.4
20-30 years 11 45.8
> 30 years 2 8.3

Male 17 71
Female 7 29
Mean age at presentation with ICC- 22 years
Mean age of diagnosis with otitis media- 5 years

Among 24 patients with ICC 3 patients had Persistent headache, chronic otorrhoea and
two or more ICC at the time of presentation causing features of space occupying lesion were commonest
total 29 various intracranial complications. 17 (58.6%) mode of presentation in these patients. Some cases of
patients had intracranial abscess. Extradural abscess extradural abscesses were asymptomatic diagnosed on
was the most common ICC (31%) followed by brain imaging. On clinical examination external auditory
abscess in 6 patients (20.7%). 3 patients had cerebral canal granulations and cholesteatoma was seen in 75%
abscess in area of petrous bone, 2 patient had temporal of patients. Proteus mirabilis, Enterococcus,
lobe abscess and 1 had cerebellar abscess. 2 patients Pseudomonas aeruginosa, Pneumococcus, Haemophilus
had subdural abscess. 9 (31%) patients had meningitis and Staphylococcus were the most common
with or without associated intracranial abscess. We saw microorganism isolated.
3 (10.4%) patients with lateral sinus thrombosis. None
of our patient had associated hydrocephalus.

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Devdatt P. Kotnis., Sch. J. App. Med. Sci., Jun 2018; 6(6): 2563-2566
Table-2: Types of intracranial complications
No. of cases %
Abscess 17 58.6
Extradural 9 31
Brain 6 20.7
Subdural 2 6.9
Meningitis 9 31
Thrombosis 3 10.4

All patients recieved IV antibiotics for 4- 6 hospitalisation is needed for patients requiring surgical
weeks depending on culture & sensitivity report. Most intervention, thus increasing economic burden. Mean
patient received third/fourth generation cephalosporins hospital stay in Penido NO et al. [9] study was 34.3
and metronidazole. Some patients required vancomycin, days (1-180 days).
imipenem or meropenem. 19 (79%) patients required
surgical intervention for either treatment of primary Once intracranial complication has occurred, a
disease or for management of complication such as multidisciplinary approach is required to ensure rapid
drainage of cerebral abscess. recovery with minimal permanent damage. Higher
parenteral antibiotics, adjuvent therapy and timely
The mean duration of hospital stay in this surgical intervention in our study resulted in complete
patient was 51 days, ranging from 35- 74 days. recovery in 82% of cases. Such high cure rate is seen in
Satisfactory recovery was seen in most of the patients other studies as well [10,11].
(82%) with no neurological sequele. 3 patients
developed deafness. Neurological defecit was more Deafness and neurological deficit was more
common in patients with cerabral abscess (p< 0.05). 2 common in patients with cerebral abscess in our study.
patients had facial nerve palsy, of which 1 patient had Penido NO et al. [9] had meningitis more commonly
hemiparesis as well. 1 patient with meningitis and associated with deafness. Permanent sequelae occurred
cerabral abscess presented in septic shock and could not in 15 patients (29.4% of all ICC cases). Cranial nerve
be revived. VII and VI nerve palsies were the most common
permanent consequences seen. Three patients with
DISCUSSION CSOM developed 2 or more neurological sequelae
Mean age of presentation of patient was 22 including hemiparesis, reduced intellectual ability,
years in our study. Maximum patients were in age dysmetria and dysarthria.
group of 20-30 years (45.8%). 11 patients presented
before the of 20 years. 71% of patients were male. CONCLUSION
Similar finding is seen in study by Penido NO et al. [9] Otitis media is disease of childhood, if not
and Miura Maurício S et al. [10]. Mean age of diagnosis treated adequately can lead to serious complication in
of otitis media was 7 years in our patients. Thus there early adulthood causing permanent deafness &
was lag of about 15 years between diagnosis of otitis neurological defecit. Patients with intracranial
media and development of intracranial complications. complications have longer hospital stay. Even after
This emphasises on correct diagnosis and management major advances in antibiotic therapy, imaging
of these patients at early age to prevent serious modalities and neurosurgical therapy these patients
morbidity later. External auditory canal granulations have significant morbidity and high mortality rate. High
and cholesteatoma were main predisposing factors index of suspician is required in any patient with
associated with ICC in our study. Brown et al. [11] and intracranial disease. A multidisciplinary approch is
Schwager et al. [12] made similar observation. required to maximize recovery once complication
occurs.
Intracranial abscesses (58.6%) were the most
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