CAS CLINIQUE / CASE REPORT

COMPLICATIONS OF ACUTE OTITIS MEDIA IN CHILDREN

Case Reports and Review of Literature
http://www.lebanesemedicaljournal.org/articles/58-4/case2.pdf

Maya ADHAMI, Souheil TOHME

Adhami M, Tohme S. Complications of acute otitis media in
children : Case reports and review of literature. J Med Liban
2010 ; 58 (4) : 231-237.

Adhami M, Tohme S. Complications de lotite moyenne aigu

chez les enfants : Prsentation de cas et revue de la littrature.
J Med Liban 2010 ; 58 (4) : 231-237.

ABSTRACT : This is a report of three cases of complications of acute otitis media. The first case describes
coalescent mastoiditis seen in a ten-month-old infant,
the second case is petrositis, sigmoid sinus thrombosis
and otitic hydrocephalus seen in a five-year-old child
and the third case is an extradural abscess encountered in a three-year-old child. The assessment, diagnosis and treatment of each case are illustrated and
discussed.

RSUM : Cest un rapport de trois cas de complications de lotite moyenne aigu. Premier cas : une mastodite coalescente rencontre chez un enfant de 10
mois. Second cas : une ptrosite associe une thrombose du sinus sigmode avec hydrocphalie dorigine
otogne rencontre chez un enfant de 5 ans. Troisime
cas : un abcs extradural rencontr chez un enfant de
3 ans. Lvaluation, le diagnostic et le traitement de
chaque cas sont revus et discuts.

INTRODUCTION

erosion of the tip of the mastoid with extension, down to

the posterior triangle of the neck. The treatment of these
abscesses is cortical mastoidectomy and drainage, with
the latter probably necessitating a neck exploration [5-6].
Mastoiditis can extend medially to the petrous apex of
the temporal bone, resulting in petrositis. Petrositis is an
uncommon and late complication of purulent otitis media.
When the inflammation extends into Dorello canal, which
transmits CN VI and the Gasserian ganglion (CN V), then
Gradenigo syndrome develops. It is characterized by a
triad of symptoms: lateral rectus (CN VI) palsy, retroorbital pain (in the distribution of CN V), and otorrhea.
The treatment of choice includes intensive antimicrobial
therapy and mastoidectomy, with opening of the involved
cell tracts leading to the petrous apex [11, 16-17].
Other intratemporal complications include labyrinthitis
and facial nerve paralysis [3]. Intracranial complications
include abscesses (temporal lobe, cerebellum, extradural,
subdural), meningitis, sigmoid sinus thrombosis, and otitic hydrocephalus.
The purpose of this article is to report three cases of the
complications of otitis media in children. The clinical presentation, diagnostic modality employed and management
options used are discussed with relevance to the literature.

Acute otitis media is one of the most common infections

in children. Usually a benign self-limited disease, it may
however progress to potentially life-threatening conditions. Clinicians must be aware of the natural course and
complications of this frequent disease.
The complications of otitis media can be divided into
intratemporal and extratemporal (intracranial). Among the
intratemporal complications, acute mastoiditis accounts
for the majority of cases. Palva et al. reported an annual
acute mastoiditis incidence of 0.3/100000 in a study of a
million population in Finland [1].
Mastoiditis is characterized by a granulomatous and inflammatory process of the mastoid bone with disruption
of its cellular system and demineralization by osteoclastic
activity. One should suspect mastoiditis if, after a period
of quiescence of about two weeks following an acute otitis media, the child has recurrent ear discharge and fever.
If the underlying bony partitions within the mastoid are
eroded and resorption of the bony septa occurs, then coalescent mastoiditis ensues. This is thought to be an uncommon progression of acute otitis media.
When the infection surpasses the mastoid cortex, a subperiosteal abscess can result. It may present, most commonly, as a postauricular fluctuance or abscess, or as a
zygomatic abscess, or as a Bezolds abscess, formed by
From Otolaryngology, Head and Neck Surgery Department,
Saint George Hospital, University Medical Center, University
of Balamand, Beirut, Lebanon.
Correspondence : Maya Adhami, MD. St George Hospital
University Medical Center. P.O. Box 166378. Beirut 800
2807. Lebanon.
Tel. : +961 1 741118
Fax : +961 1 740426
e-mail : [email protected]

CASE REPORTS

Case Study 1
A ten-month-old baby girl presented to the outpatient
clinic after a three-week history of right otorrhea, and
progressive postauricular swelling and erythema. The otologic examination revealed a right ear discharge and a
polyp filling the medial part of the external auditory canal,
associated with erythema, swelling and tenderness over
the right mastoid region with anterior displacement of
Lebanese Medical Journal 2010 Volume 58 (4) 231

FIGURE 1a. Case 1 presenting with postauricular swelling and

erythema with anteroinferior displacement of auricle.

the auricle (Figure 1a). The patient was previously treated

elsewhere with antibiotics: Cefuroxime (125 mg BID
for five days) then Azithromycin (10 mg/kg on day 1 followed by 5 mg/kg daily for five days) then Lincocin
(15 mg/kg daily for seven days) with no improvement.
Ear cultures taken from a swab from the external auditory
canal showed a heavy growth of Pseudomonas aeruginosa sensitive to common large spectrum antibiotics
given for this germ. The patient was admitted to the pediatric ward with intravenous broad spectrum antibiotics
(Ceftriaxone 70 mg/kg/day). The CT scan was out of
order at that time. Accordingly, a brain MRI with contrast
was done and it showed a right subperiosteal abscess
(Figure 1b). The patient was planned for mastoidectomy.
Intraoperative findings revealed the presence of a subperiosteal abscess of the mastoid with gross cortical bone
erosion. The whole cavity was filled with a coalescent
mass of osteitic bone and calcareous pus. Cultures were
sent for microbiological studies (bacteriological Gram
staining and acid fast bacillus stain).
A canal wall-up mastoidectomy was done. Granulations were thoroughly removed from the aditus, attic, and
around middle ear structures, leaving minor granulations
over the stapes; the remaining necrotic portion of the tympanic membrane was also removed.
Intraoperative cultures did not yield any microorganisms and Acid Fast Bacillus test to rule out the possibility
of a tuberculous infection, in a setting of florid mastoid
granulations, was negative. The patient received a one
week course of IV Ceftriaxone (70 mg/kg/day) followed
by a total of two weeks of IV Cefepime (50 mg/kg BID)
for better coverage of Pseudomonas. A computed tomography of the temporal bones was done seven days following surgery to attain a better delineation of the mastoid
bone and to follow up the underlying infection. It showed
a complete resolution of the subperiosteal abscess. The
patient was then discharged home and was followed on
outpatient basis for a period of six months postoperatively (Table I).
232 Lebanese Medical Journal 2010 Volume 58 (4)

FIGURE 1b. MRI of the temporal bones of Case 1 showing

opacification of the right mastoid with evidence of a right subperiosteal abscess.

Case Study 2
This is the case of a five-year-old previously healthy girl
with a history of recurrent left otitis media (six episodes
per year), the last episode occurring a month prior to
admission and treated by Ceftriaxone IM (50 mg/kg/day)
for three days followed by Amoxicillin and Clavulanic
acid (30 mg/ kg/day) for 10 days with poor response. She
was admitted to our institution for management of left
otalgia, otorrhea, headaches and strabismus. On physical
evaluation, the patient had nasal obstruction. Her otologic
exam revealed a left ear yellowish discharge, which after
cleaning, uncovered a central tympanic membrane perforation. Her right ear showed a bulging ear drum with a
middle ear effusion. Her eye examination revealed a left
strabismus and the funduscopic exam showed normal
optic discs and no papilledema. Nasofibroscopy confirmed the presence of adenoids. An MRI and MRA of the
brain with gadolinium contrast revealed opacification
of the mastoid air cells, with the left side being more
involved, associated with an absent flow into the left sigmoid sinus. This was confirmed by post injection views
that reported findings compatible with thrombophlebitis
of the left sigmoid sinus. No intracranial extension was
seen. Blood, ear and cerebrospinal fluid cultures were
taken. The patient was planned for left mastoidectomy,
adenoidectomy and bilateral PE tubes placement.
Intraoperative findings showed a well pneumatized left
mastoid cavity with granulation tissue filling the attic.
M. ADHAMI et al. Complications of acute otitis media in children

Marked improvement of headache, otalgia and

strabismus
Lumboperitoneal shunt removed after one year

Repeat CT scan showed repermeabilization of

sigmoid sinus and resolution of mastoiditis
Repeat fundoscopy showed decreasedf
papilledema

Repeated lumbar punctures

Acetazolamide
Lumboperitoneal shunt
Repeat fundoscopy indicative of papilledema
Lumbar puncture: normal fluid and analysis
but increased opening pressure
CT/MRI: petrous apicitis

MRI and MRA of brain showed left

mastoiditis and sigmoid sinus thrombosis
Fundoscopy unremarkable
After 3-week history of persistent left otalgia,
otorrhea, and new onset headache and
strabismus

Postoperatively, headache became worse

5 years

Symptoms improved
F/U CT scan showed complete resolution
MRI showed right coalescent mastoiditis
with a subperiosteal abscess
10 month

After 3-week history of right otorrhea and

postauricular swelling

IV Ceftriaxone (1 wk) followed by

IV Cefepime (2 wks)
Mastoidectomy

Outcome
Treatment
Imaging Results
Time to Diagnosis
Age

TABLE I

CLINICAL PRESENTATION, TIME TO DIAGNOSIS, IMAGING MODALITY, TREATMENT, AND OUTCOME OF CASES 1 AND 2

IV Ceftriaxone and steroids

Mastoidectomy + PE tubes
Conservative management of sigmoid
sinus thrombosis
CASE 2

CASE 1

M. ADHAMI et al. Complications of acute otitis media in children

Osteitic, eroded bone was seen over the sigmoid sinus

which was also covered by granulations. Slight pulsations
were visible in the sigmoid sinus and needle aspiration of
the sinus revealed half a milliliter of blood and no pus.
Mucopus filled the middle ear. Her adenoids were moderately enlarged.
The patient underwent adenoidectomy and a Shepard
PE tube was inserted in the right ear. A left mastoidectomy
was performed. Despite florid granulations in the attic, a
mucosa lined passage was found between the aditus, attic,
and middle ear. After needle aspiration of the sigmoid
sinus, it was elected not to open it, allowing the sinus to
recanalize. Cultures and biopsies were taken from the mastoid. A left anteroinferior myringotomy was done with the
insertion of a long Armstrong PE tube. Polymerase chain
reaction screening of mastoid fluid sent intraoperatively
was compatible with streptococcus species.
The patients headache became worse and she started
vomiting. Postoperatively, a funduscopic exam was repeated and it showed tortuosity of vessels with optic nerve
swelling bilaterally, indicative of early papilledema. Several lumbar punctures were done that resulted in mild
improvement of symptoms. Cerebrospinal fluid analysis
was normal and cultures (CSF, blood, surgical wound) were
negative for soluble bacterial antigens. With the presence of
headaches, vomiting and papilledema compatible with
increased intracranial pressure and a normal CSF analysis,
the diagnosis of otitic hydrocephalus was established. So
the patient was put on Acetazolamide for ten days. A lumboperitoneal shunt was installed due to the inefficacy of the
lumbar punctures in relieving otitic hydrocephalus.
The patient was not put on antiocoagulation since a
CT venogram of the brain done ten days postoperatively
showed partial repermeabilization of the left sigmoid sinus
and the origin of the left internal jugular vein estimated
to be around 30% patent. The CT scan of temporal bones
showed however a possible periosteal reaction at the anterior aspect of the left petrous apex with poor aeration compared to the normally aerated right petrous apex. The diagnosis of petrous apicitis was confirmed by MRI of the temporal bones that showed opacification and enhancement
of the left mastoid air cells that has increased and extending towards the petrous apex.
With the clinical triad of headaches involving the ophthalmic and maxillary distribution of CNV, left strabismus
secondary to lateral rectus paralysis and acute petrositis,
the patient was diagnosed with Gradenigo syndrome.
The patient was given a total of 3 weeks IV Ceftriaxone (75 mg/kg/day in two divided doses) and two
weeks of steroids. The ophthalmology consult reported
marked improvement in the patients strabismus with
greatly decreased edema and loss of tortuous blood vessels on funduscopic exam. A repeat MRI of the temporal
bones showed a decrease in the enhancement of the left
petrous bone and mastoid air cells. No definite thrombosis was seen in the left sigmoid sinus or jugular vein. The
lumboperitoneal shunt was removed after one year (See
Table I).
Lebanese Medical Journal 2010 Volume 58 (4) 233

Case Study 3
A three-year-and-a-half-old boy presented to our institution with a four-day history of frontal headaches, following an episode of left acute otitis media diagnosed by
his pediatrician 10 days earlier. There was no associated
fever, vomiting, neck stiffness or visual disturbances. The
ENT exam revealed a persistent left otitis media and a
normal neurological exam. Due to persistence of headache, a CT scan and an MRI of the brain were done. The
CT scan showed full opacification of the left mastoid
and an abscess in the location of the left sigmoid sinus
which is either thrombosed or compressed. On MRI, a
2.5 cm x 1 cm x 2.5 cm possible abscess formation is seen
at the site of the left sigmoid sinus. It shows a fluid level
with rim enhancement. It is associated with thrombosis of
the left sigmoid sinus and decreased flow in the transverse
sinus. There is also complete filling of the mastoid air
cells (Figure 2). The patient was started on IV Ceftriaxone, Vancomycin, amd Metronidazole and was scheduled for left mastoidectomy and for evacuation of the
extradural collection. Preoperative ear, blood and CSF
cultures were taken, and were also sent to PCR.
Intraoperative findings showed a left mastoid cavity
that was filled with granulation tissue and a magma
of granulations surrounding the ossicles. Intracranially,
florid granulation tissue was found adherent to the dura
from the level of the middle mastoid cavity to a distance
of 3 cm posteriorly, which is the site of the cerebellar dura.
A complete canal wall up mastoidectomy was done.
Granulation tissue was removed from the aditus, antrum
and off the dura. It was elected to keep the middle ear
open to improve drainage. The tympanic membrane was
reclined anteriorly. It was also elected not to open the sigmoid sinus since needle aspiration of the sinus did not
yield pus. Intraoperative specimens were sent to culture
and pathology.
The neurosurgery team performed a left occipital craniotomy for evacuation of the extradural posterior fossa
collection. Intravenous antibiotic therapy was continued
for a period of three weeks, with the exception of Metronidazole that was given for five days postoperatively.
All cultures were negative. However, the PCR for
screening of common pathogenic bacteria was compati-

FIGURE 2. CT scan of the temporal bones of Case 3 showing full

opacification of the left mastoid and an abscess in the location of
the left sigmoid sinus which is either thrombosed or compressed.
ble with Streptococcus pneumonaie and Enterococcus
faecium.
Postoperatively, an MRI of the brain revealed that the
left sigmoid sinus and the left internal jugular vein became patent. No brain parenchymal lesion was seen.
The patients symptoms completely resolved and the
follow-up was done monthly for six months, after which
the patient underwent exploration of the left middle ear
and a left myringoplasty to repair the surgically created
posterior tympanic membrane defect. A fat graft obtained
from the left lower abdominal quadrant was used to repair
the defect. The patient was then followed monthly for four
months then twice yearly for two years, showing good
healing and no complications (See Table II).

TABLE II
CLINICAL PRESENTATION, TIME TO DIAGNOSIS, IMAGING MODALITY, TREATMENT AND OUTCOME OF
CASE 3
Age
Time to Diagnosis
Imaging Results
Treatment
Outcome

3 years and a half

After a 4-day history of frontal headache following left acute otitis media
CT scan showed left mastoiditis; evidence of extradural abscess and left sigmoid sinus thrombophlebitis
IV Ceftriaxone, Vancomycin, and Metronidazole
Mastoidectomy, evacuation of extradural abscess through a left occipital craniotomy
Symptoms resolved completely
Repeat MRI showed patent sigmoid sinus and no abscess
Exploration of left middle ear + reconstruction 6 months after

234 Lebanese Medical Journal 2010 Volume 58 (4)

M. ADHAMI et al. Complications of acute otitis media in children

DISCUSSION

Acute coalescent mastoiditis (ACM) is a rare complication of acute otitis media. It is, however, more common in
the pediatric population. Spremo et al. reported in 2007 an
84% incidence of ACM in a series of 13 patients developing acute mastoiditis [2].
Case1 presented with swelling, erythema and tenderness over the mastoid bone with sagging of the posterosuperior canal wall. These symptoms are consistent findings in all series describing ACM [4, 7]. The first had
more than a 3-week history of right otorrhea and progressive postauricular swelling and erythema not responsive
to multiple antimicrobial therapies. According to Quinn
et al., masked mastoiditis should be suspected when there
is persistent pain for two weeks after antibiotic treatment
in a poorly aerated ear [5, 7].
The diagnosis was made based on the clinical presentation and MRI of the brain with contrast, that showed a right
mastoid filled with a soft tissue enhancing lesion and evidence of a subperiosteal abscess. It is important to note that
an MRI was done in this case because the CT scan was out
of order. CT scan of the temporal bones is the standard in
the evaluation of acute mastoiditis. In order to classify
mastoiditis as incipient or coalescent, a CT scan should be
performed early. CT scan is considered the diagnostic tool
that will guide therapy. If intracranial complications are
suspected, then MRI would be more useful in identifying
soft tissue fluid, edema and vascular problems [10].
Mastoiditis can be associated with a subperiosteal
abscess [5, 9]. In a series of 70 cases of mastoiditis, studied by Kuczkowski et al., a subperiosteal abscess was considered the commonest extracranial complication, occurring in 90.2% of the cases [8]. Traditionally, subperiosteal
abscesses were treated by mastoidectomy. In our case of
ACM concomitant with a subperiosteal abscess, a complete mastoidectomy was done.
However, according to Bauer et al., treatment of a subperiosteal abscess with intravenous antibiotics, tympanostomy tube insertion and postauricular incision and drainage was considered adequate but required lengthy followup. This way of management was advocated to avoid the
complications of mastoidectomy [9].
Ear cultures from case 1 showed a heavy growth of
P. aeruginosa. ACM is usually caused by the same organisms as acute otitis media [4, 11]. The most frequently
involved organisms are Streptococcus pneumoniae and
Hemophilus influenzae. In subacute and chronic disease,
Staphylococcus aureus, Gram negative bacteria such as
Escherichia coli and Pseudomonas aeruginosa may be
present. Kuczkowski et al. (2007) reported their series of
70 children with acute mastoiditis complicated by extraor intra-cranial disease, among which Staphylococcus
aureus, Streptococcus pneumoniae, and Pseudomonas
aeruginosa were the most common isolates in ear cultures
[8]. According to Quinn et al. (1998), among anaerobes,
the most common pathogen is Bacteroides sp. [8, 16].
Concerning the management of ACM, it is divided into
M. ADHAMI et al. Complications of acute otitis media in children

medical care, consisting of appropriate antimicrobial therapy, and surgical care. The timing is of great clinical significance. Surgical therapy should be directed promptly
and it involves myringotomy and/or tympanocentesis for
obtaining specimens with tympanostomy tube placement
to provide access to the middle ear and mastoid for antibiotics and/or steroids. A simple or complete mastoidectomy is necessary to remove the areas of coalescence in the
temporal bone [7, 11]. In our case, a simple mastoidectomy with tympanostomy tube insertion was done and middle ear structures were preserved.
The second case was that of sigmoid sinus thrombosis,
otitic hydrocephalus (OH) and petrositis associated with
Gradenigo syndrome. Otitic hydrocephalus (OH) is one of
the rarest intracranial complications of acute otitis media.
The clinical characteristics include signs of increased intracranial pressure (headaches, papilledema and vomiting)
with the absence of focal neurological signs and no effect
of hydrocephalus (no ventricular dilation). According to
Kuczkowski et al. (2006), in a patient with a history of ear
disease, a normal cerebrospinal (CSF) cytology and biochemistry with an opening pressure greater than 240 mm
of water is essential for the diagnosis of OH and to differentiate it from meningitis [13].
The pathophysiology of OH is still unknown. Symonds
in the 1930s suggested that mural non-obstructing thrombus, extending from the lateral to the sagittal sinus leading
to malabsorption of CSF, is required to produce increased
intracranial pressure in OH [12]. According to Mete et al.,
patients with otitic hydrocephalus require ventriculoperitoneal shunt placement [15].
Since an intracranial complication was suspected from
the clinical features found in Case 2, an MRI of the brain
with contrast was used for diagnosis. It showed an opacified left mastoid cavity and thrombosis of the sigmoid
sinus with no evidence of ventricular dilation. All cultures
including CSF, ear and blood were negative and CSF
cytology and biochemistry were normal. However, the
PCR of the mastoid fluid that was sent intra-operatively
was compatible with streptococcus species, one of the
most common microbiologic agents seen in acute otitis
media and mastoiditis [8, 11].
Sigmoid sinus thrombophlebitis is an uncommon but
serious complication of acute otitis media. Secondary to
venous obstruction, patients present with spiking fevers
and headaches. The diagnosis is made when there is a high
index of suspicion because clinical signs might not be present. MRI and CT are necessary to show lack of enhancement of the thrombus filling the dural venous sinus [14].
Agarwal et al. reported that venous obstruction usually
resolves after 4-6 weeks without the need for surgical
exploration of the sinus or anticoagulation, thus preferring
a more conservative therapy [18]. The generally accepted
approach, however, is simple mastoidectomy with decompression of the sigmoid sinus without opening it [15].
Some authors, on the other hand, suggest needle aspiration of the sigmoid sinus. If pus is present, the sinus
is incised and drained into the mastoid [15]. For more
Lebanese Medical Journal 2010 Volume 58 (4) 235

advanced cases, ligation of the internal jugular vein and

resection of the thrombosed sinus can be attempted.
In our case, the needle aspiration of the left sigmoid
sinus yielded half a milliliter of blood and no pus, so it
was elected not to open the sinus.
Although rare since the advent of antimicrobial therapy, a serious complication such as Gradenigo syndrome
can arise, as an extension of a middle ear or mastoid infection [16]. First described by Gradenigo in 1904, the syndrome is characterized by a triad of otorrhea, pain in the
orbital area of the trigeminal nerve distribution, and ipsilateral CNVI palsy. The tendency for mastoiditis to lead
to petrositis is partly due to the fact that the petrous apex
is rich in pneumatized cells which are susceptible to infection and inflammation. In addition, the close proximity of
venous sinuses to the petrous apex explains the high incidence of associated venous thrombosis [5, 16].
The most common pathogens involved in this disease
are Group A Streptococcus, Pneumococcus, Staphylococcus, P. aeruginosa and Mycobacterium tuberculosis. However, these organisms are difficult to recover in petrous
apicitis [17]. On the other hand, Yeung et al. (2006) reported that Pseudomonas was considered the most common
pathogen and that tuberculosis was identified as a potential
cause in patients younger than 20 years [16].
In the evaluation of petrous apicitis, a high resolution
CT scan is the diagnostic method of choice that allows for
detailed visualization of the petrous bone. Cuts should
include the central nervous system and the temporal bones
with the assessment of bone window settings [17]. In our
case, petrous apicitis was confirmed by a CT scan and an
MRI that showed a periosteal reaction at the anterior
aspect of the left petrous apex and opacification of the left
mastoid bone extending towards the petrous apex.
The treatment of this disease may involve radical mastoidectomy [5]. Treatment should be prompt in order to
avoid intracranial extension and permanent abducens
nerve injury. According to Lutter et al. (2005), conservative therapy with high dose broad spectrum antibiotics and
myringotomy with tympanostomy tube placement is advocated [17]. If the infection persists or even progresses, then
mastoidectomy, ranging from simple to radical, is warranted. To access the petrous apex for adequate drainage, a
complete petrous apicectomy is reserved for patients
whose anterior petrous apex could not be approached by
familiar routes [16].
One of the most challenging complications to deal with
is an intracranial abscess, because of its associated mortality and morbidity. However, this has changed dramatically after the antibiotic era [5, 18]. In a study involving
13 children with acute mastoiditis by Spremo et al.
(2007), intracranial complications (IC) occurred in three
patients; two had meningitis and one had a peridural
intracranial abscess [2]. The most common intracranial
complication is meningitis, followed by brain abscess and
sigmoid sinus thrombosis [5, 18]. Early symptoms include
otorrhea, fever, and headache while late findings involve
altered mental status, cranial nerve palsies, nuchal rigidi236 Lebanese Medical Journal 2010 Volume 58 (4)

ty, seizures, loss of consciousness, focal neurologic findings [5,19].

Most IC abscesses are polymicrobial. Streptococcus
species are the commonest pathogens, combined with
Hemophilus influenzae, Pseudomonas aeruginosa and
anaerobes [19]. IC abscesses are difficult to diagnose,
especially in the setting of early clinical features. CT scan
and more preferably MRI of the brain are essential and
should precede a lumbar puncture when required [10, 19].
An abscess appears as a ring enhancing lesion or as a
space occupying process. Imaging can also point the clinician to the source of infection [19]. CRP, ESR and elevated white cell counts are also useful, particularly when
monitoring response to treatment.
Surgery is the mainstay of therapy after initiation of
high dose broad spectrum antibiotics and urgent neurosurgical referral. Surgical options range from aspiration
to craniotomy. Image-guided stereotactic aspiration has
recently become the most utilized technique for abscess
drainage [19]. This procedure is particularly effective in
small (< 2 cm) and deep abscesses when localization is
more accurate. Craniotomy can be done as a primary procedure or secondarily if the abscess recurs after initial aspiration [19]. Steroids are generally not used in the treatment
of brain abscesses due to their immunosuppressive effects.
However, marked edema may surround the abscess and
contribute to the signs of increased intracranial pressure.
Accordingly, if the clinical situation deteriorates, steroids
are used for their anti-inflammatory effect [19].
CONCLUSION

Intracranial and extracranial complications of acute otitis

media should be suspected in the setting of unrelenting
otalgia and otorrhea, high fever and headaches. Prompt
diagnosis with CT scan, MRI and pancultures is essential.
Early antimicrobial therapy directed against the most
common pathogens may avert complications of acute otitis media. However, surgical therapy remains the mainstay of treatment in most cases.
REFERENCES
1. I. Dhooge. Acute otitis media in children. In : Graham J,
Scadding G, Bull P, editors. Textbook of Pediatric Ear,
Nose and Throat, Germany : Springer, 2007 : 404.
2. Spremo S, Udovcic B. Acute mastoiditis in children :
susceptibility factors and management. Bosn J Basic
Med Sci 2007 May ; 7 (2) : 127-31.
3. Gaio E, Marioni G, de Filippis C, Tregnaghi A, Caltran S,
Staffieri A. Facial nerve paralysis secondary to acute otitis
media in infants and children. J Paediatr Child Health
2004 Aug ; 40 (8) : 483-6.
4. Jaklis A, Tohme S. Coalescent mastoiditis in a child with
severe congenital neutropenia : report of a case. J Med
Liban 1996 ; 44 (2) : 96-9.
5. Quinn F, Stierman K, Vrabec J. Complications of otitis
media. Department of Otolaryngology, UTMB, Grand
Rounds published article, 1998 May.
6. Parker J. Acute Mastoiditis. Bobby R. Alford Department
M. ADHAMI et al. Complications of acute otitis media in children

of Otolaryngology-Head and Neck Surgery. Grand

Rounds published article, 1994 Feb.
7. Shambaugh Jr GE, Girgis TF. Acute otitis media and
mastoiditis. In : Paparella MM, Shumrick DA, editors.
Otolaryngology, 3rd ed, Philadelphia : WB Saunders Co.,
1991 : 1344-5.
8. Kuczkowski J, Naronzy W, Stankiewicz C, Kowaska B,
Brzoznowski W, Dubaniewicz-Wybieralska M. Complications of acute mastoiditis in children. Otolaryngol Pol
2007 ; 61 (4) : 445-51.
9. Bauer PW, Brown KR, Jones DT. Mastoid subperiosteal
abscess management in children. Int J Pediatr Otorhinolaryngol 2002 May ; 15 ; 63 (3) : 185-8.
10. Vazquez E, Castellote A, Piqueras J et al. Imaging of
complications of acute mastoiditis in children. Radiographics 2003 ; 23 : 359-72.
11. Bluestone CD, Klein JO. Intratemporal complications
and sequelae of otitis media. In : Bluestone CD, Stool
SE, editors. Pediatric Otolaryngology, 2nd edition. City ;
WB Saunders Co, 1990 : 523-5.
12. Sadoghi M, Dabirmoghaddam P. Otitic hydrocephalus :
case report and literature review. American J of Oto-

M. ADHAMI et al. Complications of acute otitis media in children

13.

14.
15.
16.
17.
18.
19.

laryngol May-June 2007 ; 28 : 187-90.

Kuczukowski J, Dubaniewicz-Wybieralska M, Przewozny
T, Narozny W, Mikaszewski B. Otitic hydrocephalus
associated with lateral sinus thrombosis and acute mastoiditis in children. Int J Pediatr otorhinolaryngol 2006
Oct ; 70 (10) : 1817-23.
Douglas J, Esa B, States L, OReilly, R. Sigmoid sinus
thrombosis as a complication of otitis media. Otology
and Neurotology 2007 Oct ; 28 (7) : 988-9.
Mete I, mer A, Emre U, Grkan K, Ahmet A. Management of lateral sinus thrombosis in chronic otitis media.
Otology and Neurotology 2006 Dec ; 27 (8) : 1098-103.
Yeung A. Skull base, petrous apex infections. eMedicine
June 16, 2006.
Lutter S, Kerschner J, Chusid M. Gradenigo syndrome :
a rare but serious complication of otitis media. Pediatric
Emergency June 2005 ; 21 (6) : 384-6.
Johnson R. Intracranial complications of otitis media.
Baylor College of Medicine General Rounds published
article, May 10, 2001.
Whitfield P. The management of intracranial abscess.
ACNR March/April 2005. Volume 5, number 1.

Lebanese Medical Journal 2010 Volume 58 (4) 237