International Journal of Pediatric Otorhinolaryngology 100 (2017) 128e131

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International Journal of Pediatric Otorhinolaryngology

journal homepage: http://www.ijporlonline.com/

Intracranial complications of CSOM in pediatric patients: A persisting

problem in developing countries
Avani Jain*, Nikhil Arora, Ravi Meher, J.C. Passey, Ramanuj Bansal
Department of ENT, MAMC, New Delhi, India

a r t i c l e i n f o a b s t r a c t

Article history: Background: Intracranial complications (ICC) of chronic suppurative otitis media (CSOM) occur even in
Received 17 April 2017 the antibiotic area. These complications are commonly seen in pediatric patients due to poor hygiene and
Received in revised form low immunity. They are more prevalent in developing countries due to illiteracy, low socioeconomic
28 June 2017
status and lack of access to health care facilities.
Accepted 30 June 2017
Objective: To study the incidence, clinical profile, treatment and outcome of pediatric patients presenting
Available online 1 July 2017
with intracranial complications of chronic suppurative otitis media.
Methods: A retrospective analysis of intracranial complications of CSOM in pediatric patients was con-
Keywords:
Intracranial complications of otitis media
ducted over a period of 15 years at a tertiary level institute. Data regarding age, sex, clinical presentation,
Mastoidectomy laboratory and radiological investigations, management, duration of hospitalization, and outcomes were
Brain abscess recorded.
Lateral sinus thrombosis Results: There were 142 patients, in the pediatric age group, diagnosed as having intracranial compli-
cations due to chronic otitis media during the study period. There was a decline in the incidence of ICC of
CSOM. The most frequent intracranial complication seen was brain abscess (58.5%). All patients were
administered intravenous antibiotics for 4e6 weeks and underwent canal wall down mastoidectomy.
Neurosurgical intervention was considered in the required patients. The case fatality rate in our study
was 2.8% (4 patients).
Conclusion: Otogenic intracranial complications can be fatal if not managed appropriately and timely.
Broad spectrum intravenous antibiotics are usually required for 4e6 weeks with or without neurosur-
gical intervention and mastoid exploration. A high index of suspicion is required in all patients pre-
senting with danger symptoms.
© 2017 Elsevier B.V. All rights reserved.

1. Introduction The purpose of this study is to report the incidence, clinical

features and management of intracranial complications of CSOM in
The recent advances in immunization and antibiotics have led to pediatric patients at a tertiary level institute. This study was un-
a dramatic decline in the incidence of chronic suppurative otitis dertaken as there is paucity of literature on the intracranial com-
media (CSOM) as well as its complications. After the introduction of plications of CSOM in pediatric patients, particularly from this part
antimicrobial agents, there has been a reduction in the incidence of of the world.
intracranial complications of otitis media from 4% to 0.24%, and
mortality from 25% to 8% [1e3]. Despite this overall decline, life 2. Methods
threatening complications of CSOM still persist. This is particularly
common in developing countries due to poverty, ignorance, and A retrospective analysis of intracranial complications of CSOM in
lack of health care facilities. Also, emerging bacterial resistance to pediatric patients was conducted over a period of 15 years, from
antibiotics have been implicated in the increasing incidence of 2001 to 2015, at Maulana Azad Medical College and Lok Nayak
complications in some cases. Hospital, New Delhi, India. Patients were evaluated with respect to
the clinical, radiological and laboratory findings. Data regarding
* Corresponding author. Department of ENT, Maulana Azad Medical College and
age, sex, clinical presentation, laboratory and radiological in-
Associated Lok Nayak Hospital, New Delhi 110002, India. vestigations, management, duration of hospitalization, and out-
E-mail address: [email protected] (A. Jain). comes were recorded. The number of cases of ICC occurring every 5

http://dx.doi.org/10.1016/j.ijporl.2017.06.038
0165-5876/© 2017 Elsevier B.V. All rights reserved.
 A. Jain et al. / International Journal of Pediatric Otorhinolaryngology 100 (2017) 128e131 129

years were recorded and the incidence compared.

In this study, all the patients underwent detailed ENT and
neurological examination. Pure tone audiometry (PTA) was done in
all the cases. All patients underwent high resolution computed
tomography (HRCT) temporal bone with contrast enhanced
computed tomography of brain. Magnetic resonance imaging (MRI)
of brain and venography was done in the required cases.
Neurology/Neurosurgery opinion was sought in all the cases and
surgical intervention was carried out in the required cases. Mastoid
exploration was done in all the patients, either along with neuro-
surgical intervention or after resolution of the intracranial
complication. All the patients received a combination of broad
spectrum antibiotics.

3. Results

There were 142 patients, in the pediatric age group, diagnosed Fig. 1. Graph showing a decline the incidence of ICC of CSOM in our study.
as having intracranial complications due to chronic otitis media
during the study period (Table 1). The age ranged from 3 to 20 years
with an average of 13.8 years. The most common age group affected followed by meningitis, lateral sinus thrombosis and extradural
was 10e15 years. There were 85 (60%) males and 57 (40%) females. abscess. Multiple complications were seen in 11 patients (7.8%).
Majority of the patients (65%) belonged to low socioeconomic class.
Prior to presentation with complication, only 22% patients had 3.1. Brain abscess
consulted a specialist for treatment of CSOM and had received
antibiotics, systemic or topical. There was a decline in the incidence Among the 83 patients with brain abscess, 44 had temporal lobe
of ICC of CSOM over a period of 15 years in our study (Fig. 1). abscess and 39 had cerebellar abscess. All brain abscesses were on
The most common presentation was ear discharge followed by the same side as the ear disease. Of 83 cases, there were 50 males
hearing loss, headache, fever, vestibular symptoms, neck stiffness and 33 females. Age incidence ranged from 5 to 20 years with an
and seizures. Evidence of atticoantral disease was seen in all the average of 14.4 years. The main presenting systemic symptoms
patients. The other common signs were papilloedema, meningeal were headache and fever. Other complaints included seizures, neck
signs and cerebellar signs. The most frequent intracranial compli- stiffness and gait instability. Diagnosis of brain abscess was made
cation seen was brain abscess (temporal lobe and cerebellar ab- on CT/MRI brain. The size of abscess ranged from 1.5 to 5.0 cm, with
scess), which accounted for 58.5% of the complications. This was a mean of 3.2 cm. All patients were started on broad spectrum
intravenous antibiotics. The antibiotic regimen administered was
intravenous vancomycin, ceftriaxone and metronidazole. Conser-
Table 1 vative management with broad spectrum intravenous antibiotics
Clinical features of patients in our study.
for 4e6 weeks was carried out in 53 patients. These patients
Number Percentage responded clinically or radiologically to medical treatment.
Age (in years) Neurosurgical drainage of the abscess was required in 30 patients.
>5 4 2.8% It was carried out in patients not responding clinically or radio-
5e10 43 30.3% logically to treatment, in expanding abscess with mass effect
10e15 59 41.6%
despite medical therapy and in abscess with potential to rupture
15e20 36 25.3%
Total 142 100% into ventricles. All of the patients underwent modified radical
Sex mastoidecotmy during the course of the therapy.
Male 85 60%
Female 57 40%
3.2. Meningitis
Symptoms
Ear discharge 142 100%
Hearing loss 136 95.8% Meningitis accounted for 24.6% (35 cases) of the intracranial
Headache 130 91.5% complications in our study. The age ranged from 3 to 19 years with
Fever 87 61.3% an average of 12.6 years. The main systemic complaints were fever,
Vestibular symptoms 38 26.7%
headache and neck stiffness. Diagnosis was made based on clinical
Neck stiffness 31 21.8%
Seizures 26 18.3% signs of meningitis, lumbar puncture and MRI brain. All patients
SIGNS were managed conservatively with intravenous broad spectrum
Atticoantral disease 142 100% antibiotics. After resolution of meningitis, all the patients under-
Papilloedema 36 25.4%
went modified radical mastoidectomy.
Meningeal signs 31 21.8%
Facial palsy 18 12.7%
Nystagmus 9 6.3% 3.3. Lateral sinus thrombosis
Cerebellar signs 25 17.6%
Intracranial Complication
Nine patients had lateral sinus thrombosis. The average age of
Cerebellar abscess 39 27.5%
Temporal lobe abscess 44 31% these patients was 14.3 years. Presenting symptoms included ear
Meningitis 35 24.6% discharge, hearing loss, fever, neck stiffness, nausea/vomiting.
Lateral sinus thrombosis 9 6.3% Diagnosis was based on MRI brain and venography. The location of
Extradural abscess 4 2.8% the thrombosis in all of these patients was in the sigmoid sinus
Multiple complications 11 7.8%
ipsilateral to the side of ear infection. All the patients were
130 A. Jain et al. / International Journal of Pediatric Otorhinolaryngology 100 (2017) 128e131

managed by modified radical mastoidectomy and intravenous an- discordant sex ratio in our country, as well as delay in seeking
tibiotics. In all the cases, the sinus plate was removed and the treatment.
sigmoid sinus skeletonised. The surrounding granulation tissue and The most common complication encountered in our study was
choloesteatoma was removed. Erosion of the sinus plate was seen brain abscesses, which accounted for 58.5% (83 patients) of the
in 3 cases and all these cases had perisinus abscess. None of the intracranial complications. As to the commonest intracranial
cases required exploration of the sinus or ligation of internal ju- complication, there are some differences in literature. Brain abscess
gular vein or anticoagulant therapy. was the most common ICC complication in studies by Sharma et al.
[9] (52%), Kurien et al. [11] (26%), Pennybacker et al. [12] (42.5%).
3.4. Extradural abscess Whereas meningitis was the most common ICC in studies by Miura
et al. [13], Kuczkowski et al. [14] (35.2%).
Four patients had extradural abscess. The average age of these In our study, among brain abscess, temporal lobe abscess was
patients was 12.7 years. It was noted as an incidental finding on more common (44 patients) as compared to cerebellar abscess (39
imaging or during mastoid surgery performed for another patients). Levent [15], Wanna et al. [16] and Sharma et al. [9] also
complication. Drainage was done by transmastoid route, the bone report higher incidence of temporal lobe abscess. Whereas, Murthy
surrounding the abscess was removed and the abscess was drained. et al. [17] and Kurien et al. [11] report a higher incidence of cere-
Modified radical masotidectomy was done in the same sitting. In bellar abscess than temporal lobe abscess. The pathogenesis of
addition, all patients were given intravenous antibiotics. otogenic brain abscess can be explained by direct extension
through tegmen erosion resulting in temporal lobe abscess, or
3.5. Result of treatment through posterior fossa bone for cerebellar abscess; or by retro-
grade thrombophlebitis in the absence of bony defect. Levent et al.
The case fatality rate in our study was 2.8% (4 patients), of which [15] showed that intracranial abscess is more common in children
3 patients died from brain herniation, and 1 patient died of sepsis. and young adults than in adults. Management of otogenic brain
The mortality in the time periods 2001e2005, 2006e2010 and abscess is controversial. Most authors advocate initial empiric
2011e2015 were 3, 1 and 0 respectively. The duration of hospital- antibiotic coverage, switching over to culture specific treatment if
ization ranged from 4 to 6 weeks. All patients were followed up on sensitivity available [11,15,17]. Some surgeons advocate early
discharge for atleast one year, and none of them had recurrence of craniotomy and excision of the abscess, whereas others prefer a
intracranial complications. However, 5 children showed evidence combined approach with abscess drainage first, followed by mas-
of recidivism cholesteatoma, and revision surgery had to be toidectomy in the same sitting [3,15]. The mortality rate from brain
performed. abscess has decreased dramatically after the antibiotic era. How-
ever, some studies report a high incidence of 36% [1]. Whereas,
4. Discussion Wanna et al. [16] report no mortality from otogenic brain abscess.
Meningitis may occur by direct invasion of the disease, inflam-
Over the past few decades, there has been a shift in the epide- mation in areas close to the meninges or hematogenic dissemina-
miological and complication patterns of otitis media globally. The tion from the infected ear. Signs and symptoms include fever,
incidence of otitis media and its complications, both, have shown a headache, malaise, nausea/vomiting and neck rigidity. Treatment
decline in incidence [4e6]. A significant decline in the incidence of includes intravenous antibiotics and mastoid exploration to remove
ICC of CSOM, over the past 15 years, was also seen in our study. The the source of infection. In our study, meningitis was the second
rapid improvement in the standards of living and development of most common complication (24.6%).
health care systems have contributed greatly to the decline. How- Lateral sinus thrombosis is a rare and serious complication.
ever, in developing countries like ours, reports indicate a persis- Some authors consider it the second most frequent intracranial
tence of high prevalence of complications, particularly intracranial complication after meningitis [18]. In our study, it was seen in 6.3%
complications of otitis media [7]. Illiteracy and poor socioeconomic patients. It is frequently associated with other intracranial com-
factors contribute to prevalence of the disease as well as, delay in plications. It occurs by erosion of the bone overlying the sinus by
seeking treatment. This contributes to the high rate of complica- cholesteatoma, granulations or coalescence, which form a perisinus
tions seen in these patients, including fatal conditions like intra- abscess. The abscess leads to thrombus formation which my
cranial complications of CSOM. propagate to other sites. The diagnosis is made by contrast
Intracranial spread of infection of otitis media can occur by the enhanced CT, MRI and magnetic resonance venography. Urgent
following routes: by extension through bone that has demineral- mastoidectomy is advised with the intent to drain the perisinus
ised during acute infection, or resorption by cholesteatoma or abscess and prevent further intravascular thrombosis and intra-
osteitis in chronic destructive disease; spread through venous cranial disease. Mortality from lateral sinus thrombosis has reduced
channels; spread through normal anatomical pathways; via from 100% in the preantibiotic era to 0e25% currently [19,20].
developmental or traumatic bony defects [8]. Wanna et al. [16] reported 0% mortality in these patients. In our
The complications of otitis media have a predilection for study as well, there was no mortality in these patients.
younger age probably due to their immature immune system and A high index of suspicion is required in patients with otitis
negligence about personal hygiene. Most studies in literature media and symptoms of headache, fever, neck rigidity or altered
report a peak incidence of intracranial otogenic complications in mental status. Otogenic ICC can be fatal if not diagnosed and
the first two decades of life [1e3]. Hence, this study was under- managed appropriately. Urgent imaging (CT/MRI) is required to
taken to study the clinical features and management of intracranial confirm the diagnosis. Broad spectrum intravenous antibiotics are
complications of CSOM in pediatric patients at a tertiary level required for 4e6 weeks. In cases of progression or no improvement
institute. The most common age group affected in our study was in symptoms, urgent neurosurgical intervention is required. This is
10e15 years of age, with an average of 13.8 years. Neeta Sharma followed by mastoid exploration in the same sitting or following
et al. [9] reported a peak incidence in 5e10 years of age. In our the stabilization of the intracranial complication. In our study, canal
study, males were predominantly affected with a male: female ratio wall down mastoidectomy was done in all the cases because of
of 1.5:1. This was similar to that reported by Neeta Sharma et al. [9] extensive disease and possibility of lack of follow up after surgery as
(1.5:1) and Wahid et al. [10] (1.3:1). This can be explained by the most patients were from low socioeconomic status and distant
 A. Jain et al. / International Journal of Pediatric Otorhinolaryngology 100 (2017) 128e131 131

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