Mastoid Exploration in the Management of Chronic Otitis Media with Complications

Chronic suppurative otitis media, infection of the middle ear
cleft, is still a common disease in the developing countries...


Introduction
Chronic suppurative otitis media, infection of the middle ear cleft, is still a common disease in the developing countries. The complications associated with it, especially intra cranial, still pose a major problem in the developing countries. The anatomical proximity of the middle ear cleft and mastoid air cells to the extracranial and intracranial compartments places structures located in these areas at increased risk of infectious complications [1]. Majority of the intra cranial are seen more in the rural population than in urban population. Its incidence is decreased since the introduction of antibiotics, but the problem still exists.
Complications due to chronic suppurative otitis media remain a serious concern, particularly in developing countries. Chronic suppurative otitis media is classified into squamous and mucosal types. The complications of chronic suppurative otitis media are classified into extracranial complications and intracranial complications [1,2]. Complications are more common in patients having squamous type otitis media than in patients with mucosal type of otitis media. Many studies have shown that vast majority of subjects who had complications due to chronic suppurative otitis media were found to have cholesteatoma [3][4][5][6][7][8]. immunocompromised diseases, these complications may again become more prevalent as our current antibiotics become less effective [1].

Complications of Chronic Otitis Media Are Classified as Follows
For an Otologist it is important to review the changing trends in presentation of the disease and its complications in order to understand and instill the most appropriate management for the same.

Materials and Methods
A.

Observations and results
In this study there were 81 patients with squamous type of  Table 1]. Correlation of extracranial and intracranial complications according to age showed that facial palsy was more common in age below 20 years (p value 0.012*), labyrinthine fistula is more common between 20 to 40 years of age (p value 0.054+) and cerebellar abscess is more common in age below 20 years (p value 0.095+) and it was significant [ Table 2].

Otogenic complications
The incidence of extracranial complications was more than intracranial complications. The commonest extracranial complication was subperiosteal mastoid abscess and the commonest intracranial complication was brain abscess. Brain abscess was the commonest intracranial complication followed by lateral sinus thrombosis [ Table 3].

Discussion
The MRI gives better information about the abscess than CT scan, but CT scan is preferred because it gives detailed information about bony erosion of the mastoid, and can help in determining the etiology of the abscess and helps in the most appropriate surgical treatment options [1,9]. The treatment of choice for brain abscess is neurosurgical drainage. Patient must be stabilized before neurosurgical intervention. Neurosurgical drainage is performed, either through an open craniotomy with drainage or excision, or by stereotactic aspiration through a burr hole. After neurosurgical intervention, mastoidectomy should be done to remove the source of infection. The appropriate time to perform the mastoidectomy is controversial [1]. Murthy et al. [9] stated that first neurosurgical drainage and later ear operation should be done. Morwani et al. [10] stated that single stage, transmastoid approach to both the chronic ear infection and the intracranial abscess is a safe and effective treatment strategy to decrease the mortality and morbidity arising from this pathology. Syal et al. [11] recommend that transmastoid drainage of pus can successfully treat mastoid disease and brain abscess with single surgical intervention. Sinha et al. [12] are of the opinion that endoscopic aspiration of brain abscess is a safe and effective alternative method of treatment. It has been conventional teaching that a mastoidectomy is performed in a delayed manner after the patient recovers from the abscess and neurosurgical drainage. Current recommendations, however, are to perform a mastoidectomy at the time of abscess drainage to remove the infectious focus, assuming the patient is stable enough to tolerate this additional surgery [1].
According to Kurien et al. [13], craniotomy with concurrent mastoidectomy is not only safe, but also removes the source of infection at the same time the complication is being treated, thus avoiding reinfection while the patients awaiting the ear surgery. In addition, the treatment is completed in single, shorter stay, which is beneficial for the patient. In the present study there were 17 cases of temporal lobe abscess, one case of occipital lobe abscess and 9 cases of cerebellar abscess. Except in three cases of temporal lobe abscess (abscess size less than 1.6cms), all patients underwent neurosurgical intervention for the management of brain abscess.
All the patients who underwent neurosurgical drainage of the brain abscess underwent canal wall down mastoidectomy as soon as they recovered from the abscess and neurosurgical drainage. There were no complications during the waiting period. Early mastoidectomy following neurosurgical drainage of the brain abscess is found to be effective in this study. However, specific parameters dictating resolution. This study showed that small otogenic brain abscess, which were less than 1.6 cm in size responded to treatment with antibiotics and could be managed by medical therapy. Surgery was required only for the management of atticoantral ear disease.
Close collaboration between otologist, neuroradiologists, and neurosurgeons, as well as adequate surgical interventions and appropriate antimicrobial therapy, remain the cornerstones of effective medical management of small brain abscess secondary to atticoantral ear disease.
In the present study patients with intracranial complications

Early mastoidectomy
Mastoidectomy is performed as soon as they recovered from the abscess and neurosurgical drainage procedure. In the present study patient with intracranial complication underwent early mastoidectomy. There was no reinfection during waiting period for surgery.

Concurrent mastoidectomy
Mastoidectomy and neurosurgical drainage procedure is done at the same time. Current recommendations are to perform a mastoidectomy at the time of abscess drainage to remove the infectious focus.
Early mastoidectomy is the best treatment of choice for the management of squamous otitis media with complications especially in situations where concurrent mastoidectomy cannot be done due to lack of facilities, especially in developing countries. In the present study patient with intracranial complication underwent early mastoidectomy. There was no reinfection during waiting period for surgery.