Original Paper

Received: July 6, 2008

Accepted after revision: November 3, 2008
Published online: January 15, 2009

ORL 2009;71:8792
DOI: 10.1159/000191472

Complications of Suppurative Otitis

Media: Still a Problem in the 21st Century
Badr Eldin Mostafa Lobna M. El Fiky Mohammed M. El Sharnouby
Department of Otorhinolaryngology, Faculty of Medicine, Ain-Shams University, Cairo, Egypt

Key Words
Suppurative otitis media, complications Brain abscess
Mastoiditis

Abstract
The purpose of this study was to review the incidence of
complicated suppurative otitis media in 10 years at a tertiary
referral university hospital. During this period, 3,364 patients with suppurative otitis media (acute and chronic) were
admitted to the department. The number of patients presenting with complications was 422 (12.54%). The ratio of extracranial to intracranial complications was nearly 1: 1. The
most frequent extracranial complication was mastoiditis
while the most frequent intracranial one was lateral sinus
thrombophlebitis. Multiple complications may present in
the same patient. The onset of complications was insidious
and 96% of the patients were already aware of their disease.
There were 6 mortalities (1.42%), and additional morbidity
was recorded in 16 patients (3.79%). Changes in the clinical
picture should always alert the physician to the onset of a
complication. Complications tended to occur in young patients from a lower socioeconomic class and without sex preponderance. Physicians should be aware of the continuing
incidence of complications and the subtleness of their onset
and investigate patients for the presence of more than one
complication.
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Although there was a significant decline of infectious

problems during the twentieth century, complications of
suppurative otitis media persist and may even increase [1,
2]. The incidence of complications varies widely between
communities depending on the level of health care [35].
However, this is changing dramatically with easier air
travel, massive internal and external migration and the
emergence of multidrug resistance in patients with immune deficiencies. Moreover, diminished awareness in
developed communities and changes from the classical
clinical pictures may lead to undue delay in diagnosis and
mismanagement with subsequent significant morbidity
and mortality [3, 68]. This is a review of cases presenting
with complicated suppurative otitis media in a tertiarycare university hospital.

Patients and Methods

This is a retrospective study including all cases presenting
with suppurative otitis media presenting to the Ain-Shams University Hospitals, Cairo, Egypt, Department of ENT-HNS, from
January 1998 to January 2008. Review of the charts of the patients
was performed to determine their presentations, duration of the
disease, previous therapies and the presence of complications.
Available investigations (audiological and radiological) were also
included.

Prof. Badr Eldin Mostafa

48 Ibn El Nafees Street
11341 Nasr City, Cairo (Egypt)
E-Mail bemostafa@yahoo.com

Fig. 1. One-year-old child presenting with

a 3-week history of otalgia and fever. Diagnosed by her pediatrician as ASOM and
treated by 3 daily intramuscular ceftriaxone injections. Fever responded but a nontender firm postauricular swelling appeared. Examination revealed a bulging
opaque drum with sagging of the posterosuperior meatal wall. Coronal CT scans
showing cortical erosion (black arrow)
and subperiosteal collection (white arrow).

Table 1. List of complications

Complication

Number

Percent

Mastoiditis
Facial palsy
Extratemporal abscesses
Lateral sinus thrombosis
Brain abscess
Cerebellar abscess
Labyrinthitis
Labyrinthine fistula
Meningitis
Extradural abscess
Cochlear erosion
Subdural empyema
Petrositis

386
122
121
120
88
70
69
54
53
53
34
17
16

91.6
29
29
29
21
16.5
16.5
12.5
12.5
12.5
8
4
4

Results

During this period 3,364 patients with suppurative

otitis media (acute and chronic) were admitted to the department. There were 1,952 males (58.026%) and 1,412
females (41.973%). Their ages ranged between 3 and 65
years (mean 36.8). As regards the type of otitis media,
2,376 had chronic otitis media without cholesteatoma,
950 had cholesteatomas and 38 with acute suppurative
otitis media. The duration of disease ranged between 3
months and 25 years. There were 724 diabetic patients
(21.52%), 16 under chemotherapy for malignancies, 12
with rheumatoid arthritis, 4 with systemic lupus erythematosus and 1 with AIDS.
The number of patients presenting with complications
was 422 (12.54%). There were 201 males and 212 females.
Their ages ranged between 2 and 56 years (mean 21.5
years). Four hundred and two patients were diagnosed as
88

ORL 2009;71:8793

having cholesteatoma while 10 had chronic otitis media

without cholesteatoma and 8 with acute suppurative otitis media. The duration of disease in the group with
chronic suppurative otitis media (CSOM) was 4 months
to 20 years with a mean of 3.4 years. Systemic problems
(diabetes, chemotherapy, chronic steroids...) were present
in 81 patients (19%).
Most of these patients (396, 96.1%) were already diagnosed as having CSOM and received medical treatment
for their disease prior to presentation. All patients with
acute otitis media were already under treatment prior to
presentation (mean duration of therapy 112 days).
Three hundred and fifty patients were from rural areas, 40 were immigrants (Sudan, Somalia, Gaza strip,
Tchad), and 22 came from slum areas in the greater Cairo region and 10 from the middle social classes.
All patients were admitted to hospital and underwent
full audiological evaluation and radiological studies including at least a contrast-enhanced CT and when needed a contrast MRI. Bacteriological studies were performed in 375 patients. Infection was usually mixed. The
commonest combinations were: Streptococcus pneumoniae, Haemophilus influenzae and Streptococcus pyogenes; Pseudomonas aeruginosa, Proteus mirabilis and
Streptococcus faecalis; Escherichia coli, Moraxella catarrhalis and anaerobes. In 10% of cases, cultures were negative
due to previous antibiotic therapy.
The ratio of extracranial to intracranial complications
was nearly 1:1. The most frequent extracranial complication was mastoiditis (fig. 1) while the most frequent intracranial complication was lateral sinus thrombophlebitis (LST; tables 1, 2). Multiple complications may present
in the same patient (fig. 2). Two combined complications
occurred in 228 patients (54%) while 3 or more complications occurred simultaneously in 187 patients (44.7%).
The commonest combinations were: mastoiditis and exMostafa/El Fiky/El Sharnouby

Fig. 2. Fourteen-year-old girl with a 10-

year history of CSOM. Rapid onset of fever, rigors and deterioration of the level of
consciousness. Contrast-enhanced CT
shows LST (white arrow) with absent contrast uptake and cerebellar abscess (black
arrow).

Table 2. Extracranial versus intracranial complications

Extracranial

Percent Intracranial

Percent

Mastoiditis
Facial palsy
Extratemporal abscesses
Labyrinthitis
Labyrinthine fistula
Petrositis

92
29
29
16.5
12.5
4

29
21
16.5
12.5
12.5
4

LST
Temporal lobe abscess
Cerebellar abscess
Meningitis
Extradural abscess
Subdural empyema

Gg

Lateral SCC

tracranial abscess; labyrinthine fistula and facial paralysis (fig. 3); mastoiditis and LST. Other combinations may
also be present (fig. 4).
It seems that some complications are more prone to occur in certain age groups (table 3). For example of the 121
patients with an extracranial abscess, 102 (84.29%) were
below the median age of 21.5 years. On the other hand of
the 122 patients with facial paralysis, only 13 (10.65%)
were of the younger group. The commonest complication
below the age of 21.5 was extradural abscesses, and in the
older patients facial paralysis was the commonest.
In patients with CSOM, different complications tended to occur in a variable time scale. Labyrinthitis, extracranial abscesses, subdural and cerebellar abscesses could
develop very early in the course of the disease, whereas
other complications could appear after a very long duration such as extradural abscesses, LST, brain abscesses
and cochlear erosion (table 4).
All patients received parenteral combination antibiotic therapy: a third-generation cephalosporin and metronidazole or a quinolone with metronidazole depending
on the results of culture and sensitivity. Surgery was performed once the general condition of the patient was staComplications of Suppurative Otitis
Media

Fig. 3. Forty-five-year-old male patient with bilateral cholesteatomas since childhood. Progressive hearing loss and sudden onset
of facial paralysis. Intraoperative photograph showing a lateral
canal fistula and exposure of the geniculate ganglion (Gg). SCC =
Semicircular canal.

bilized. The extent of surgery was tailored according to

the pathological findings. This ranged from myringotomy only in 5 patients with acute suppurative otitis media
to radical mastoidectomy. Complications were managed
simultaneously or sequentially. Temporal lobe abscesses,
LST, perisinus abscesses, extradural and subdural collections and extracranial abscesses were managed in the
same session. On the other hand, cerebellar abscesses
were excised by the neurosurgeons followed 1 week later
by otosurgical management. Patients with meningitis
were treated with antibiotics and repeated lumbar drainage until they were stable and then operated upon.
ORL 2009;71:8793

89

Fig. 4. Mastoiditis and Bezolds abscess.

The white arrow shows the collection of
pus within the sternomastoid sheath and
the connection to the mastoid cavity. Thirty-two-year-old diabetic male with 5-year
history of CSOM. Sudden onset of neck
pain and swelling and torticollis.

Fig. 5. Temporal lobe encephalitis and

periventricular abscess. Forty-two-yearold female with leukemia treated with chemotherapy. One-year history of bilateral
CSOM. Rapid deterioration of consciousness and fits.

There were 6 mortalities (1.42%). Two patients with

temporal lobe abscesses (fig. 5), both adults, 2 with cerebellar abscesses, 1 adult and a 5-year-old girl, one 32year-old male with LST and systemic pyemia and one 10year-old boy with meningitis. Additional morbidity was
recorded in 16 adult patients (3.79%). Eight patients suffered additional sensorineural hearing loss and 4 had facial paralysis. Three patients had residual otitic hydrocephalus necessitating a shunt. One patient had a recurrent brain abscess.

Discussion

Complications of CSOM carried up to 75% mortality

in the preantibiotic era [9]. However, with the advent of
antibiotics and microsurgical techniques in the management of ear disease, this incidence declined dramatically
90

ORL 2009;71:8793

[1, 3, 4]. Unfortunately these complications did not disappear completely, and occasional resurgences occur. In the
past couple of decades, the incidence of infectious diseases increased steadily. Many factors are responsible [10]
with massive deterioration of health services in underdeveloped countries, and migration problems and diseases
are exported around the world [1014]. Five factors have
been associated with the spread of infection. In this study,
we reviewed the incidence of complicated suppurative otitis media in patients presenting to a tertiary-care university center. The incidence of complications is 12.54%. This
is a relatively high incidence compared to other studies [3,
4, 15, 16] but this is due to a referral bias. The commonest
complications were mastoiditis and LST. Other studies report variable proportions of complications [1, 6, 8, 17].
However, intratemporal and intracranial complications
coexisted in a high proportion of patients [1, 5, 6, 1618].
In our series more than half the patients had multiple
Mostafa/El Fiky/El Sharnouby

Table 3. Incidence of complications as a

function of age

Complications

Facial paralysis
Extracranial abscess
LST
Brain abscess
Cerebellar abscess
Labyrinthitis
Labyrinthine fistula
Meningitis
Extradural abscess
Cochlear erosion
Subdural empyema
Petrositis

Number
total

<21.5 years

>21.5 years

122
121
120
88
70
69
54
53
53
34
17
16

13
102
50
20
40
51
28
47
4
16
15
4

10.6
84.3
41.7
22.7
57.1
74
51.9
88.7
7.5
47
88
25

109
19
70
68
30
18
26
6
49
18
2
12

89.4
15.7
58.3
77.3
42.9
26
48.1
11.3
92.5
53
12
75

p value

<0.0001
<0.0001
n.s.
<0.018
<0.001
<0.0001
<0.02
<0.0001
<0.005
n.s.
<0.001
n.s.

n.s. = Not significant.

Table 4. Incidence of complications depending on time of occur-

rence
Complications
Facial paralysis
Extracranial abscess
LST
Brain abscess
Cerebellar abscess
Labyrinthitis
Labyrinthine fistula
Meningitis
Extradural abscess
Cochlear erosion
Subdural empyema
Petrositis

Shortest interval
months
12
6
28
24
8
4
12
12
108
64
6
12

Longest interval
months
115
42
216
220
36
24
240
38
236
204
29
76

complications. There are differences in the infecting organisms in different series but in most cultures they are
mixed with a high incidence of negative cultures [3, 7, 8].
Most patients were either under treatment or at least aware
of their ear problems, and this did not present a safeguard
against complications [3, 7, 8, 17]. In our series, most of
the patients had been aware of their ear problem for a long
time (mean 3.4 years) and presented to their physician
with each exacerbation. Most received occasional medications which reduced the discharge and pain, and then they
did not follow up until the moment of presentation. Although most patients with acute suppurative otitis media
Complications of Suppurative Otitis
Media

are treated by antibiotics on an outpatient basis, this is not

always a safeguard against complications. Although complicated acute otitis media represented only 1.8% of all
cases, among hospitalized patients with acute otitis media
21% had a complication compared to 12.4% for CSOM.
Our mortality rate is relatively low (1.42%) compared to
other studies [2, 5, 15, 18, 19]. The male:female ratio was
1:1 with an older mean age of presentation [6, 15, 20]. The
type of complications seems to vary with age. Younger
patients were more prone to extradural abscesses, labyrinthitis, LST and meningitis. In the older age group, the
commonest were facial paralysis followed by LST, brain
abscess and finally extradural abscess. Similarly certain
complications appeared quite early during the course of
the disease such as labyrinthitis and extracranial abscesses. Other complications could appear a very long time after the diagnosis of CSOM such as brain abscesses, extradural abscesses and LST.
Patients with otitis media should be properly managed
whenever diagnosed and followed up quite closely. Unfortunately most patients do not seek medical advice except when pain occurs, when discharge increases or when
a complication becomes established. This problem is
multifaceted: poor physician and patient education and
increasing health care cost and inadequate availability especially in marginalized and illiterate communities [10
13]. The key point here should be increasing physician
awareness of the problems inherent in otitis media, especially pediatricians, family doctors and general practitioners as well as encouraging early referral to specialized
centers for the proper management of these cases.
ORL 2009;71:8793

91

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Mostafa/El Fiky/El Sharnouby

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