Acta Oto-Laryngologica, 2005; 125: 819
/822

ORIGINAL ARTICLE

Otogenic intracranial complications: A review of 28 cases

LELA MIGIROV, SHAY DUVDEVANI & JONA KRONENBERG

Department of Otolaryngology and Head and Neck Surgery, Sheba Medical Center, Tel Aviv, Israel

Abstract
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Conclusions . Antibiotic treatment does not absolutely prevent the development of otogenic intracranial complications (ICC);
however, their incidence is relatively low (0.36%).Various pathogens can be isolated in cultures of patients with these
complications, but combinations of third- or fourth-generation cephalosporins with chloramphenicol, vancomycin,
metronidazole or aminoglycosides can provide good results. Underlying cholesteatoma is common and is usually associated
with intracranial abscess or sinus thrombosis. High morbidity rates warrant long-term follow-up. Objective . To evaluate
the cause and nature of otogenic ICC in patients treated at 1 medical center over an 18-year period. Material and
methods . This was a retrospective chart review of 28 patients admitted to Sheba Medical Center, Israel with otogenic
ICC between 1984 and 2002. Results. Meningitis was the commonest complication (46.4%), followed by brain abscess,
epidural abscess, sigmoid sinus thrombosis, subdural empyema, perisinus abscess and transverse and cavernous sinus
thrombosis. Twelve patients (42.9%) had received antibiotic treatment prior to admission. Chronic otitis media,
For personal use only.

cholesteatoma and brain abscess were diagnosed mainly in adults, while acute otitis media and epidural abscess were
more frequent in children. Twenty-one patients underwent mastoidectomy to eradicate the source of infection. The
commonest finding at surgery was granulations (81%). Cholesteatoma was seen in 38.1% of cases. Cholesteatoma and brain
abscess were usually associated with Gram-negative bacterial infection. Meningitis, however, was caused by Streptococcus
pneumoniae in 40% of cases. CT showed a sensitivity of 92.75% for diagnosing otogenic ICC. There was no mortality. The
morbidity rate was high (71.4%) and included hearing impairment, hemiparesis, hydrocephalus, mental retardation,
polyneuropathy and epilepsy.

Keywords: Complications, otitis media

Introduction subdural abscess (empyema), sigmoid sinus throm-

Despite the implementation of modern antibiotic
treatment, intracranial complications (ICC) of otitis
media (OM) continue to develop in a small number
of patients. It is generally believed [1
/3] that acute
OM leads to ICC more frequently than chronic
middle ear infection, and that these complications
are seen more often in children than adults. Choles-
teatoma has been found [1] to be associated mainly
with brain abscess and chronic OM. A review of
the literature [1
/8] reveals that a great variety
of microorganisms have been isolated in patients
with otogenic ICC and that various antibiotics given
prior to admission have had conflicting effects
in terms of influencing outcome. According to
the accepted classification [9], the ICC of OM
include meningitis, extradural abscess, brain abscess,
bosis, thrombophlebitis and otitic hydrocephalus.
When they occur, ICC of middle ear infection
may lead to significant mortality (8
/26.3%) and
morbidity (12.2
/13.6%) [1
/6]. Thus, we retrieved
the data of 28 patients who suffered from otogenic
ICC from a database of thousands of patients
diagnosed and treated for OM over an 18-year
period. We analyzed the nature of these complica-
tions within our patient population compared to the
experience of others.
Material and methods
This retrospective chart review study identified
patients who were admitted to our hospital and
diagnosed as suffering from otogenic ICC between
May 1984 and June 2002. Their medical and

Correspondence: Lela Migirov, MD, Department of Otolaryngology and Head & Neck Surgery, Sheba Medical Center, Tel Hashomer 52621, Israel. Tel:
/972 3 530 2242. Fax: /972 3 530 5387. E-mail: smigirov@leumit.co.il

(Received 15 March 2005; accepted 23 March 2005)

ISSN 0001-6489 print/ISSN 1651-2551 online # 2005 Taylor & Francis
DOI: 10.1080/00016480510038590
 820 L. Migirov et al.
Table II. Otogenic ICC of acute versus chronic OMa. The values
surgical records were reviewed regarding age, sex,
shown represent numbers of patients.
history of pre-admission middle ear infection, clin-
ical signs, indications for surgery, treatment before
ICC Adults Children
and after admission, surgical, bacteriological and
radiological findings and outcome. Acute OM
Meningitis 7 5
Subdural empyema 2 0
Results Epidural abscess 2 3
Brain abscess 1 0
During the 18-year study period, 7792 patients had Perisinus abscess 0 1
been admitted with the diagnosis of OM and the 28 Sigmoid ST 0 1
of them (0.36%) who had ICC comprised the study Cavernous ST 0 1
cohort. There were 19 males and 9 females (17 Chronic OM
adults, 11 children; age range 8 months to 79 years; Brain abscess 4 1
Meningitis 1 0
mean age 28.5 years). The mean follow-up period Sigmoid ST 1 0
was 3.1 years. Transverse ST 1 0
Table I displays the distribution of ICC. Com-
a
One adult patient had meningitis and an epidural abscess,
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plaints at admission included headache (42.9%),

otalgia (28.6%), vomiting (14.3%), ataxia (10.7%),
aphasia (10.7%), vertigo (7.1%), impaired vision
(7.1%) and retroauricular pain (7.1%). Fifty percent
of patients presented with fever, 46.4% were lethar-
gic and 46.4% presented with meningismus. Otor-
rhea was present in 46.4% of patients, facial nerve
paralysis in 17.8% and hemiparesis in 7.1%. Three
patients (10.7%) were comatose upon admission.
For personal use only.
another adult had meningitis and a subdural empyema and one
child had an epidural abscess and cavernous sinus thrombosis.
ST/sinus thrombosis.
empyema, 1 had a perisinus abscess, 1 had an
epidural abscess and cavernous sinus thrombosis, 1
had sigmoid sinus thrombosis and 1 had transverse
sinus thrombosis. Eight radical mastoidectomies, 3
modified radical mastoidectomies and 10 simple

Table II compares the ICC in terms of acute
versus chronic OM. The symptoms of complicated
OM developed within 1 week prior to admission in
23 patients, 8 of whom had received antibiotic
treatment previously. Five patients were admitted 1
week after the onset of ICC, four of whom had
received antibiotics at home. In 12 cases treated at
home (42.9%), antibiotic treatment prior to admis-
sion varied in duration from a few hours to /1 week
and included amoxicillin, amoxicillin clavulanate,
cefuroxime and cephalexin. Three patients who
presented with meningitis had a past history of
meningitis. Thirteen patients (46.4%) had no his-
tory of OM prior to the index admission.
Twenty-one patients (75%) underwent a mastoi-
dectomy procedure: 5 had meningitis, 6 had a brain
abscess, 4 had an epidural abscess, 2 had a subdural
Table I. Otogenic ICC in the 28 study patientsa. The values shown represent numbers of patients, with percentages in parentheses.
mastoidectomies were performed. Intracranial col-
lections were drained simultaneously with mastoid
surgery in 13 patients (46.4%). The brain abscesses
were drained by means of a stereotactic approach in
two cases and by craniotomy in the other four. The
main findings at surgery were pus with granulations
(11 cases; 52.4%). In 6 cases (28.6%), granulations
were the sole finding and purulent discharge was the
sole finding in 2 (9.5%). Cholesteatoma was re-
vealed during mastoidectomy in seven adults and
one child: five adult patients suffered from chronic
middle ear infection prior to admission (three of
them had a brain abscess and two others had sigmoid
and transverse sinus thrombosis); two other adult
patients had acute OM (one had an epidural abscess
and the other had subdural empyema). The child
had acute OM complicated with an epidural abscess.

ICC Children Adults Total

Meningitis 5 (45.5) 8 (47) 13 (46.4)

Brain abscess 1 (9.1) 5 (29.4) 6 (21.4)
Epidural abscess 3 (27.3) 2 (11.8) 5 (17.9)
Sigmoid ST 1 (9.1) 1 (5.9) 2 (7.9)
Subdural empyema 0 2 (5.6) 2 (7.1)
Transverse ST 0 1 (5.6) 1 (3.6)
Perisinus abscess 1 (9.1) 0 1 (3.6)
Cavernous ST 1 (9.1) 0 1 (3.6)
a
One adult patient had meningitis and an epidural abscess, another adult had meningitis and a subdural empyema and one child had an
epidural abscess and cavernous sinus thrombosis.
ST/sinus thrombosis.
 Otogenic intracranial complications 821
Table III. The bacteriologic findings obtained from 21 of the 28
means of a double or triple antibiotic regimen. A
study patients with otogenic ICCa.
combination of third- or fourth-generation cepha-
losporins with chloramphenicol, vancomycin, me-
Organism n (%)
tronidazole or aminoglycosides provided good
No growth 6 (28.6) results. The mean length of hospital stay was 21.4
Streptococcus spp. 9 (42.9) days.
Pseudomonas spp. 5 (23.8)
Twenty patients developed sequelae of compli-
Staphylococcus aureus 3 (14.3)
Citrobacter 3 (14.3) cated middle ear infection during the follow-up
Bacillus 2 (9.5) period (Table IV). In the 11 patients (39.3%) whose
Enterococcus 1 (4.8) hearing was impaired, four had moderate-to-severe
Klebsiella pneumoniae 1 (4.8) mixed hearing loss, three had moderate conductive
Diphtheroides 1 (4.8)
loss and four had profound sensorineural hearing
a
Two pathogens were isolated in 10 patients. loss. Notably, hearing gradually deteriorated to
deafness within a few months after hospitalization
All eight patients with cholesteatoma were managed in 4 of these 11 patients, 1 of whom underwent
with radical mastoidectomy. successful cochlear implantation 3 years after the
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CT was available in 17 cases and correctly
diagnosed sinus thromboses and intracranial ab-
scesses. One epidural abscess was missed on CT
but was picked up on MRI. CT showed a sensitivity
of 93.75% for the diagnosis of otogenic ICC.
Bacteriological cultures obtained from either aural
discharge, blood, cerebrospinal fluid (CSF), mastoid
cavity or abscess cavity were available in 27 patients.
In 6 of them (22.2%), the pathogen isolated from the
For personal use only.
episode of meningitis. The facial nerve recovered
completely a few months after surgery in four cases,
but facial nerve palsy was permanent in one.
There was no mortality and the overall morbidity
rate was 71.4%.
Discussion
Otogenic ICC still persist in spite of progress in the

aural discharge was different from the organism
cultured from the blood, CSF, mastoid cavity or
abscess cavity and, therefore, only 21 of the culture
results were analyzed (Table III). Cholesteatoma was
associated with Proteus spp. in three patients,
Citrobacter in two, Staphylococcus aureus in one,
Enterococcus in one, Diphtheroides in one and
Klebsiella pneumoniae in one. Among the 10
patients with meningitis, the cultures were sterile in
3 (30%), Streptococcus pneumoniae was isolated in
4 (40%), Citrobacter in 1 (10%), S. aureus in 1
(10%) and Bacillus in 1 (10%). Proteus spp. were
found only in the cases of chronic middle ear
infection, while S. pneumoniae was grown in
28.6% of the cultures and was found only in the
patients with acute OM.
Ceftriaxone as a single antibiotic was effective in
four patients with meningitis, two with epidural
abscess and one with transverse sinus thrombosis.
The other 21 patients (75%) were managed by
Table IV. Sequelae of otogenic ICC (in a 28 patient cohort).
Sequela
Impaired hearing
Mental retardation
Hydrocephalus
Hemiparesis
Epilepsy
Polyneuropathy
Total
antibacterial treatment of OM. In our study, the rate
of ICC was 0.36% of patients admitted with the
diagnosis of OM over the 18-year study period.
Our case management protocol includes myrin-
gotomy at first examination with culturing of dis-
charge, i.v. administration of antibiotics, high-
resolution CT of the temporal bones and contrast-
enhanced brain CT. Brain or subdural abscesses are
drained in collaboration with the neurosurgeon.
Mastoidectomy is performed in patients with me-
ningitis only in the case of associated abscesses,
worsening of symptoms or a poor response to
conservative treatment. In other cases of otogenic
meningitis, surgery is considered after the patient
has been stabilized.
The commonest complication in our study was
meningitis (46.4%), followed by brain abscess
(21.4%) and epidural abscess (17.9%). As reported
by others [1
/5], subdural empyema and sinus
thromboses were relatively rare. We recorded a lower
rate of concurrent complications (in 3 patients;
10.7%) than some other authors [5,7]. More than
38% of our patients had cholesteatoma, compared to
n (%) 12.5
/78.5% in other reports [1,5
/7].
11 (39.3)
Of our patients, 82% developed symptoms of
3 (10.7) otogenic ICC within 1 week, and 42.9% of all
2 (7.1) patients had been treated by oral antibiotics prior
2 (7.1) to admission. The same trend was reported by others
1 (3.6)
[7,8].
1 (3.6)
20 (71.4) In most studies on complicated OM [2,3,7,8],
specimens were taken either by ear swabbing or
 822 L. Migirov et al.
myringotomy or from an operative wound and
various percentages of different bacteria were re-
ported. We believe that only pathogens isolated from
the CSF, blood or mastoid cavity or during craniot-
omy in patients with intracranial collection accu-
rately reflect the causative organisms in such cases.
Our findings showed that 22.2% of pathogens
isolated from the aural discharge differed from those
cultured from the CSF, blood, intracranial collection
or operative wound. Cultures were sterile in 6/21
patients (28.6%) for whom there were bacteriologic
findings (Table III). Three of these six patients had
been treated by antibiotics prior to admission.
In 1983, Gower and McGuirt [2] reported that
otogenic meningitis was most commonly caused by
Haemophilus influenzae (39% of cases), followed
by S. pneumoniae and Pseudomonas aeruginosa. In
Acta Otolaryngol Downloaded from informahealthcare.com by UB Kiel on 10/23/14
another study [5], Proteus mirabilis was the com-
monest bacteria (46.4%) isolated from an intracra-
nial septic focus. In our study, Streptococcus spp.
were found more frequently than other organisms
(42.9%). Cholesteatoma and brain abscess, how-
ever, were mainly associated with Proteus infection,
and S. pneumoniae was the commonest pathogen
cultured in patients with meningitis. Kangsanarak
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et al. [5] reported similar results. We did not find H.
influenzae infection in our patients. This could
possibly be explained by the widespread use of oral
antibiotics that are effectively active against it.
A combination of two or more antibiotics was
required in the treatment of 75% of our patients.
It has been shown in recent studies [5
/8] that
cephalosporins, aminoglycosides, metronidazole
and chloramphenicol are the most frequently used
antibiotics in the management of complicated OM.
Cholesteatoma was found more frequently in
adults than children and was usually associated
with intracranial abscess (subdural empyema, n /1;
brain abscess, n /3; and epidural abscess, n /2) or
sinus thrombosis (sigmoid and transverse sinus
thrombosis, n /1 each), but not with meningitis.
In addition, cholesteatoma was usually associated
with Gram-negative infection. Our findings corre-
spond with those of other reports [1,2,5]. Under-
lying cholesteatoma may be found in patients with
ICC and chronic OM, as well as in cases of acute
middle ear infection. Granulations were found in
81% of our patients at surgery, and we suggest that
they play an important role in the spread of infection
from the middle ear and mastoid into the cranium.
The frequency of meningitis in our study was
similar among children and adults. Brain abscess,
however, occurred approximately three times more
often in adults than children, while epidural abscess
was seen twice as frequently in children than adults.
In our series, acute OM caused ICC 2.5 times more
frequently than chronic middle ear infection, similar
to the findings of another study [2].
Our data showed a high morbidity rate (71.4%)
for patients who recovered from otogenic ICC. One-
half of the sequelae were related to hearing impair-
ment, which may worsen over time.
Conclusions
Various pathogens can be found in the cultures of
patients with otogenic ICC. Combinations of third-
or fourth-generation cephalosporins with chloram-
phenicol, vancomycin, metronidazole or aminogly-
cosides are required in most cases and are likely to
ensure good results. Underlying cholesteatoma is a
common finding in patients with ICC of acute or
chronic OM: it is more frequent in adults than
children and is mainly associated with intracranial
abscesses, sinus thrombosis and Gram-negative in-
fection. In spite of modern treatment and the use of
CT and MRI for the early diagnosis of complicated
OM, the morbidity rate in this group of patients
continues to be high.
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