1. External ear diseases.

Acute and chronic otitis

media. Otogenic intracranial complications.

Ear, nose and throat diseases department

Sechenov University
Moscow, Russia
1.1. Lecture 1st part
External ear diseases. Acute otitis media.
Mastoiditis.

Lecturer Professor Viktor Dobrotin, PhD

Ear, nose and throat diseases department

Sechenov University
Moscow, Russia
Othematoma
•Complaints of a painful spheric-
shape edema at the upper part of the
conchae
• Clinical signs : spheric- shape
edematous lump, fluctuated during
palpation. The skin above the lump is
blueish or sometimes with hyperemia.
• Collection of blood between the
skin and the layers of cartilage of
the ear.
•Treatment: obligatory wide dissection
of hematoma with evacuation of blood архив кафедры
(clot) and pressure dressing
Perichondritis
•Complaints of pain, edema, hyperemia. Lobe
is intact.
•In some cases there is a fluctuation.
•Inflammation of the perichondrium.
•There are two forms: catarrhal and purulent.
•Treatment of catarrhal form is conservative
(physical therapy and antibiotics).
•Treatment of purulent form is surgical
(dissection and damaged cartilage resection).
•In severe cases perichondritis may lead to
pinna deformity.

ENT department of Sechenov University

Erysipelas
•Cause: Streptococcal infection may
enter the skin through minor trauma or
chap.
•Complaints of pain, edema, well-
demarcated rash  of the pinna.
•Treatment involves either oral or
intravenous antibiotics,
using penicillins, clindamycin,
or erythromycin. Physical treatment
can be used.

ENT department of Sechenov University

Eczema
•The most common predictor is purulent
discharge in patients with chronic otitis
media. Risk factors include diabetes
mellitus and allergy.
•There are two different types of
eczema:«dry» and «moist» eczema.
•The skin of the pinna, external auditory
canal and postauricular region may be
involved in a process.
•Symptoms: persistent itching (patients
damage the skin due to scratching and
provoke the disease elongation) ENT department of Sechenov University

•Treatment: ointments with corticosteroids.

Furunculosis
•Causes: local (different traumas of the
external auditory canal) and common
(diabetes mellitus).
•There are two stages: infiltration and
suppuration.
•Symptoms: severe pain, that is made
much worse by movement of the pinna or
pressure on the tragus or mouth opening
and chewing.
•There is often no visible lesion during
infiltration stage but the introduction of an
aural speculum causes intense pain.
•If the furuncle is larger, it will be seen as
a red swelling in the outer meatus. At a
more advanced stage, the furuncle will be
seen to be pointing or may present as a ENT department of Sechenov University

fluctuant abscess.
•Treatment may be conservative
(infiltration stage) or surgical (suppuration
stage).
Otitis externa

•Disease may be acute, subacute or

chronic
•The infection may be bacterial
(Staphylococcus, Pseudomonas) or
fungal. The most severe cases are
usually caused by Pseudomonas
aeruginosa and Proteus.
•Diffuse inflammation of the skin
lining the external auditory meatus. http://go-url.ru/javf
Fungal otitis externa (otomycosis)
•Complaints of itch, pain and,
sometimes, deafness.
•Clinical signs depend on the
etiological agent.
•Microbiological investigation of the
swab.
• Treatment: antifungal ointments,
physical treatment.
архив кафедры
Malignant otitis externa
(necrotizing otitis externa)

•Soft tissue, auricular cartilage and bone are

involved in a pathology.
•The process may spread into the cranial base
and even to the other side.
•More common in elderly patients with diabetes
mellitus or immunodeficiency.
•Treatment: antibiotics, in case of resistant to
antibiotics or significant tissue damage
(surgical excision of the damaged tissue). архив кафедры
Acute otitis media
acute inflammation of the middle-ear cavity (tympanic cavity, mastoid cells, Eustachian
tube)
Acute otitis media is about 25 % of acute diseases of ear, nose and throat

Infection pathways to tympanic cavity:

•Transtubarius
•Contact
•Haematogenic

Stages: архив кафедры

•Before tympanic membrane perforation

•After tympanic membrane perforation, purulent discharge
•Reparation stage
Pre-perforation stage
•Symptoms: pain, deafness,
tinnitus.
•Otoscope signs: redness of the
tympanic membrane (at the
beginning localized only around
the malleus handle, after that
radial and then total); bulging of
tympanic membrane with loss of
landmarks.
архив кафедры
Perforative stage

After perforation or paracentesis purulent

discharge is decreasing or discontinued, pain
resolves, but the deafness and tinnitus still
present.
•Otoscopy: redness and fullness of the drum,
perforation with otorrhoea, which will often
be blood-stained. Profuse and mucoid at first,
later becoming thick and yellow.

Tympanic membrane perforation

Tympanostomy tubes
ENT department of Sechenov niversity
Treatment of acute otitis media

• The restoration of the Eustachian tube function (nasal

vasoconstrictors).
• Antibiotic therapy.
• Topical treatment (ear drops).
• At the stage of purulent discharge topical antibiotics and
corticosteroids.
• Paracentesis (miringotomy)– the incision at the posterior-
inferior part of the tympanic membrane.
Paracentesis
Indications: bulging of the tympanic
membrane at the stage of pre-perforative
acute purulent otitis media

http://gidmed.com/
otorinolarintologija/
lechenie-lor/hirurgiya-
lor/paratsentez.html
Mastoiditis– acute purulent inflamation ot the mastoid

• primary (posttraumatic, specific infections,

infectious disease)
• secondary (complication of acute otitis media or
the exaceboration of the chronic otitis)
Signs and symptoms of mastoiditis

• Pain worsening
• Conductive hearing loss
• Local signs:
-redness of tympanic membrane,
- swelling and hanging of the posterior-superior
external auditory canal wall,
- purulent discharge ( «reservoir» symptom)– not
obliratory,
- swelling in the postauricular region, with
obliteration of the sulcus
- pinna is pushed down and forward
• Radiological features:
- opacification of the mastoid air cells
- erosion of mastoid air cell bony septum may be архив кафедры

present in coalescent mastoiditis

Occasional features of acute mastoiditis

• Subperiosteal abscess over the mastoid

process.
• Bezold’s abscess —pus breaks through the
mastoid tip and forms an abscess in the neck.
• Zygomatic mastoiditis —results in swelling
over the zygoma.
Types of surgical treatment
• Partial antromastoidectomy (mastoid trepanation for
pathological tissues removing and tympanic cavity
drainage)
• Expanded antromastoidectomy (trepanation of all mastoid
cells with the dura mater and/or sigmoid sinus wall
revision)
• Antrotomy (in case pf so called antritis in children under 1
year old)
Antromastoidectomy
Indications to expanded antromastoidectomy

• Intracranial complications (otogenic meningitis, sigmoid

sinus trombosis (otogenic sepsis), brain abscess ( temporal
lobe abscess or cerebellum abscess, occurred as an outcome
of acute purulent otitis media)
1.2. Lecture 2nd part
External ear diseases. Acute otitis media. Mastoiditis.

Lecturer Professor Viktor Dobrotin, PhD

Ear, nose and throat diseases department

Sechenov University
Moscow, Russia
 Clinical forms of chronic otitis media

1. Localisation of pathological process:

•Mesotympanitis (meso- and hypotympanum)
•Epitympanitis (epitympanum)
•Epymesotympanitis (meso-, hypo- and epitympanum are
involved in a process)

2. Stage
•Recurrence
•Remission
The predisposing factors in the development
of chronic suppurative otitis media

• Inadequate or inappropriate treatment of acute otitis

media
• Сhronic upper airway infections
• Bacterial agents resistant to antibiotics
• Lowered resistance, e.g. malnutrition, anaemia,
immunological impairment.
Pathogenesis of chronic otitis media
1. Chronic tympanic membrane perforation after acute otitis media
2. Long-term dysfunction of the Eustachian tube leads to

•Retraction of tympanic membrane and perforation of the tympanic

membrane;

•Hyperplasia of the mucous membrane, pathologic discharge, polyps

and granulations formation, cholesteatoma; destruction of the bony
walls of middle and internal ear.
Diagnostic investigations

• Otomicroscopy.
• Hearing tests and vestibular function tests
• CT scan (multispiral computer tomography of temporal bones)
• X-ray of temporal bones (when CT scan is impossible)
• Microbiological investigation of purulent ear discharge swab
CT scan of temporal bones
Axial scan
1. Pneumatisation of
temporal bones is normal
2. Opacification of the
tympanic cavity

1 2
Coronal scan

Архив Кафедры болезней уха горла и носа

Clinical signs of mesotympanitisn (mucosal-
type of chronic suppurative otitis media)

• Chronic central tympanic membrane perforation of the pars

tensa;
• Recurrence: mucous or muco-purulent discharge without
odor
• Swollen mucosa, granulations or polyps at the tympanic
cavity;
• Hearing loss (hearing test results – mostly conductive
hearing loss, sometimes– mixed)
Mesotympanitis: otoscopy
1. Mesotympanitis,
remission (central
tympanic membrane
perforation)

2. Mesotympanitis,
1
recurrence (central
tympanic membrane
perforation)

Atlas der Hals-Nasen-

Ohren-Krankheiten. Von
Walter Becker, Richard A.
Buckingham, Paul
H.Holinger, W. Steiner,
1983
Treatment of mesotympanitis
1. Conservative – during recurrence
•Restoration of the Eustachian tube function, including sanation of the
paranasal sinuses or nasopharynx if necessary
•Regular aural toilet, appropriate (as determined by the culture report)
topical antibiotic therapy (ear drops);
•Physical therapy in combination with special exersises for Eustachian tube.

2. Surgical (mastoidectomy, tympanoplasty)

Epitympanitis (bony or attico-antral type of
chronic suppurative otitis media)
Pathogenesis
•Retraction of tympanic membrane at the pars flacida and its perforation
due to long-term Eustachian tube blockage.
•Complications of discharge outflow of discharge from the attic
(epitympanum).
•Invasion of the epidermis via marginal perforation from the external
auditory canal into the tympanic cavity, formation of cholesteatoma
•Destruction of middle ear bony walls by cholesteatoma
Clinical signs of epitympanitis (attico-antral type of CSOM)

• Hearing loss, tinnitus

• Muco-purulent discharge with odor
• Pain (variable)
• Possible vestibular dysfunction
• The perforation is postero-superior or in the pars
flaccida (Schrapnell’s membrane);
• Granulations, polyps from the perforation at the pars
flaccida;
• Cholesteatoma;
• Hearing loss (hearing tests) - mostly, mixed
 Epitympanitis (attico-antral type of CSOM)

• Epitympanitis has more latent disease course

• High risk of complications :
1. Labyrintitis
2. Intracranial complications
Cholesteatoma
Consists of:
• epidermis, lipids, cholesterol.
• The outer fibrous layer – matrix is consisted of stratified
squamous epithelium, that is adjacent and even invade the
auditory canal bony wall.
• Cholesteatoma produces proteolytic enzymes, that may
destruct the temporal bone structures.
Epitympanitis: otoscopy
1. Postero-superior
perforation (at pars
flaccida) of tympanic
membrane,
cholesteatoma
1
2. Retraction pocket at
pars flaccida
Atlas der Hals-Nasen-
Ohren-Krankheiten. Von
Walter Becker, Richard A.
Buckingham, Paul
H.Holinger, W. Steiner,
1983

2
Sanation surhery – the first stage of treatment
http://www.studmed.ru/oxta/289.html

The only way to treat the chronic suppurative otitis

media – surgical

1.Antrotomy

2.Conjunction of three cavities (external auditory

1 canal, tympanic cavity and antrum) into one cavity
after resection of the posterior wall of external auditory
2 canal and lateral attic wall.

http://vmede.org/sait/?
id=Otolaringologiya_ped_bogomilskii_2007&menu=Otolaringologiya_ped_bogomilskii_2007
&page=2
Tympanoplasty – the second stage of
treatment

1 2 3 4

1. Myringoplasty
2. Neotympanic membrane graft is placed onto the
incus
3. Neotympanic membrane graft is placed onto the
head of stapes
4. Neotympanic membrane graft is fashioned in a
way to isolate the round window niche
5 5. Neotympanic membrane graft is placed onto the
H. Berbom, 2012 perforated lateral semicircular canal
1.3. Lecture 3d part
External ear diseases. Acute otitis media. Mastoiditis.

Lecturer Professor Viktor Dobrotin, PhD

Ear, nose and throat diseases department

Sechenov University
Moscow, Russia
Intracranial complications
after acute or chronic suppurative otitis media

• Extradural abscess
• Subdural abscess
• Brain abscess
• Meningitis
• Sinus thrombosis (sigmoid sinus thrombosis)
Middle ear infection pathways

1 – extradural abscess; •Contact

2 – brain abscess; •Haemathogenic
3 – subdural abscess and •Lymphogenic
meningitis; •Perivascular
4 - phlebitis, •Perineural
8 thrombophlebitis, sigmoid •Through aqueductus vestibuli
sinus thrombosis;
5 – sigmoid sinus;
6 - Bezold’s abscess ;
7 – subperiostal abscess;
8 – cerebellar abscess

http://yamedik.org/?p=48&c=gospitalnaya_hirurgiya/lor_pal4_b
Extradural abscess
Clinical features
•Massive purulent discharge and pulsation of the pus due to
cerebral vessels pulsation
•Fever, variable general state
•The main symptom: headache, mostly presented at night,
irradiation depends on abscess localization (occipital, frontal or
postauricular) https://studfiles.net/preview/1225386/

•Ophtalmoscopy: optic disk swelling (papilledema) Otoscopy. Обильное гнойное

отделяемое в наружном слуховом
•When abscess is localized at the posterior cranial fossa: проходе.

nystagmus, dizziness
•The involvement of the temporal bone apex is accompanished
by abducens nerve palsy (VI), and, as consequence, diplopia
and strabismus

https://ortocure.ru/pozvonochnik/
prochee/epiduralnyj-abstsess.html
Subdural abscess
Local accumulation of pus between dura mater and arachnoid
mater
Clinical features:
• General symptoms (headache, nausea with no connection to
eating, impaired consciousness ) – dominant
• Meningeal and localizing neurologic signs

The prognosis is poor.

Subdural abscess due to connection with subarachnoid space
may lead to meningitis!
Clinical features of meningitis
Inflammation of meninges due to expansion infection into subarachnoid space
Clinical features:
1. General
•General state is poor
•Impaired consciousness (either confusion or psychomotor excitement)
•Paleness of skin
•Photophobia, hypereshesia
•Pyrexia
•Leukocytosis (neutrophylia), increase of ESR
Clinical features of meningitis

2. Raised intracranial pressure

•Intensive headache without localization
•Nausea and vomity, with no connection to eating
•Photophobia

3. Meningeal symptoms
•Neck rigidity
•Positive Kernig’s sign
•Positive Brudzinsky’s sign
•Forced position of a patient

4. Cerebrospinal fluid (CSF) changes

Clinical stages of abscess formation
• Initial – corresponds to local encephalitis before encapsulation (1-2 weeks) and
accompanied by light headache, slight pyrexia (under 37,5 °С), nausea and
vomiting, confusion
• Latent, «lucid interval», make an illusion of recovery. Poor symptoms.
Drawsiness, poor appetitis, periodic headache
• Evident (enlargement of abscess and its disruption)
• Terminal
Localizing neurologic symptoms of brain
abscess
• Temporal lobe abscess
• –dysphasia (more common with left-sided abscesses), contralateral upper quadrantic homonymous
hemianopia, paralysis (contralateral face and arm, rarely leg), hallucinations of taste and smell.
• Frontal lobe abscess– psychiatric disturbances, inadequate behavior, euphoria, amnestic aphazia

MRI (temporal lobe abscess) CT scan (temporal lobe

abscess)
https://dialabs.ru/uk/treatment-of-edema/symptoms-of-
purulent-abscess-symptoms-treatment-at-home- http://vmede.org/sait/?
autopsy-and-postoperative-care.html page=10&id=Nevrologija_mozaev_2009&menu=Ne
vrologija_mozaev_2009
Principles of intracranial complications
treatment
• Urgent surgery– sanation
• Systemic high-dose antibiotic therapy
• Detoxification, antihidropic treatment
• Symptomatic treatment (analgaesics, correction of respiratory
disturbances etc.)
Sigmoid sinus thrombosis
Etiology: acute suppurative otitis media, mastoiditis

Clinical features
•General state moderate to poor
•Intensive severe headache, localized at the temporo-occipital area
•Painfull palpation of mastoid process and vena jugularis
•Swinging pyrexia —up to 40 °C, rigors
•Polymorph leucocytosis
•Rarely otogenic sepsis accompanied with continued pyrexia
•Severe intoxication, polyorganic insufficiency
Sigmoid sinus thrombosis
1. MRI - Sigmoid sinus
thrombosis
2. CT scan - Sigmoid
2
sinus thrombosis

https://www.picquery.com/c/sigmoid-sinus_I|
iCadJuJM4BBh2bnwjyL3gdpMMXL3q*oW3RYr http://trombanet.ru/tromboz-sinusov-tvyordoj-mozgovoj-obolochki/
ExHxU/
Clinical features of sigmoid sinus thrombosis

1. Postaricular
swelling
2
2. Fistula at the
postauricular
1
region

https://otorrinos2do.wordpress.com/category/otology/page/2/ www.yandex.ru/images
Sigmoid sinus thrombosis treatment:
antibiotic therapy
• Urgent temporal bone sanation surgery
• Systemic high-dose antibiotic therapy
• Antiplatelet drug