CLINICO-PATHOLOGICAL STUDY OF EXTRACRANIAL COMPLICATIONS OF
MIDDLE EAR INFECTIONS
Dr Sitashree Sethy*,Dr KC Mallik**
ADDREESS OF CORRESPONDENCE
DR SITASHREE SETHY
RESIDENT
C/O-DR K C MALLIK
Plot no-1195/C-27,Sector -6,CDA,
MARKAT NAGAR,
CUTTACK,ODISHA
753014
Foot Note
*Resident, **Associate Professor
Post Graduate Department of Otorhinolarygology and Head and Neck Surgery
V.S.S.Medical College,Burla,Sambalpur,Odisha
ASRTACT
Suppurative otitis media is a common occurrence and so are its complications. Its various
complications are of frequent occurrence in E.N.T. clinics .The incidence of extracranial ones are
still posing a problem to the otologists Present work has been, undertaken from September 2010
to September 2012 to study the incidence of extracranial complications in relation to suppurative
otitis media and to study the clinical presentatiABon and pathology of extracranial complications
of suppurative otitis media. Total 6130 cases of suppurative otitis media were observed
(23.96%). Out of these patients 4890 cases (19.11%) were having CSOM and 1240 cases
(4.85%) had ASOM.In the present study, it is seen that 23.96% of total patients were having
suppurative otitis media.. The incidence of complications due to ASOM is 1.45%. Mastoiditis
comprises of 59.35% of total extracranial complications and is the commonest in the present
series followed by subperiosteal abscess, labynthitis and facial palsy. The prevalence can be
decreased by means of health awareness regarding how to take care of the ear and when to report
the physician.
1
KEY WORDS: ExtracranialComplications,Middle ear infections,Clinicopathological study -
INTRODUCTION
Suppurative otitis media is a common occurrence and so are its complications. Its various
complications are of frequent occurrence in E.N.T. clinics.The growing children are the worst
sufferers of complications . Though the incidence of intracranial complications have appreciably
reduced, the incidence of extracranial ones are still posing a problem to the otologists.Infections
of middle ear cleft are very common in India. 40% of attendance in E.N.T. department of general
hospitals consists of cases of infections of middle ear cleft. Contribution towards the treatment of
this malady has yet to be achieved to a standard, in developing countries.India being
subcontinent where 80% of the population live in rural areas in the altar of poverty, ignorance,
and illiteracy, still lags behind in facilities of transport and early specialist advice.Thus patients
attend outdoor chiefly with complications of suppurative otitis media. Further the indiscriminate
use of antibiotics and ear drops have produced resistance strains of bacteria rarely responding to
treatment.In the modern era the treatment of suppurative otitis media and its complications have
undergone a revolutionary change in the hands of otologist. The ultimate aim of the otologist is
to have a ear dry, socially useful and safe from the threatening complications.The present work
has been designed to stress upon the clinico-pathological evaluation
of extracranial
complications of middle ear infections amongst the patients attending E.N.T. department of
V.S.S. Medical College Hospital, Burla which is the tertiary apex hospital in whole of the
western Odisha for specialized consultations so that we can
predict the eventuality and also
create the awareness among the public to prevent the complications.
2
AIMS AND OBJECTIVES
The present study is planned (a)To study the incidence of extracranial complications in relation
to suppurative otitis media. (b)To study the clinical presentation and pathology of extracranial
complications of suppurative otitis media.(c)To make a comparative study of different
extracranial complications of suppurative otitis media relating to their incidence. (d)To study the
extracranial complications in relation to seasonal variation.(e)To study the incidence relating to
age and sex, socio-economic-status, rural and urban distribution and bathing habits.
MATERIALS AND METHODS
Present work has been, undertaken in the department of otorhinolaryngology of V.S.S
Medical College, Burla (Orissa), from September 2010 to September 2012. All cases of
clinically diagnosed chronic and acute suppurative otitis media attending the E.N.T outdoor and
those admitted to indoor with complications were taken into consideration. Hospital records were
studied from registration section and the following statistical data were collected for (a)Total no.
of new E.N.T cases registered In O.P.D with different ailments. (b)Total no. of CSOM and
ASOM cases. (c)Total no. of CSOM cases with complications. (d)Total no. of ASOM cases with
complications. The patients with tubercular OM and suppurative otitis media in association with
external or middle ear malignancies were excluded from the study.The patients were examined in
detail and the records were maintained as per prescribed proforma set before the study to be
started. Then required investigations pertaining to the study were carried out ,such as the
following routine blood ,stool and urine tests including Sickling test and Special investigations
like Aural swab for culture & sensitivity test, Pure Tone Audiometry,X- Ray mastoid both
side,CT Scanning of skull and brain,MRI when required and Histopathological study in selected
cases from tissue obtained at surgical exploration.
3
OBSERVATIOS AND DISCUSSIONS
Total 25580 patients attended the E.N.T. O.P.D. during the period of observation. Total 6130
cases of suppurative otitis media were observed (23.96%). Out of these patients 4890 cases
(19.11%) were having CSOM and 1240 cases (4.85%) had ASOM.In the present study, it is seen
that 23.96% of total patients were having suppurative otitis media, which can be compared with
that of Vakil et al (1966) – 16.32% De, S. K. (1970) – 25.5% of all otological cases. Sachdev and
Bhatia (1965) from a study of hospital record of P.G.I. hospital, Chandigarh, found that 30% of
the patients attending E.N.T. Outpatients department suffered from chronic suppurative otitis
media.Amit K. Verma et al (1995) in their study of 613 children, found CSOM in 94 cases. The
incidence of CSOM in this study was 15.3%. Browing GG et al (1992) found the total prevalence
of chronic otitis media to be 16%.
The present study shows 286 (5.84%) cases having various complications due to CSOM and
18(1.45%) cases having various complications due to ASOM (Table-I). This is comparable to
that of Kangansarak et al (1993), who in their study of 17,44 cases of CSOM reported incidence
of complications of CSOM range from 6.45%-7.5%. Palva et al (1964) in a study of 191 patients
of CSOM, found complications in 8 cases (4.2%). Sachdev & Bhatia (1965) from their
observation of 2643 cases of CSOM found complications in 90 (3.4%) cases.
The incidence of complications due to ASOM is 1.45% is comparable to that of P.T.
Wakode et al (2006) who in their study of 4104 school going children, age ranging from 3-15
years for duration of 1 year, found the incidence of complications of acute otitis media to be
1.3%. The maximum number of patients with CSOM and its complications are of less than 10
years. Total 2348 cases were found in this age group, comprising 48.01% of total number of
CSOM cases.. In this study the incidence of cases as well as complications shows a declining
4
trend with increase in age. This can be compared with the study of OO Olubanjo (2008), who
found maximum incidence of suppurative otitis media in < 6 yrs age group, Niskar et al. (1998),
Canter (1997) and Bluestone et al. (1974) found majority of CSOM patients belonged to 2-11 yrs
age group (25.83%) and Ahmed M. Alabbasi (2010) in his study found maximum population of
CSOM patients belonged to 2-11 year age group.
The maximum incidence of ASOM and its complications is in the first decade followed by
second decade (88.8%). It is comparable with the study of strangerup SE and Tos M (1886), in
which they recorded incidence of ASOM to be 49% in the first decade. Alister K. Ross et al
(1988) in a study of 10,000 children found incidence of ASOM in the first decade to be
70.9%.Duncan (1960) in their study, they stressed upon posture of infant during feeding. They
proposed 35-40c with the horizontal should be maintained during bottle feeding. Bluestopne
C.D. (1971) had a similar view.
It is observed that the incidence of CSOM cases and its complications are more in male
sex (66.33%) than in females (33.16%). The ratio of male to female is 2.5:1 for CSOM cases,
2.6:1 and 2.3:1 for extracranial (72.35%:27.64.%)) and intracranial cases (70%:30% )
respectively.This is comparable with studies of Asif Alam Gul et al (2003), in their study, they
recorded higher prevalence of CSOM in male i.e.64%. Ahmed M Alabbais (2010), in his study
found male preponderance of CSOM cases i.e.54.16%. But it differs with the findings of OO
Olubanjo (2008) reported female preponderance in his study. In his study he found, out of 104
cases of CSOM 55(52.9%) were females.This series also showed the
male preponderance for
ASOM cases as well as for its complication. The present study does not agree with that of P.T.
Wakode et al (2006). In their study out of 123 cases of ASOM, 71(57.72%) were females.More
no of suppurative otitis media cases and its complications reported in male may be explained by
5
following factors ; a)The attendance of male, in the OPD is higher than females ; b)Male are
more prone to infections as they take up more of outdoor activities exposing themselves to
changing environment ; c) Male children given priority over their female siblings by parents ; d)
General hesitant nature of women to seek medical advice for small thing like discharging ear.
The maximum patients of SOM were found in the rainy season(45.87%) followed by
winter(29.93%) & spring season(22.56%). This is comparable with the study of G.N. Das
(1967). He observed maximum occurrence during cultivation, while lucio A. Castagnoa, Luiz
Lavinskyb (2001) found the peak incidence of suppurative otitis media in the winter and Hayes
and Hall (1984) observed peak incidence in winter.
In the present study, 62.45% CSOM case and 72.03% of complicated cases belongs to
rural population and 37.54% of CSOM and 27.97% were from rural population . This matches
with study of OO Olubanjo (2008), in which maximum population of his study group were from
rural area. In his study of 104 cases of CSOM, 78 lived in poorly ventilated house. This higher
prevalence in rural population is due to lack of eduction, lack of understanding to know the
seriousness of health conditions and frequent treatment by untrained personnel, while the
urbanities have the advantage of getting treatment by specialists with proper antibiotic usage
resulting in arrest of disease process.
The preponderance of CSOM and its complications are highest among the patients of
lower socio economic status 79.14% in CSOM and 67.48% in complicated cases followed by
middle socio economic status. Incidence is quite low in high socio economic status. This is
comparable to that of Browning GG et al (1992). They found higher prevalence of CSOM in
lower socio economic groups with manual workers. In the study of Asif Alam gul (2003), 79%
of his study population belonged to low socio economic status & P.T. Wakoda et al (2006) found
6
96 patients out of 123 cases were from families of low socio economic status.S. K. Chadha et al
(2006) in their study, found prevalence to the 19.6% in school children of slum areas, family
belonged to low socioeconomic status while the same in children of higher socioeconomic status
was 2.13%.Adhikari et al (2007) in their study, noted higher prevalence of CSOM I, e 5.7% in
children of the government school & 4.8% in children of the private school. This difference may
be due to different socioeconomic status.
Out of 286 cases of various complications, 40 cases were
intracranial. Rest 246
complications were extra cranial, which comprises of 5.03% of total CSOM & 86.01% of total
complications. The above result is comparable to that of Leskinsen K et al (2005). In their study
of 50 cases of CSOM, 41 (82%) had intratemporal and 9(18%) had intracranial complications. it
is evident from the present series that extracranial complications out number intracranial
complication; which is comparable to Leskinen K et al (2005). The same pattern is observed in
ASOM cases & its complications. Leskinen K, Jero J (2004) in their retrospective study of 33
pediatric patients with complications of AOM, aged from 3 months 14.2 years, found
intratemporal (32 cases) and intracranial (1 case) complication.It is evident that mastoiditis
comprises of 59.35% of total extracranial complications and is the commonest in the present
series followed by subperiosteal abscess, labynthitis and facial palsy.
This is comparable to that of Siba P Dubey et al (2009) who
found commonest
extracranial complications were mainly mastoid abscess in 26 (37%), postauricular fistula in
17(24%) and facial palsy in 10 (14%) cases.Lela Migirov et al (2005) in his study opined that the
incidence of mastoiditis is higher in developing countries, mostly as a consequence of untreated
OM.Incidence of facial palsy in the present study is 9.58% which is comparable to the incidence
7
rate of following studies i.e. Jongkees (1961) – 9.2%, Camethorne (1963) – 5.7%, Siew (1972) –
5.6% Ralmalani H.P. (1974) – 0.85%.
The subperiosteal abscess has the highest incidence i.e. 56.25% followed by mastoiditis.
Goldstein NA et al (1998) reviewed their experience with 100 children between 1980 and 1995
with intratemporal complication of acute otitis media. 72 patients had acute mastoiditis, showing
an incidence of 72%.Maximum patients reporting to OPD of VSS medical college are from
remote areas and they come in a neglected state after taking inadequate local treatment. So, in
this study incidence of subperostel abscess is higher i.e. 56.25%. Otrorrhoea was seen in 93.29%
of CSOM cases and 100% patients with extracranial complication and intracranial complication.
This finding matches with studies of Gulati (1997) and Ahmed M. Albbas (2010). Both of them
reported otorrhoea in 100% cases. Rao et al (1994) in a study of 120 cases observed discharge
from ear in 100% cases.Hwang et al (2002) shared the same view that otorrhoea is the most
common symptom while Bardanis et al (2003) disagreed with it. They found otitis externa to be
the common cause of purulent otrrhoea.Defness constituted 53.53% cases of total CSOM cases
and comparable with that of Amit K. Verma et al (1995). In their study out of 603 children 94
had CSOM, out of that 58 (61.7%) had hearing impairment. Deafness is present in 74.12% of
extracranial complications and 88.33% of intracranial complications.Anoop Raj. Ramanuj
Bansal (1998) studied hearing loss in rural population, and they concluded that otitis media is the
commonest etiological factor i.e. 57.25%.Sanjay Kumar, Joan d’mello (2006) in their study
found prevalence of hearing loss in school going children is 11.3%.In this present study otalgia
has been noted in 53.65% of having extracranial complications. Fever occurred in 33.33% with
extracranial complication.
8
The incidence of conductive, mixed hearing loss in CSOM cases is found to be 60.35%,
39.65% respectively. This is comparable to finding of Ahmed M. Alabbasi et al (2010). In the
study of 120 cases of CSOM, they found conductive hearing loss in 55.5% cases, mixed hearing
loss in 44.3% cases and sensory neural in 16.6% cases.Kamaljit Kaur et al (2002) in a study of
100 patients of unilateral CSOM found the incidence for SNHL to be 24%, involving higher
frequency and the incidence increased with duration of CSOM. Ramanuj Bansal (1998) in a
study of 758 cases, found otitis media (57.25%) is the commonest cause and conductive hearing
loss (86.17%) in otitis media is the commonest type. B. M. Minja (1995) in a study of 189 cases
of CSOM found the prevalence of hearing loss in CSOM was 89 (47%). Out of that conductive
hearing loss was seen in 73 (82%) and sensorineural (SHL) was seen in 16 (18%) cases.
The incidence of conductive, mixed and sensory neural hearing loss in ASOM cases is
found to be 78.22%, 19.17% and 2.09%, respectively. The same in the complications of ASOM
is found to be 72.22%, 16.66% and 11.11% respectively.
The attic perforation occurred maximally (55.24%) in all complicated cases followed by
posterior-superior (19.58%),central perforation (17.48%) and total perforation(7.69%) . This
finding is similar to Asif Alam Gul et al (2003) who observed attic perforation in 62% cases.
The study of mastoid in radiologic investigation in Laws’s / Schuller’s lateral oblique
views showed that most of the ears with complications have sclerotic mastoid i.e. in 79.03%
cases followed by Cellular mastoid in 9.79% and Diploeic mastoid is seen in 11.18%. This is
supported by Scott – Brown (1971)..HRCT finding of brain with special reference to temporal
bone showed cholesteatoma in 51.74 cases followed by ossicular chain involvement in 23.07%
cases. Out of 25 cases of facial palsy, only 9 cases had facial canal dehiscence in CT finding.
Diagnosis of the entire intracranial abscess was done on the basis of CT scan finding. These
9
findings were correlated with intra operative findings. Bacteriological study showed that
Pseudomonas aeuroginosa 114 (43.51%) is the most frequent organism, followed by
Staphylococcus aureus 78(27.27%) followed by proteus 35 (13.35%) this coinsides with the
finding of Kamran Iqbal et al. (2011) that is P. aeuroginosa 45.9%, Staphylococcus eureus
26.4%. Harvindar Kumar et al, (2010 ) P. aeuroginosa 45.5% followed by staphylococcus 37.7%.
R. Shymala et al (2012) – Incidence of P. aeuroginosa is the most prominent organism causing
complication of CSOM i.e. 40% of the cases followed by staphylococcus aureus 31%.
CONCLUSION.
Suppurative otitis media is frequently seen in people of low socioeconomic status This
percentage is little higher in rural population i.e. 37% while in urban population it’s 32%
according to the planning commission of India (1994).Children are more susceptible because of
obvious factors. In India 50% of it’s population are less than 25 years of age. The incidence of
CSOM in India has increased in the past two decades due to various factors, like increased
population and its consequences. Besides this general health, diet, overcrowding, low education
(indicaters low Socio-economy status) are major determinants in etiopathogenesis of CSOM. The
prevalence can be decreased by means of health awareness regarding how to take care of the ear
and when to report the physician.
10
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Table – I-Showing the age wise distribution of CSOM and its complications
Age in yrs No. of CSOM
%
No. of Total Complications % of complication
< 10 years
2348
48.01%
98
34.26%
11 – 20
890
18.20%
64
22.37%
21 – 30
588
12.02%
55
19.23%
31 – 40
542
11.08%
54
18.88%
41 – 50
296
6.05%
06
2.09%
51 – 60
158
3.23%
06
2.09%
> 60 yrs
68
1.39%
03
1.04%
15
Table – II-Showing the age wise distribution of ASOM and its complications
Age in years
No. of ASOM
% to total
No. of total
% of
cases
ASOM
Complications
complication
Up to 10 yrs
886
71.45
14
77.77
11 – 20
206
16.61
02
11.11
21 – 30
78
6.29
00
00
31 – 40
58
4.67
01
5.55
41 – 50
12
0.96
01
5.55
Table – III-Showing Incidence of Individual extracranial complications of CSOM
Name of
No. of
% out of extracranial
% out of Total CSOM
complications
cases
complications
cases
Mastoidits
146
59.35%
2.98%
Subperiosteal abscess
49
19.92%
1.002%
Facial palsy
28
11.38%
0.57%
Labrynthitis
23
9.35%
0.47%
Table –IV- showing incidence of individual extracranial and intracranial
complications of ASOM
No. of cases
No of cases of individual complications
% of complications
ASOM – 1240
Mastoiditis – 4
Complications – 18
Subpriosteal abscess – 9
56.25%
Extracranial – 16
Facial palsy – 2
12.5%
Intracranial - 2
Labrynthitis – 1
6.25%
Meningitis – 1
100%
25%
16
FIG-I-Incidence of complications
70
88)
60
Cholesteatoma
50
Granulation tissue
40
Ossicular chain involvement
90)
30
Facial canal dehiscence
91)
20
Subdural abscess
89)
Extradural abscess
10
92)
Brain abscess
0
No. of cases
93)
% out of total 286 cases
Fig-II-Microbiological incidence
94)
Pseudomonas
120
Staphylococcus eureus
95) 100
96)
Proteus
80
Streptococcus
60
Pneumococcus
97) 40
Diptheroid
20
Micrococci
E. Coli
0
No. of extra cranial
complications ear
Percentage
Mixed
No growth
17