Complications pathology of mastoid ear infections
The bacteria that cause the disease are usually the same type as the bacteria that cause ear infections. But in chronic mastoiditis, there are many cases of superinfection bacteria.
Otitis is a serious complication that can be fatal. Before antibiotics, the death rate from complications from the ear was very high. Nowadays, with the development of antibiotics, the means of diagnosis and treatment, the mortality rate has dropped a lot compared to before. However, intracranial complications due to the ear are still dangerous complications that can be life-threatening.
Intracranial complications due to the ear: meningitis, epidural abscess, brain abscess, lateral venous sinus obstruction, atrial inflammation and facial paralysis.
Mechanism of pathogenesis
Universal meningitis usually occurs hours, days or longer after focal meningitis. Bacteria, after overcoming the barrier in focal meningitis, multiply rapidly in the cerebrospinal fluid, using glucose and causing infection, inflammation of the arachnoid and nourishing membranes surrounding the brain and spinal cord.
Meningitis can be caused by acute (very rare) mastoiditis primarily due to chronic inflammation.
In acute mastoiditis
Often there is a meningeal reaction and sometimes true meningitis. Bacteria penetrate the meninges by blood, bone lesions are few.
In chronic mastoiditis
Meningitis usually occurs after an episode of inflammation, and the bacteria can invade the meninges in several ways:
Through the inflammatory bone in the atrium ceiling, in the group of cells after the atrium.
Through the atrial inflammatory drive, causing brain abscess.
Through inflammatory foci in the lateral vein: inflammation of the veins or thrombophlebitis.
Through the inflammatory drive in the brain: brain abscess.
Due to surgical trauma: meningeal tear, rupture of the labyrinth.
The bacteria that cause the disease are usually the same type as the bacteria that cause ear infections. But in chronic mastoiditis, there are many cases of superinfection bacteria. Common bacteria are Pneumococcus, Streptococcus, Staphylococcus… in children under 4 years old, Haemophilus influenza is common.
Inorganic meningitis, the lining of the brain is damaged, especially the area facing bone lesions.
The sclera may be congested or overproduce thick or rough.
The soft membranes are congested, or purulent infiltrates, especially under the culturing membrane and in the furrows of the brain.
In meningitis, the secretion of lesions is often more discreet. We do not see cavities, no pus, only mild congestion in soft membranes.
In the case of severe meningitis and rapid death, the lesions in the meninges are often very few, not consistent with the clinical picture. The respiratory, circulatory centres ... are inhibited by bacterial toxins before pus is formed in the meninges.
Inflammatory lesions can be localized in the different layers of the meninges and cause:
Epidural abscess: A purulent sac located between the sclera and the skull. The sclera is often rough.
Intradural abscess: A purulent sac located in the splitting space of the sclera, for example in the endothelium, in the Gasser ganglia.
Subarachnoid abscess: Also known as a subarachnoid abscess, the pus is localized into sacs within the subarachnoid space but does not connect with cerebrospinal fluid. In some cases, the pus may be between the sclera and the outer leaf of the arachnoid or between the inner and outer leaves of the arachnoid. The following cases are usually only diagnosed on the operating table.
Disseminated meningitis: The entire subarachnoid space is infiltrated. When puncturing the spinal cord, there are pathological changes in the cerebrospinal fluid. This is a typical type of meningitis with a variety of symptoms.
Clinically, people divide ear meningitis into 3 categories depending on the characteristics of the cerebrospinal fluid: organic meningitis, aseptic meningitis and meningitis.
This is the typical and common form. The disease often appears after atrial anaesthesia.
Early-stage: Patient is suffering from acute otitis media or chronic inflammatory otitis media and has the following unusual symptoms that make meningitis think.
Headache: constant headache, pain behind the fovea spreading to the back of the neck, increasing pain. Take a pain reliever that doesn't get better. Light and noise increase headache. Sometimes there is lumbar spine pain.
Vomiting: vomiting easily, on hunger as well as on fullness, no abdominal pain.
Fever 38C-39 0 C.
Poor physical symptoms: the patient is somewhat stiff, unable to lower his head. When we press on the area behind the patient's jaw, it hurts, and when we squeeze the nape, we also cause pain. Sometimes there is a paralysis of the VI nerve (squint). Before those symptoms, we must think of meningitis, especially when accompanied by mood changes such as stubbornness, irritability. Should puncture the spinal cord.
Full phase: After a short period of time, the disease turns into a full phase with symptoms typical of meningitis.
Severe headache, all over the patient screaming. When tapping on the head or pressing on the vein the pain increases. After spinal puncture, headache subsided for a while.
Vomiting: Vomiting most suddenly, especially when the patient moves around, changes position. As the disease progresses, these symptoms may decrease or disappear.
Constipation: Is one of the 3 classic symptoms, but in some cases, we see diarrheal
Muscle spasm: The patient has symptoms of stiff neck, teeth grinding, mouth chewing shrimp. Demonstrate a stiff neck with Kernig symptoms, Brudzinski symptom. At first, the patient was bent over like a trigger, facing the darkness, and then lying upright, due to the spasticity of the spinal muscles. In children, seizures are relatively common.
Polio: the phenomenon of polio appears after spasm: paralysis of the limbs, paralysis of the eyeballs, irregular pupils, droopy eyelids, pharyngeal paralysis (difficulty swallowing ...)
Sensory Disorders: Patients complain of pain all over the body when they are touching their bodies.
Disorder of reflexes: kneecap reflexes, heel tendon reflexes, abdominal skin reflex ... all increase. Sometimes Babinski symptoms.
Vasomotor disorders: facial skin sometimes flushes; the skin of the abdomen leaves red marks when we draw the armpit (meninges).
Sensory disorders: pupil contraction, photophobia, fear of sound, dizziness, hallucinations ...
Mental disorders: mental depression, drowsiness, dark consciousness, or vice versa, the patient is delirious, screaming, or struggling.
Fever is 40 ° C high and persistent. Occasionally with chills.
The circuit is usually fast and weak. If the pulse is slow, think of intracranial compression or brain damage.
High Blood Pressure.
Little urine, yellow and albumin.
Cerebrospinal fluid: At the beginning or at the very late stage, it is in full development. Must puncture the spinal cord. In case of suspicion of a cerebral abscess, caution should be exercised: use a fine needle with a barrel and only 3 ml of cerebrospinal fluid should be collected.
Meningitis is called when the cerebrospinal fluid has more than 5 white blood cells / 1ml for adults and 10 white cells / 1ml for children.
In purulent meningitis, the cerebrospinal fluid can be clear or cloudy, and the pressure is usually high (35 cm H2O2). When microscopic examination shows degenerative leukaemia bacteria. Albumin increased much: 2 g / litter, sugar decreased <0.2g / litre. NaCl decreased to <0.73mg / 100ml (126mEq / litter).
Must puncture the spinal cord several times (3 or 4 days/times) to monitor the evolution of cells, of albumin and sugar. When albumin down and sugar up return to normal again with improvement in the clinical picture, it can be confirmed that the prognosis is good.
Final Stage: After about 1 week, the patient enters the final stage. On the surface the disease can be relieved: the patient lies still, has less headache, less vomiting, muscle contraction, less fever ...
The signs are only false because the pulse becomes weaker and irregular, the phenomenon of paralysis appears (paralysis of the throat, paralysis of the anal sphincter and bladder), Cheyne-Stocks-style breathing, dragonfly hands. Eventually, the patient fell into a coma and died.
Because of the meningeal reaction next to an inflamed organ, the bacteria have not yet entered the space between the meninges.
Purulent otitis media or inflammatory otitis media.
Inflammation of lateral thrombophlebitis.
Abscess in brain.
Covered by the symptoms of complications, symptoms are both mild and lacking, begin less suddenly, meningeal symptoms are less pronounced.
Cerebrospinal water: clear or cloudy, but free of germs. The pressure is slightly high, the cells have less lymphocytosis, a lot of albumin, no bacteria.
Characterized by increased cerebrospinal fluid pressure, but the chemical and cellular composition does not change.
Common in young patients.
Chronic otitis media.
Maybe after surgery, the base is about to heal.
There may be a need to do level tricks to relieve pressure.
Acute form: rapid increase in pressure, unconsciousness, and death. If the pressure reduction procedure will save the patient's life.
Prolonged recurrence: headache, stagnation, slow pulse, oedema.
Cerebrospinal fluid, pressure increased.
Ventricular form: usually ventricular puncture.
Temporal region: rare.
Posterior cerebral fissures: cerebral abscess like.
Surgical and medical treatment.
Surgery: Depending on the injury in the ear, mastoid bone, there are different surgical methods.
Cut the mastoid bone if it is acute mastoiditis.
Empty the mastoid stone if it is chronic inflammatory otitis media. In addition, if there is an atrial or lateral vein lesion, the atrial curettage or the lateral vein must be exposed.
Internal Medicine: When the bacteria that cause the disease cannot be identified, using a broad-spectrum antibiotic can use one of the following regimens:
Ampicillin 200-400mg / kg / day intravenously in 4 divided doses with Chloramphenicol intravenously 75 mg / kg / day in 4 divided doses.
Use Cephalosporin third generation such as Ceftriaxone intravenously 2g every 12 hours or 24 hours, 7 days treatment for Haemophilus influenza and 10 days for pneumococcus or other pathogens.
During treatment, the cerebrospinal fluid should be punctured 24 hours to 48 hours after antibiotic therapy to assess response to antibiotics. If the cerebrospinal fluid does not improve and there is no clinical response of the patient, the drug should be changed according to the results of culture and antibiotic.
Ensure respiration, electrolyte adjustment, acid-base balance.
Anticonvulsants: use Diazepam 5mg (ampoule) intramuscularly.
Watery meningitis and aseptic meningitis
Mastoid surgery: Cut the mastoid bone or cut the mastoid bone to resolve inflammation.
Spinal puncture in case of diffuse soggy: Let the patient lie on his side and withdraw about 5 ml if the water splashes out into a jet and the patient feels comfortable, continue taking another 25 ml. If after taking 5 ml but does not help, to think of ventricular sebum and should puncture the ventricles.
Ventricular puncture: Drilling scales (clams) of the temporal bone, 3 cm from the upper edge of the outer ear canal, using a large needle to poke a depth of 4 cm to absorb ventricular water. If smoking on one side, it is not necessary to smoke both sides.
Noun for an abscess resting on the sclera in the medial fossa or posterior fossa (for an abscess around the lateral venous sinus). Thus, epidural abscess includes abscess around the lateral venous sinus.
Epidural abscess due to chronic inflammatory otitis media or acute mastoiditis caused by one of the following 3 ways:
Due to bone erosion: most common.
Due to spread along the pre-created fibrous tissue lines.
Due to the rupture of the small veins by the blood clot, the bones above it are very rare.
There is always a protective inflammatory granular tissue between the purulent and sclera. In some cases, however, the cholesteatoma progressively grows to erode the bone, exposing the sclera and its matrices lining directly on the sclera. There is little or no inflammatory granulomatous tissue in this site. In this case, although there is no pus resting against the sclera, some authors still classify it as an epidural abscess due to the sclera coming in direct contact with the infected area.
Most cases of epidural abscesses progress silently, have no specific symptoms and are usually detected at the surgery. The following are the types that make doctors suspect that you have an epidural abscess:
There is a beating of the purulent ear, which becomes clear when we press on the internal carotid vein.
Persistent headache in the affected ear.
Unexplained low-grade low fever followed by an acute otitis media.
Meningitis not caused by Meningococcus recurred several times.
In some cases, there is a sclera reaction: headache, stiff neck, cloudy and sterile cerebrospinal fluid, and increased white blood cells and albumin.
In rare cases, when the epidural abscess is very large, squeezing the brain, causing symptoms of increased intracranial pressure: vomiting, papillary oedema, slow pulse but no focal nerve symptoms such as brain abscess.
CT Scan helps diagnose epidural abscess very well.
If the epidural abscess is operated promptly, it will heal quickly. If left untreated: the pus sac will rupture on its own, often rupture into the subarachnoid space, causing widespread meningitis. The purulent sac can also cause a brain abscess.
Treatment includes surgery to remove the mastoid bone or to remove the mastoid stone. The sclera can reveal itself due to an injury or the physician must actively reveal when there are signs of suspicion above. When an abscess is found, the sclera must be revealed and surrounding it until it heals to make sure there are no remaining areas of pus to cover.
Antibiotics are used simultaneously and after surgery to prevent infection from spreading through the protective granular tissue that would inevitably be partially damaged by surgery.
After and not
In industrialized countries, ear abscesses are almost not found. In our country today, the cerebral abscess is a common complication, the rate of the cerebral abscess is equal to cerebral abscesses (in contrast, cerebral abscesses are higher than cerebral abscesses). Cerebral abscesses have many causes, but 50% of the ear abscesses are caused by cerebral abscesses. In our country, this complication often occurs due to chronic inflammatory otitis media, acute mastoiditis is less common.
Infections from the ear to the brain:
From the ear-mastoid mucosa to hard meningitis through osteomyelitis, cholesteatoma, bone destruction, through blood vessels, natural fissures.
From the hard meningeal to the brain substance can be manifested by:
Perforation of the meninges, then into the brain matter, follows the blood vessel pathway into the brain.
A cerebellar abscess can originate from two sources: atrial inflammation and lateral phlebitis.
The direction of progression of the abscess can go from shallow to deep or vice versa from the inside out and then rupture the meninges.
The volume can be large or small, maybe 1 or more, the abscess is often found on the same side with the inflamed ear, sometimes on the opposite side.
Progression of an abscess through the stages:
Inflammation of oedema.
Finally, pus formation.
For the ear abscess we usually see in the period of oedema and necrosis, very rarely we see in the shell phase.
Common bacteria are staphylococci, streptococci, pneumococcus, sometimes we meet anaerobic bacteria.
The first phase rarely pays attention to:
Headache is the most important, at first mild pain, after intermittent, headache at the location of the abscess, taking painkillers does not help. Accompanied by a chronic inflammatory otitis media.
Focus on 3 major syndromes (Bergmann's syndrome).
Syndrome of increased intracranial pressure:
Headache is an important, ever-present symptom. The headache of varying degrees, pain in the head, severe and increasing pain, localized pain on one side of your head or occipital pain only. The patient groans, frightened, and sometimes hits his head with his hand. Sometimes the pain is very localized, the physician may press the hand to find the pain points above the head.
Mentally slow, stagnant, duller and duller, slurred, not sad in contact with other people, not coordinating with physicians to examine.
The circuit is slow and irregular, sometimes the pulse is fast and irregular.
Trickle oedema: blurred vision at first, when we look at the fundus, we see oedema in one or both sides, but this symptom is not always present. Statistics show that this symptom is found in 50% of cerebral abscesses and 70% in cerebellar abscesses.
Spontaneous eye movement, sometimes not, hit the sick side or always change direction.
Walking unsteadily sometimes dizzy.
Infectious syndrome: fever is usually not high, but sometimes high fever, white blood cells in the blood increase, especially neutrophils, weight loss very quickly, especially in a cerebellar abscess, the above symptoms go hand in hand. in parallel with chronic inflammatory otitis media.
Focal neurological syndrome: This syndrome is often late, sometimes absent, if very valuable.
Cerebral abscess: opposite hemiplegia, ocular motor paralysis, partial or complete convulsions, aphasia, semen.
Cerebellar abscess: in theory, the symptoms are very rich, but in practice, the clinical situation is very poor and often not clear, sometimes appear some symptoms in a short time, then change. Symptoms are usually localized to the side of the cerebellum with the abscess.
Movement disturbances: wobbly moving, or falling backwards, or falling to one side, sometimes to the other side.
Active movement disorders:
Hands tremble when moving.
Too mediocre, messy.
Loss of logistics, agonism.
Passive movement disorders:
Reduced lateral muscle tone.
Disorders of the marrow.
Breathing disorders, gulping, difficulty swallowing, dilated pupils, loss of corneal reflex ...
Eye movement to beat the patient.
Progression and prognosis
Brain abscesses that, if left untreated, lead to death, and that rupture on their own to go away is extremely rare. If broken, then chisel through the ceiling of the cells, the atrium and pus fill the outer ear canal. Progress rapidly 1-2 weeks, or takes 1-2 years.
The prognosis is good if the abscess is localized, shielded, diffuse type or multiple abscesses are poor prognoses.
Remaining sequelae of ear abscess: headache, epilepsy, tinnitus, hearing loss, jerky attacks, blurred vision, unable to speak.
The recurrent problem of cerebral abscess: brain abscess patients need lifelong monitoring. Many cases are completely cured, but there are some cases that recur even while in hospital, after being discharged from the hospital a few weeks or a month. There are also some cases after a long time to relapse, after 1 year, 2 years, 10 years later or 20-30 years.
Implementing the quadrants
Based on clinical symptoms: chronic inflammatory otitis media, symptoms of Bergmann's syndrome.
Cerebrospinal fluid, need to be very careful.
Back eye exam.
X-ray: Schuller posture, straight and tilted skull, prepared ventricular scan, cerebral angiography, computerized tomography (CT Scan).
Ventricular sore: bouts of water.
Non-purulent encephalitis: high temperature, delirium, paralysis, seizures.
Brain tumour: progressing slowly.
High blood urea causes brain oedema: blood urea test.
Nowadays, when we have CT Scan, the differential diagnosis of the above patient has become simpler. However, due to the lack of equipment, not everywhere to work. Consequently, knowing the very important clinical developments in diagnosis, monitoring and treatment.
Before entering the treatment of cerebral abscesses, it should be noted that ear abscesses are usually acute, rarely in the shell phase and often in the stage of oedema and pus. As an emergency, early intervention is needed.
Purpose of treatment
Type of mastoid ear infections.
Reduce pressure in the brain, anti-oedema.
Drain the pus out by drainage.
Specific treatment methods
Surgical treatment: sterilize the mastoid bone root, expose the cerebellum or cerebellum to probe and drain the abscess. After many years of research and experience, it was found that the abscess drainage method brought out the highest results, even when the abscess had formed a shell.
Internally medical treatment:
Hypertonic sweet serum or Dextrose 20-40% drip intravenously.
Urea 30% from 1-1 / 5g / 1kg body in 24 hours, is contraindicated for people with kidney failure.
Mannitol 20% for from 1-1 / 5 g / 1kg body in 24 hours.
Glycerol or Glycerine: give 1-1.5g / 1kg body, after 4 hours for 1g / 1kg body, then every 3-4 hours to drink once.
Magnesiumsulfate 15-25%, intravenous injection, injection 3-4 times a day, total dose 1-1.7ml / 1kg
Antibiotics: use high-dose antibiotics and combine, especially new antibiotics with strong effects. Nowadays, after many studies, it is found that 1-2 antibiotics combined with Klion (flagyl) are used to both fight anaerobic bacteria and increase the effectiveness of antibiotics.
Infusion: rehydration of water and electrolytes, on demand and need to do electrolytes. Ensure alkaline balance in the blood.
Nurturing patients, taking care of patients in coma: respiratory system, circulatory system, bone and joint, oral, eye, anti-ulcer.
Note: surgery for patients with brain abscess is only one of the stages of treatment, need to pay attention to many aspects of treatment, to bring good results.
Lateral vein inflammation, sepsis.
Complications of phlebitis due to otitis media can be found in the following veins:
The most common lateral veins.
Upper vertical veins.
Cavernous sinus cavities.
Of these, the lateral veins are the most common and are a common complication of mastoiditis.
The lateral vein is large in diameter.
There is a zigzag path.
The flow rate of the blood flow is slow.
Usually, due to acute otitis media or chronic mastoiditis, especially chronic inflammatory mastoid ear infections with cholesteatoma can be caused by surgery.
The disease can spread into the veins by direct route: osteitis then spread directly into the veins or possibly bacteria can enter the bloodstream and then into the lateral vein.
Inflammation of the extra vein or bone of the lateral vein membrane becomes inflamed. The outer surface of the vein is rough or has a white pseudo membrane. Sometimes there is an abscess between the periosteal membrane and the venous wall.
Phlebitis: in which we can see:
Inflammation of the wall of the veins: the wall of the veins is thickened; this type of blood infection is less likely.
Intravenous inflammation: blood clots located in the lumen of the veins make it difficult for blood to circulate or completely blocked.
Can attach to the vein wall, not completely blocked.
Can cause a complete obstruction in the mastoid bone. The thrombus can climb up to the Herophille intersection or down the carotid bay and clear carotid vein.
Infection in the blood that does not block veins: bacteria cross the walls of the blood vessels without causing the blood clot.
Inflammation of the extra vein (or inflammation around the veins)
Symptoms are very few, sometimes discovered on the operating table. There may be a few symptoms: headache in the back of the neck, pain in the back of the mastoids.
If the abscess is surrounding the vein, there is a symptom of mild cranial hypertension caused by pressing on the meninges.
If spread to the bay causes paralysis of wire IX, X, XI, XII.
Vein drainage: swelling of the posterior region of the mastoid bone.
Inflammation in the veins or thrombophlebitis
The typical body has sepsis.
The first stage: the patient has chronic inflammatory otitis media, suddenly has a high fever trembling. Sometimes chills, headache shiver.
Full-blown phase: high fever fluctuates, there are recurring chills, temperature table shaped bell tower. The circuit is also fast and slow with the temperature. The patient has a markedly infectious face: dry lips, dirty tongue, Gray face.
The bank behind the patient's mastoid bone pain.
The skin of the drainage vein is oedema.
Sometimes the patient has difficulty turning neck.
Swollen and painful carotid grooves.
Complete blood count: leukocytes increased; multiple nuclei increased.
Blood cultures can reveal bacteria.
Do the Queskenstedt test: pressure on the healthy side increases pressure, pressure on the patient side does not increase.
The composition of cerebrospinal fluid changes slightly.
Schuller scan: fuzzy mastoid bone may have cholesteatoma or uneven lateral margin.
Localized form, potentially constricted, no sepsis: depending on where the blood clot is located, there are specific signs.
If the blood clot is in a lateral vein: the posterior margin of the mastoid is swollen and presses on the painful patient.
If sheltering in bay scene
The cymbals are swollen.
Nerve paralysis IX, X, XI and XII.
Nerve paralysis IX.
Signs pull the curtain.
Solids swallowing disorder.
Disorders of the feeling of swallowing 1/3 behind the tongue.
Nerve paralysis X.
Disorder feeling half of the soft.
Disorders of saliva secretion.
Nerve paralysis XI.
Industry: soft half of the palate, larynx and tachycardia.
External branch: paralysis of the trapezium and sternum muscles.
Nerve paralysis XII: half tongue paralysis
Localized in the inner carotid vein: the patient has neck curl to one side pain and swelling.
Localized in another vein.
Vein drainage: the posterior margin of the mastoid bone is swollen.
The cavernous sinus veins.
Swelling of the eyelids.
Eyes bulging, or pus in the eye socket.
Blindness, paralysis of extrinsic muscles.
Upper jaw nerve pain.
Varicose veins in the forehead.
Upper vertical veins: symptoms of increased intracranial pressure, nosebleeds, varicose veins in the forehead
Blood clots can move to places causing: septicaemia, lung abscess, liver, kidney.
Queskenstedt (+) solution.
Test for cerebrospinal fluid.
Blood tests and blood transplants.
Damn the mastoid bone.
Reveal lateral veins until healed.
If there is an abscess inside the vein, open the abscess.
The problem of constriction of intravenous veins is still fever after 3-4 days.
Grunert's surgery is rarely done today.
Fight infection with high dose of antibiotics and combination.
Improve physical condition: support heart, vitamins, sometimes need a blood transfusion.
Anticoagulants for lateral thrombophlebitis have no effect.
Actively treat otitis media or mastoiditis.
Early diagnosis and early management are required for chronic inflammatory otitis media.
May occur after acute otitis media or chronic cholesteatoma otitis, especially in the presence of recurrent inflammation.
Deaf reception type, tinnitus.
Serum atrial anaesthesia, clinical symptoms are usually milder: antibiotics, corticosteroids.
Purulent anaesthesia: mastoid surgery, antibiotics. There are cases to destroy the atrium.
Note: Atrial labyrinthitis can cause meningitis through the inner ear canal. Meningitis, on the other hand, can also cause labyrinthitis, leading to severe hearing loss on one or both sides.
Ear infections, acute and chronic otitis media can all cause peripheral facial paralysis.
The motor paralysis of the facial muscles manifests very differently. In the lightest body, when showing facial expressions, the face is disproportionate and the eyelids are not closed. Severe form: complete paralysis, loss of forehead wrinkles, nasolabial folds, central eccentricity, laughing, crying ... mouth is distorted to the good side, the paralysis of the eyes on the side is not closed " brand Charles Bell).
Acute otitis media: Incision of the eardrum.
Acute and chronic mastoiditis: mastoid surgery.
In all cases, record and assess the level of paralysis from the beginning, monitor the changes of the level of paralysis if not or worsen, then send to a specialist.