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American Journal of OtolaryngologyHead and Neck Medicine and Surgery xx (2009) xxx xxx
www.elsevier.com/locate/amjoto

Intracranial spread of chronic middle ear suppuration

Siba P. Dubey, MSa,b,, Varqa Larawin, MMeda , Charles P. Molumi, MMeda
b

Abstract

a
Department of Ear, Nose and Throat, Port Moresby General Hospital, Papua New Guinea
School of Medicine and Health Sciences, University of Papua New Guinea, Papua New Guinea
Received 25 July 2008

Objective: The aim of the study was to review the pathogenesis and the result of management of the
intracranial complications of chronic middle ear suppuration.
Methods: This was a retrospective review of charts of 32 cases with intracranial complications due
to chronic middle ear infection managed between 1993 and 2007. The symptoms, clinical findings,
and medical and surgical management were reviewed and analyzed.
Results: There were 10 (31.2%) patients in the age group of 0 to 10 years, 9 (28.1%) patients in
the age group of 11 to 18 years, and 13 (40.6%) patients older than 18 years. Males were
involved twice as much as females. Among the 32 patients, 18 (56.3%) had a single intracranial
complication, whereas 14 (43.7%) had multiple intracranial complications. Among all the
intracranial complications in the 32 patients, otitic meningitis was the commonest intracranial
complication and was seen in 14 (43.7%) patients; it was followed by lateral sinus thrombosis in
10 (31.2%), cerebellar abscess in 6 (18.7%), epidural abscess in 7 (21.8%), and perisinus abscess
in 5 (15.6%). Other less common but serious intracranial complications encountered were cerebral
abscess and interhemispheric abscess in 2 (6.2%) each, and subdural abscess, otitic
hydrocephalus, and otogenic cavernous sinus thrombosis in 1 (3.1%) each. Upon admission, all
patients received a combination of parenteral antibiotics. Canal wall down mastoidectomy was
performed in all but 1 patient. In addition, lateral sinus was explored in 13 (40.6%) and cerebellar
abscesses were drained in 5 (15.6%) patients. The overall mortality rate of 31.2% was found in
our series.
Conclusion: The prognosis was worse with delayed presentation because of overwhelming
intracranial infection due to multiple pathways of extension from chronic otitis media. Infected
thrombus in the dural venous sinus should be removed to prevent dissemination of septic emboli.
2009 Elsevier Inc. All rights reserved.

1. Introduction
Intracranial complications used to arise as a result of
untreated chronic middle ear infection [1]. The overall
mortality has decreased over the years [2]. This is true for the
developed world where there is better socioeconomic
condition and health care delivery system. However, in the
developing countries, this condition is still a matter of grave
concern [3]. In this article, we reviewed the mechanism of
intracranial spread and the result of management of the
Corresponding author. PO Box 3265, Boroko, National Capital
District, Papua New Guinea. Tel.: +675 3233059; fax: + 675 3250342.
E-mail address: dubeysp@datec.net.pg (S.P. Dubey).
0196-0709/$ see front matter 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjoto.2008.10.001

patients with intracranial complications from chronic

suppurative otitis media.
2. Materials and methods
The medical and surgical records of 32 patients with
intracranial complications were investigated retrospectively.
All patients were admitted to our hospital and were managed
between 1993 and 2007. The surgical interventions were
determined by the clinical, pathologic, and radiologic
findings. All patients underwent canal wall down mastoidectomy. Additional procedures were mandated by their
underlying diagnosis. Parenteral antibiotics consisting of
metronidazole, chloramphenicol, crystalline penicillin, and

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Table 1
Dubey-Larawin [3] classification of intraoperative lateral sinus conditions
Type Intraoperative finding
I
II

III

IV

Normal blue sinus wall, blood flow in sinus was verified by aspiration
with syringe and needle.
Dull lusterless sinus wall; blood could not be aspirated by syringe and
needle; soft infected thrombus found in the sinus lumen after opening
it; sinus blood flow encountered after removal of clot.
Thick sinus wall with perisinus granulation; sinus outline was
apparent proximally and distally; with or without scanty intrasinus
pus; no proximal and distal blood flow due to thrombotic occlusion;
blood flow can be established with balloon catheter at the transverse
sinus end.
Extensive perisinus granulation with perisinus abscess; osteitic bone
all around the sinus; sinus outline indistinguishable; involvement of
transverse sinus proximally and internal jugular vein distally; difficult
to establish proximal blood flow with balloon catheter.

third-generation cephalosporins in different combinations

were administered to patients immediately upon admission.
The timing of operations was determined by the general and
neurologic conditions of these patients. During the same

period, we managed 5 cases of intracranial complications

from patients with acute otitis media who primarily
presented to the otolaryngologist.
3. Results
There were 10 (31.2%) patients in the age group 0 to 10
years, 9 (28.1%) patients in the age group 11 to 18 years, and
13 (40.6%) patients older than 18 years. The oldest patient
was 31 years old. The male-to-female ratio was 2:1.
Among the 32 patients, 18 (56.2%) had a single
intracranial complication, whereas 14 (43.7%) had multiple
intracranial complications. Of those 18 with single intracranial complication, otitic meningitis were seen in 10 (31.2%)
patients and lateral sinus thrombosis (LST), subdural
abscess, and cerebellar abscess in 2 (6.2%) patients each,
and temporal lobe abscess and interhemispheric abscess in 1
(3.1%) patient each. Of the 14 patients with multiple
intracranial complications, 4 (12.5%) patients had combination of more than 2 complications; those were LST,
cerebellar abscess with otitic hydrocephalus, epidural
abscess, LST, perisinus abscess with meningitis, epidural
abscess, cerebellar abscess with meningitis and LST, and
interhemispheric abscess with meningitis in 1 (3.1%) case
each. Ten (31.2%) patients had combination of 2 intracranial
complications. Those were LST with perisinus abscess in 3
(9.4%) cases and epidural abscess with cerebellar abscess in
2 (6.2%) cases, and LST with epidural abscess, LST with
cavernous sinus thrombosis, epidural abscess with meningitis, perisinus abscess with epidural abscess, and parietal lobe
abscess with epidural abscess in 1 (3.1%) case each.
All patients presented with offensive ear discharge. This
was found in the right ear as much as in the left. Intermittent
fever and headache were seen in 32 (100%) and 16 (50%)
patients, respectively. Cerebellar symptoms such as falling
Table 2
Diagnosis of patients who died
Serial no. Sex/age Extracranial and other Intracranial complications
complications

Fig. 1. Photographs of the CT scan showing A) cerebellar abscess drained

through the mastoid bowl and B) drainage tube in abscess cavity for
aspiration and instillation of antibiotics in the postoperative period.

1
2

F/4
F/5

3
4

F/6
F/6

M/7

6
7

M/18
M/24

8
9

F/26
M/26

10

M/30

Mastoid abscess
Facial palsy

Mastoid abscess,
septicemia
IJVT, septicemia

Meningitis
Meningitis, LST, perisinus
abscess
Meningitis, extradural abscess
Interhemispheric abscess

Cavernous sinus
thrombosis, LST
Meningitis
Interhemispheric abscess,
Conninga
meningitis, LST
Bezold abscess, IJVT LST
Bezold abscess, IJVT, LST, perisinus abscess
septicemia
LST

IJVT indicates internal jugular vein thrombosis.

a
Sudden death.

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sensation, ataxia, and disequilibrium were seen in 6 (18.7%)

patients each. Seizures were also encountered as presenting
compliant in 4 (12.5%) patients. On admission, 32 (100%)
patients were noted to have high-grade fevers; this was
followed by neck stiffness in 26 (81.2%), meningism in 15
(46.8%), irritability in 13 (40.6%), positive cerebellar signs
in 6 (18.7%), altered mental status in 3 (9.3%), and
Griesinger sign in 1 (3.1%). Positive signs of cavernous
sinus thrombosis, namely, ipsilateral ptosis, conjunctival
chemosis, ophthalmoplegia, and 6th nerve palsy were seen in
1 (3.1%). Contrast-enhanced computed tomographic scans
were performed routinely to plan a more definitive course of
management.
Canal wall down mastoidectomy was the baseline
surgical procedure performed in 31 (96.8%) patients. One

(3.1%) was conservatively managed as the patient was too

sick to undergo operation. The patient had lateral sinus,
internal jugular vein, and cavernous sinus thrombosis. The
patient ultimately died of the infection. Cholesteatoma with
or without granulation tissue was found in the tympanic
cavity of all the 31 (96.8%) patients who underwent surgical
exploration. Lateral sinus infection was suspected in 13
(40.6%) patients. Of these, 3 (9.3%) had type I, 2 (6.2%) had
type II, 6 (18.7%) had type III, and 2 (6.2%) had type IV
lateral sinus condition according to the Dubey-Larawin [3]
classification (Table 1). Drainage of cerebral and cerebellar
abscesses was done in 2 (6.2%) and 5 (15.6%) patients,
respectively (Fig. 1). One (3.1%) patient with cerebellar
abscess left the hospital to seek treatment elsewhere. Ten
(31.2%) patients in our series died as a result of their

Fig. 2. Flowchart showing the possible routes of spread of chronic middle ear suppuration to the cranial cavity.

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Fig. 4. Photographs of the CT scans showing (A,B) cerebellar abscess of

the right side with empty lateral sinus (delta sign) and the thickened dura
and sinus wall (*) in between; tentorium is also visible in the coronal
section (B).

underlying intracranial as well as other associated complications (Table 2).

4. Discussion
The pathways by which infection used to spread
intracranially are (i) osteothrombophlebitis of the venules
of the adjoining cranial bones, (ii) bone erosion by pressure
and/or enzymatic actions of the cholesteatomas, (iii)
preformed pathways, and (iv) hematogenous spread [4]. A
flow chart showing the possible pathways of spread of
infection to the cranial cavity from the tympanic cavity is
described in Fig. 2.

Fig. 3. Photographs of the CT scan showing (A,B) interhemispheric abscess

in between the cerebral hemispheres and (C) coronal reformation image
showing that the abscess is also extending between the ipsilateral cerebral
and cerebellar hemispheres.

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Symptoms and signs of intracranial complications are

similar to those seen in other studies [5]. The presence of
offensive otorrhea and headache with intermittent fevers
should alert the clinician to the possibility of underlying
intracranial complications. A careful history and physical
examination is important in diagnosing these complications
[6]. Although these complications can affect all age groups
[5,7], the age group from 11 to 30 years was predominantly
affected in our series. Males seem to be more affected than
females [5,7], as shown in our series with a male-to-female
ratio of 2:1.
The similar pattern of intracranial infections like our
series was also observed by others [8,9]. We encountered 2
unusual cases of interhemispheric abscess from otogenic
infection [3]. The subdural abscess gravitated over the
cerebral cortex and accumulated in between cerebral hemispheres ( Fig.3A and B) and between ipsilateral cerebral and
cerebellar hemispheres (Fig. 3C) leading to the formation of
interhemispheric abscesses. Matsui et al [10] reported a case
of interhemispheric abscess and also reviewed the similar
cases by other authors; the source of infection was
rhinosinusitis in most of those cases. Without advanced
imaging technology and immediate intervention by a
neurosurgeon, interhemispheric abscess has poor prognosis
because of vital location, difficulty in diagnosis, and drainage
[10]. Abscess rupturing into the ventricle or ventricle
rupturing into the abscess with consequent fate of the patient
is well described by Bliouras et al [11] and Miyamoto et al
[12]. Nevertheless, early diagnosis and immediate surgical
intervention lead to a better prognosis [5].
Lateral sinus thrombosis is still a serious condition despite
good antibiotics [3]. The clinical presentation of these patients
varied because of the presence of other concurrent complications, patient's own body resistance, and use of antibiotics.
Picket fence fever was seen in all patients with LST. Classic
fever pattern might be absent when patients received antibiotics
before presentation to the otologist. Contrast-enhanced
computed tomographic scan showed thrombosed or empty
lateral sinus or delta sign (Fig. 4). In type III and type IV
sigmoid sinus, there would be increased chance of thrombus
spreading to the cavernous sinus by the superior and inferior
petrosal sinus; it happened in one of our cases. We used to
remove the clot or thrombus from the lateral sinus whenever
possible. In all type III and type IV lateral sinus situations, no
blood flow was noticed at the opening of the superior petrosal
sinus at the junction of the sigmoid and transverse sinuses. The
use of anticoagulant in management of LST is controversial,
and Bradley et al [13] failed to show any conclusive evidence of
its effectiveness. We did not use anticoagulant to avoid
systemic dissemination of infective thrombus. In our opinion,
recanalization of the lateral sinus with anticoagulant and
antibiotics might be possible only in type II sigmoid sinus
condition as the lining endothelium remains intact; and it would
be unlikely to happen in type III and least likely in type IV
sigmoid sinus when endothelium and other vessel wall lining
are damaged. We regularly aspirated the lateral sinus as and

when necessary to rule out the presence of intrasinus infective

thrombus. We feel that removal of the infected thrombus from
the lateral sinus prevents the systemic hematogenous spread
of infection and thereby improves the prognosis.
A relatively high mortality rate of 31.2% was seen in our
series. This was due to overwhelming infection or septicemia,
which led to conversion of pachymeningitis (ie, more
localized) to leptomeningitis (ie, more generalized) [4].
Another condition that led to patients' death was conning.
The latter condition resulted from raised intracranial pressure
due to (i) increasing cerebral edema secondary to cortical
venous thrombosis; (ii) increasing intracranial abscesses,
namely, subdural, extradural, and perisinus; (iii) expanding
cerebral or cerebellar abscess; and (iv) increased resistance to
cerebrospinal fluid drainage secondary to thrombosed sinus
(es). Conning manifested as elevated blood pressure, bradycardia, altered mental status, loss of consciousness, and sudden
death. Another rare but potentially fatal condition encountered
in our series was otogenic cavernous sinus thrombosis. It arises
from a propagation of infection from sigmoid-transverse sinus
to the cavernous sinus [14]. Despite immediate and vigorous
intravenous antibiotics, our patient died of the condition. The
use of anticoagulants is not advocated in this form of cavernous
sinus thrombosis because it can initiate hemorrhage at both the
operation site and into an intracerebral venous infarct [14].
References
[1] Garap JP, Dubey SP. Canal-down mastoidectomy: experience in 81
cases. Otol Neurotol 2001;22:451-6.
[2] Samuel J, Fernandes CMC, Steinberg JL. Intracranial otogenic
complications: a persisting problem. Laryngoscope 1986;96:272-8.
[3] Dubey SP, Larawin V. Complications of chronic suppurative otitis
media and their management. Laryngoscope 2007;117:264-7.
[4] Shambaugh Jr GE, Glasscock III ME. Meningeal complications of
otitis media. Surgery of the Ear. 3rd ed. Philadelphia (Pa): WB
Saunders; 1980. p. 289-315.
[5] Ferre C, Ariza J, Viladrich PF, et al. Brain abscess rupturing into the
ventricles or subarachnoid space. Am J Med 1999;106:254-7.
[6] Penido NDO, Borin A, Iha LCN, et al. Intracranial complications of
otitis media: 15 years of experience in 33 patients. Otolaryngol Head
Neck Surg 2005;132:37-42.
[7] Yen PT, Chan ST, Huang TS. Brain abscess: With special reference to
otolaryngologic sources of infection. Otolaryngol Head Neck Surg
1995;113:15-22.
[8] Osma U, Cureoglu S, Hosoglu S. The complications of chronic otitis
media: report of 93 cases. J Laryngol Otol 2000;114:97-100.
[9] Kangsanarak J, Foonant S, Ruckphaopunt K, et al. Extracranial and
Intracranial complications of suppurative otitis media: report of 102
cases. J Laryngol Otol 1993;107:999-1004.
[10] Matsui Y, Abekura M, Yasuda T, et al. A case of primary interhemispheric subdural abscess. No Shinkei Geka 1986;14:1607-11.
[11] Bliouras K, Skevas A, Vrettos X. Otogenic abscess of the brain
rupturing the lateral ventricle. HNO 1989;37:303-5.
[12] Miyamoto Y, Kyoshima K, Takeichi Y. Intraventricular rupture of brain
abscess. Report of 3 cases including 2 survivals. Nippon Geka Hokan
1988;57:233-9.
[13] Bradley DT, Hashisaki GT, Mason JC. Otogenic sigmoid sinus
thrombosis: what is the role of anticoagulation? Laryngoscope 2002;
112:1726-9.
[14] Doyle KJ, Jackler RK. Otogenic cavernous sinus thrombosis.
Otolaryngol Head Neck Surg 1991;104:873-7.