Oto Primary Care FINALhigh

otitis media

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Figure 5.4.

Otoscopic view of left eardrum with

cholesteatoma involving the

pars flaccida.

The white material is keratin filling the canal.

Intravenous antibiotics may initially

be used to treat patients with acute

mastoiditis. Surgery, including PE tube

placement or mastoidectomy, may be

necessary in patients who do not

respond to medical therapy.

Other less common, but potentially

devastating, complications of otitis

media include epidural and brain

abscesses, sigmoid sinus thrombosis,

and facial nerve paralysis. A collection

of pus can occur just outside the

dura

(termed an

epidural abscess)

, or with-

in the brain itself (a

brain abscess)

and surgical drainage is required. The

sigmoid sinus can become infected and thrombosed

, and can serve as a

nidus of infection

. This classically leads to

showers of infected emboli

causing

“picket fence fevers.” Facial nerve paralysis

in the setting of

acute otitis media

is believed to be caused by

inflammation

around the

nerve, and thus generally responds to appropriate intravenous antibiotic

therapy as well as drainage of the pus. This can be done via either a

myrin-

gotomy (an incision in the eardrum)

or, if necessary, a

mastoidectomy

Cholesteatoma

As mentioned above, some patients do not outgrow their eustachian tube

dysfunction, and they go on to suffer from chronic negative middle ear

pressure. This can result in

retraction

of the superior part of the ear drum,

known as

pars flaccida,

back into the middle ear space. The outside of the

eardrum is actually lined with

squamous epithelium

, which

desquamates

and produces keratin. Over time, the

keratinous debris

can get caught in

the

pars flaccida

retraction pocket

. This can continue to accumulate,

expanding the pocket, and is then called a

cholesteatoma,

which often

gets infected. Patients with cholesteatoma usually present with chronic ear

drainage, often due to

Pseudomonas

Proteus bacteria

. These patients may

be put on

ototopical antibiotic drops,

and their drainage may get

better, only to return when the treatment is stopped. If the cholesteatoma is

left untreated, it will

continue to grow and erode bony structures.

Possible

sequelae include

hearing loss secondary to necrosis of the long process of

the incus; erosion into the lateral semicircular canal,

causing dizziness;

subperiosteal abscess; facial nerve palsy

; meningitis; and brain abscess.