EN4.8 | Complications of CSOM — Summary & Reflection

KEY TAKEAWAYS

Complications of CSOM are classified as extracranial (intratemporal) or intracranial and represent the most serious consequences of undertreated or progressive chronic middle ear disease. Extracranial complications include subperiosteal mastoid abscess (post-auricular swelling, pinna displacement), Bezold's abscess (mastoid tip erosion with neck tracking), masked mastoiditis, facial nerve palsy (ipsilateral LMN, surgical emergency requiring urgent decompression), labyrinthitis (sudden SNHL + vertigo, risk of meningeal spread), and petrositis — Gradenigo syndrome (persistent discharge + retroorbital V1 pain + CN VI lateral rectus palsy). Intracranial complications include meningitis (most common, gram-negative cover required), extradural abscess (often silent), subdural abscess (rapid neurological deterioration), brain abscess in the temporal lobe or cerebellum (most dangerous, 10–40% mortality, ring-enhancing lesion on CT), lateral sinus thrombophlebitis (spiking picket-fence fever + bacteraemia + sigmoid sinus filling defect), and otitic hydrocephalus (raised ICP, normal CSF chemistry, no abscess). Key principles: image before LP; start IV antibiotics immediately; mastoidectomy to eradicate the source is mandatory in all complications; neurosurgery liaison for all intracranial disease. The sudden cessation of ear discharge in active CSOM is a red flag — not reassurance — and may indicate tegmen breach with intracranial pus accumulation.

REFLECT

You are on ENT call when a 22-year-old student is referred from a district hospital with a 5-day history of worsening headache, fever, and right ear discharge. He has a known right-sided CSOM. He is confused and has photophobia. Pupils are equal and reactive. CT head shows no mass lesion but there is opacification of the right mastoid with possible tegmen erosion. His temperature is 39.8°C. Reflect on the following: What is your immediate clinical action before any further investigations? In what order will you proceed — imaging, LP, antibiotics, surgery? How will you decide whether this is meningitis alone or a concurrent intracranial abscess that needs neurosurgical intervention? Who else do you call at this moment, and what is your surgical plan for the ear once the acute intracranial phase is stabilised?