AAO-HNSF Primary Care Otolaryngology Handbook

CHAPTER 4

occur by blood-borne spread of the bacteria from the middle ear space into the meninges . Historically, the most common offending organism was Haemophilus influenzae , though epidemiologic patterns have been changing since the advent of the Haemophilus influenzae vaccine. Meningitis caused by otitis media is most often treated with intrave- nous antibiotics. A potential complication of pediatric meningitis is hearing loss. Fluid collection in the air cells of the mastoid bone just behind the ear often occurs when acute otitis media is present. However, if the fluid becomes infected and invades the bony structures, acute mastoiditis develops. Patients with acute mastoiditis present with fever, ear pain, and a protruding auricle . Over the mastoid bone, the patient may have erythema of the skin, tenderness, and even a fluctuant mass. A computed tomography (CT) scan is a useful diagnostic tool if acute mastoiditis is suspected. Intravenous antibiotics and ear tube placement may initially be used to treat patients with acute mastoiditis. A more extensive surgery, such as mastoidectomy (drilling of the bone behind the ear), may be necessary in patients who do not respond to initial treat- ment or in those with more severe disease on presentation. 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 within 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 myringotomy (an incision in the eardrum) with ear tube placement or, if necessary, a mastoidectomy . Cholesteatoma As mentioned above, some patients do not outgrow their Eustachian tube dysfunction and have chronic negative middle ear pressure. This can result in retraction of the superior part of the eardrum, known as pars flaccida , back into the middle ear space. The outside of the eardrum is actually lined with squamous epithelium , which desquamates and

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Primary Care Otolaryngology