Original article

J Neuroscience 1:36-39, 2004

Intracranial complications of chronic

suppurative otitis media, attico -antral
type: Experience at TUTH

Naramaya Thapa, MS
Department of Otorhinolaryngology and
Head and Neck Surgery
Tribhuvan University Teaching Hospital
Kathmandu, Nepal
Rakesh P. Shrivastav, MS
Department of Otorhinolaryngology and
Head and Neck Surgery
Tribhuvan University Teaching Hospital
Kathmandu, Nepal

Address for correspondence:

Naramaya Thapa, MS
Department of Otorhinolaryngology and
Head and Neck Surgery
Tribhuvan University Teaching Hospital
Kathmandu, Nepal
Email:
[email protected]

The objective of this study is to find out the prevalence

and types of intracranial complications among 699 patients
having attico-antral suppurative otitis media who underwent
mastoid exploration from April 1997 to December 2003 at the
Department of Otorhinolaryngology (ORL) and Head and
Neck Surgery, Tribhuvan University Teaching Hospital,
Kathmandu, Nepal. Of the 699 patients, 33 (4.72%) had
intracranial complications. Out of these, 3 patients had both
extra and intracranial complications. The age of the patients
with intracranial complications ranges from 4 55 years
(mean 17.23 years). Twenty-six (79%) patients were male,
while 7 (21%) were female. Brain abscess was the
commonest intracranial complication, found in 16 (48.48%)
patients, followed by meningitis, found in 9 (27.27%)
patients. Thirty-day mortality rate was 3.03%.
Key Words: abscess, complications, CSOM, meningitis

Received, December 12, 2003

Accepted, December 25, 2003

Existence of chronic suppurative otitis media (CSOM)

has been documented since prehistoric times. The potential
seriousness of this disease was appreciated by Hippocrates. 1
Morgagni recognized the potential of suppurative otitis
media to invade intracranium and also established a direct
relationship between CSOM and brain abscess.3
Chronic suppurative otitis media is one of the
commonest otolaryngologic problems especially in
underdeveloped countries like Nepal. Its high incidence in
low socio-economic status is associated with poor hygiene,
overcrowding associated with the ignorance and lack of
awareness of disease and its consequences amongst patients.
In developed countries the incidence of complications of
CSOM has come down to 0.04% of all cases of suppurative
ear disease.6,11 In a rural area of India it was found to be
4.26%4 whereas in Thailand it varies from 6.45-7.60%.9,15
Similarly, the mortality rate due to intracranial
complications of CSOM varies from country to country. A
study in Thailand showed the mortality rate to be 18.4%7

whereas studies in Bangladesh and Egypt revealed it to be

only 4% and 3% respectively.2,5
The aim of this study was to evaluate the prevalence and
types of intracranial complications in patients with atticoantral type of CSOM who underwent mastoid exploration in
Tribhuvan University Teaching Hospital, Maharajgunj,
Kathmandu, Nepal.
Materials and Methods
Six hundred and ninety nine patients with attico-antral
type of CSOM who underwent emergency or routine
mastoid exploration in the Department of ORL and Head &
Neck Surgery, TUTH, Maharajgunj, Kathmandu from April
1997 to December 2003 were enrolled in the study. Of
these, 33 (4.72%) patients had intracranial complications.
These patients constitute the basis of this study. Records of
all these patients were reviewed regarding age, sex and
types of complications, hospital course and short-term
outcome at discharge.

36

All patients with proven or suspected CSOM were seen

by the ORL team. Examination finding was confirmed by
Examination Under Microscope (EUM) just prior to
surgery. Pure tone audiogram and x-ray mastoids Townes
and lateral oblique views were advised in each case. When
the clinical features suggested possible intracranial
complications, either a CT scan of the head or a lumbar
puncture was performed. Those patients with brain abscess
were treated surgically by neurosurgeons first and
intravenous antibiotic was given for 6 weeks. Those with
meningitis were treated conservatively with intravenous
antibiotics at least for 2 weeks by a neurologist. These
patients underwent mastoid exploration as soon as their
general condition permitted general anesthesia. Those
patients with complications other than brain abscess and
meningitis underwent emergency mastoid exploration. In all
cases, postauricular incision was given. After exposure of
the suprameatal triangle, bone was drilled using cutting
burrs. During surgery, the extent of the disease, the status of
the dural plate, sinus plate and fallopian canal, and the status
of the ossicles were evaluated. After removal of the disease,
the mastoid cavity was covered either by the temporalis
fascia or by the periostium. Meatoplasty was done to
facilitate better drainage of the cavity. The wound was
closed after packing with a Bismuth iodoform paraffin
soaked pack.
Results
A total of 699 patients having attico-antral type of
CSOM underwent either emergency or routine mastoid
exploration. Of these, 33 (4.72%) patients had intracranial
complications and out of these extra- and intracranial
complication was present in 3 patients (Table 1).

Complication

a.
b.
c.
d.
e.
f.
g.
h.
i.

Brain abscess
Meningitis
Subdural empyema
Perisinus abscess
Extradural abscess
Lateral
sinus
thrombosis
Brain abscess, acute
mastoiditis
Subdural empyema,
facial nerve palsy
Extradural abscess,
acute
mastoiditis,
Bezolds abscess

No. of
patients
16
9
2
2
1

% of total
intracranial
complications
48.48
27.27
6.06
6.06
3.03

3.03

3.03

3.03

3.03

The age of the patients with intracranial complications

ranged from 4 to 55 years with a mean age of 17.23 years.
As shown in Table 2, the commonest age group to have
intracranial complications was 11-20 years (14 (42.42%)
patients). Twenty-six (79%) patients were male while 7
(21%) were female.
Age group (years)

0 10
10 20
21 30
31 40
41 50
51 - 60

No. of patients

11
14
6
1
0
1

% of
intracranial
complications
38.38
42.42
18.18
3.03
0
3.03

Table 2. Age distribution of patients with intracranial

complications (n = 33)
Various intracranial complications of CSOM among 33
patients are shown in Table 1. Brain abscess was present in
16 (48.48%) and meningitis in 9 (27.27%) patients. Of 16
patients with brain abscess, 1 patient had acute mastoiditis
also. Three (9.09%) patients had subdural empyema. Of
these 3 patients, 1 patient had facial nerve palsy along with
empyema. Two (6.06%) patients had perisinus abscess.
Extradural abscess was found in 2 (6.06%) patients. One of
these patients had acute mastoiditis and Bezolds abscess
also. One (3.03%) patient who had lateral sinus thrombosis
died. Two patients who had brain abscess had developed
aphasia. However, both of them recovered completely after
a few days. Figure 1 shows computerized tomography scan
of head of a 12-year-old child with CSOM who presented
with headache and irritability. A low-density lesion with a
high-density peripheral rim (enhanced after contrast
administration) in the left temporoparietal region highly
suggestive of brain abscess is evident. As per the
symptomatology all patients had a history of ear discharge
and hearing impairment. Those patients with intracranial
complications also complained of headache and fever. Of
these patients, 11 (9 with meningitis, 1 with brain abscess
and 1 with lateral sinus thrombosis) also had vomiting.
Three patients with brain abscess and 2 with meningitis had
altered sensorium.
Discussion

Table 1. Distribution of intracranial complications in

patients with CSOM attico-antral type (n = 33)

In the preantibiotic era the incidence of complications of

CSOM was very high. Although the incidence has decreased
with the development of antibiotics, it is still high in the
underdeveloped countries like ours. In this study intracranial
complication was found in 33 (4.72%) patients. This is in
contrast to the study done by Osma et al. that revealed that,
out of 2890 patients, 57 (1.97%) patients had intracranial
complications. 10 This difference may be due to late
presentation of our patients because of lack of awareness of
disease and education, and poverty. We found that

37

complications were more common in the age group, 11-20

years which is consistent with other studies. 2,3,5,7,8,13,14,15 The
reason behind this may be that this is socially the most
active and health conscious age group. Most of our patients
were male. The reason for this is not entirely clear, but it
might be possible that males may have sought medical
attention more frequently than females, as our part of the
world is considered a male dominant society.

Conclusions
Complications of attico-antral type of CSOM accounts
for a high rate of morbidity and mortality in developing
countries. Complications were more common in males and
in the young age group (11-20 years). Brain abscess and
meningitis were the commonest intracranial complications.
Temporal lobe abscess was more common than cerebellar
abscess. Family physicians, as well public at large, should
be made aware of the seriousness of middle ear suppuration
as this accounts for a high rate of morbidity and mortality in
our country.
Acknowledgements
I would like to thank all the staffs of the Operation
Theater, Department of Otorhinolaryngology and Head &
Neck Surgery and the Record Section of TU Teaching
Hospital for their valuable help.
References

Figure 1. Contrast enhanced CT scan of head of a 12year old by with headache and irritability. A low-density
lesion with a high-density peripheral rim (enhanced after
contrast administration) in the left temporoparietal region
highly suggestive of brain abscess is evident.
In our study, brain abscess (16 (48.48%) patients) was
the commonest intracranial complication. The reason of this
finding may be that most of our patients with intracranial
complications were from out of the Kathmandu Valley.
Because of ignorance, poverty and lack of transport
facilities, they had presented to us quite late (only after
development of abscess). The second most common
intracranial complication was meningitis (9 (27.27%)
patients). This finding is consistent with the studies done by
Chotmongkol et al.2 and Rupa et al. 13 However, studies of
Chowdhury et al. and Kurien et al. revealed meningitis to
be the commonest intracranial complication followed by
brain abscess.3,9
Among the brain abscess patients, temporal lobe abscess
(9 (27.27%)) was more common than cerebellar abscess (6
(18.18%)). This finding is consistent with the studies of
Bluestone et al. and Lund. 1,10 As shown in table 1, multiple
complications (more than one complication) were seen in
only 3 (9.09%) patients. It could well be due to small
sample size. However, Gupta et al. reported the incidence of
multiple complications being 47.82%.5
Finally, limitations of our study deserve mention. This is
a retrospective study with a small sample size and it was
carried out in only one institution. So the introduction of
bias cannot be ruled out. Further study with a large sample
size is needed to verify the findings of this study.

1. Bluestone CD, Klein Jo. Intracranial suppurative

complication of otitis media & mastoiditis. In: Pediatric
Otolaryngology. Bluestone CD, Stool SE, Sheetz MD
(eds),WB Saunders, Philadelphia, 2nd ed. vol.1:537-546,
1990
2. Chotmongkol V, Sangsaard S. Intracranial complications
of chronic otitis media. Southeast Asian J Trop Med
Public Health 23: 510-3, 1992
3. Chowdhury MA, Alauddin M. Comparative study
between tubotympanic and atticoantral types of chronic
suppurative otitis media. Bangladesh Med Res Counc
Bull 28(1): 36-44, 2002
4. Glasscock ME III, Shambough GE. Chronic suppurative
otitis media. In: Surgery of the ear, WB Saunders,
Philadelphia, 4th ed.:249 -292, 1990
5. Gupta A, Gupta V. A study of prevalence of
complications of suppurative otitis media in rural area of
Loni.Ind J Otol 2:177-183, 1996
6. Habib RG, Girgis NI, Abu el Ella AH, Farid Z, Woody
J.The treatment and outcome of intracranial
complications of otoge nic origin. J Trop Med Hyg
91:83-6, 1988
7. Jeanes A. Otogenic intracranial complications. J
Laryngol Otol 76:388-402, 1962
8. Kangsanarak J, Navacharoen N, Fooanant S,
Ruckphaopunt K. Intracranial complications of
suppurative otitis media: 13 years experience. Am J
Otol 16(1):104-9, 1995
9. Kurien M, Job Anand, Mathew J, Mathew C. Otogenic
intracranial abscess. Concurrent craniotomy and
mastoidectomy- changing trends in a developing
country. Arch Otolaryngol Head Neck surg 124:13531356, 1998
10. Lundman H. C omplications of chronic suppurative otitis
media. In: Kerr AG, Booth JB. Eds. Scott Brown's

38

Otolaryngology.
Vol
3.
6th
ed.
Newton,
Mass:Butterworth-Heinemann:4-16, 1996
11. Osma U, Cureoglu S, Hosoglu S. The complications of
chronic otitis media: report of 93 cases. J Laryngol Otol
114:97-100, 2000
12. Palva T, Virtanen H, Makinen J. Acute and chronic
mastoiditis in children. J Laryngol Otol 99:127-136,
1985

13. Rupa V, Raman R. Chronic Suppurative otitis media:

complicated versus uncomplicated disease. Acta
Otol aryngol 111:530-5, 1991
14. Samuel J, Fernandes CMC, Steinberg JL. Intracranial
otogenic
complications:
a
persisting
problem.
Laryngoscope 96: 272-278, 1986
15. Sriyanon E, Nanakorr A, Prasanuk S. Otitis media at
Sriraj hospital (10 years study). Reported at Annual
Congress of the Otolaryng. Society of Thailand, at
Pumpal, Jan 22, 1984

39