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Otogenic intracranial abscesses
An extradural abscess is the accumulation of pus between the dura and the bone. It occurs as a result of the spread of the inflammatory process from the mastoid process and tympanic cavity into the cranial cavity and is localized in the middle or posterior cranial fossae. An extradural abscess is usually a complication of chronic suppurative otitis media; often there are cholesteatoma, pus in the tympanum and mastoid process, often the destruction of its roof, and with the localization of the extradural abscess in the posterior cranial fossa - phlebitis of the sigmoid sinus, purulent labyrinthitis. With an extradural abscess complicating acute purulent otitis media, there may be clinical symptoms of mastoiditis.
According to the anatomical and topographic, morphological and clinical features, limited pachymeningitis, which is essentially the initial phase of the development of the abscess, is close to open extradural abscess. In those cases when the bone wall of the middle ear is preserved at the site of infection to the dura mater, a closed extradural abscess forms. If caries destroys this wall and it breaks up, a limited purulent space between the bone and the dura mater is not formed (open extradural abscess). In the latter case, the dura mater is the wall of the purulent focus in the middle ear.
Klinsky kartina is poor, and an extradural abscess is often diagnosed only during surgery, but the assumption about it always arises when a carious process is detected in the walls of the antrum that border the meninges. General symptoms are not very pronounced. The temperature is more often normal or subfebrile even in the presence of a perisinous abscess. A sharp rise in temperature almost always means the development of meningitis or sinus thrombosis and sepsis. Heart rate corresponds to temperature; blood tests without abnormalities; ESR is not increased. Small changes in blood are observed only with extensive pachymeningitis.
Cerebral symptoms. A common symptom of all intracranial complications is a headache, which, however, is not always noted. With an extradural abscess, it is infrequent, usually constant, not very intense and is localized with a perisinous abscess in the occiput and forehead, with an abscess in the middle cranial fossa - in the area of the temporal bone scales, in the behind-the-ear region and in the tragus; with a deeper location of the abscess with the involvement of the gasser node or its branches, there may be trigeminal pains in the face. With a posterior cranial extradural abscess, pain is localized in the neck; due to pain and dizziness, torticollis may develop. Headache is sometimes accompanied by nausea, vomiting, drowsiness. General condition is usually satisfactory, rarely severe. Meningeal symptoms are possible: mild stiff neck, Kernig symptom, often more pronounced on the side of the abscess; while the composition of the cerebrospinal fluid is normal.
An important symptom of an extradural abscess may be profuse suppuration from the ear (see below: Additional research methods). A reliable method for the topical diagnosis of all types of otogenic abscesses is computed tomography and MRI.
The obligatory method of treating extradural abscess is surgical, it also allows you to differentiate the diagnosis from intracerebral and subdural abscess. Indications for the operation are the carious process in the attic-antral region, local headache, general condition deterioration, focal symptoms, profuse suppuration from the ear.
Subdural abscess. Subdural abscess develops as a complication of chronic suppurative otitis media, especially cholesteatoma, much less often - acute. It is localized in the middle or posterior cranial fossa between the dura mater and the brain. In the posterior cranial fossa, an abscess occurs in some cases with purulent labyrinthitis or thrombosis of the sigmoid sinus. It must be emphasized once again that otogenic intracranial complications, as a rule, arise on the basis of carious, often cholesteatomic, otitis media, therefore, only timely surgery on the middle ear can be a warning of such complications.
The proximity of the subdural abscess to the pia mater (pus quickly destroys it) and the substance of the brain sometimes leads to the development of two groups of symptoms: meningeal and focal, corresponding to the localization of the abscess. Focal symptoms may be in the form of light pyramidal signs on the opposite side when localized in the middle cranial fossa or stem symptoms (nystagmus, overshot in the palatine specimen) with localization in the posterior cranial fossa. Sometimes cerebral symptoms are significantly expressed, and then a differential diagnosis with an intracerebral abscess in the preoperative period becomes possible only with the help of computed tomography. The remitting course of meningeal syndrome with moderate (up to 0.2–0.3109 / L cells) pleocytosis in the cerebrospinal fluid is considered characteristic of a subdural abscess. It should be noted that this abscess can also be asymptomatic.
Treatment of a subdural abscess is necessarily surgical, and it should be borne in mind that the timing of the operation has already been missed. An extended radical operation is performed with the obligatory exposure of the sigmoid sinus and the meninges of the middle cranial fossa. The dura mater in the place of the abscess is yellow-white or yellow-green, sometimes protrudes. At this point, it is treated with tincture of iodine and punctured with a thick needle. After a little suction of the pus with a syringe, without removing the needle, an abscess is opened with a cruciform incision, a thin soft drainage is introduced, using glove rubber for it. Antibacterial, dehydrating, restorative and other therapy is prescribed. The behind-the-ear wound is not sutured.
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Otogenic intracranial abscesses
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- Differential diagnosis of otogenic abscesses of the brain
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