COMPLICATIONS OF CHRONIC SUPPURATIVE OTITIS MEDIA AA TYPE-3 YEARS EXPERIENCE

This retrospective study was carried out in the Department of ORL and Head & Neck Surgery, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu. Three hundred patients having atticoantral type of chronic suppurative otitis media underwent emergency or routine mastoid exploration from 14 April 1997 to 12 April 2000. Of the 300 patients, 64 (21.33%) had complications. Age of the patients with complications ranged from 5-38 years. Thirty eight (59.38%) patients were male while 26 (40.62%) were female. Forty eight (75%) had extracranial and 15 (23.44%) had intracranial complications while 1 (2.08%) had both extra and intracranial complications. Cholesteatoma was present in 233 (77.66%) patients and of these 48 (20.60%) had complications. Sixty seven (22.33%) patients had granulation tissue, of these 16 (23.88%) had complications.In cholesteatomatous cases 34 (70.83%) had extracranial complications. Intracranial complications were present in 14(29.17%) cholesteatomatous cases. In patients with granulation tissue extracranial complication was present in 14 (87.50%) patients and only one patient had intracranial complication.Combination of extra and intracranial complications were found in 1 patient with granulation tissue. When compared with types of pathology extracranial complications were higher in patients with granulation tissue (87.50% vs 70.83%) and intracranial complications were found more in cholesteatomatous cases (29.17% vs 6.26%). Both these findings were , however, statistically not significant. Reasons behind these findings may be presence of granulation tissue beneath the epithelium of choleateatoma, and association of both types of pathology with infection and inflammatory process. 1. Resident, Dept. of ORL and Head & Neck Surgery, TUTH, Maharajgunj, Kathmandu. 2. Professor, Dept. of ORL and Head & Neck Surgery, TUTH, Maharajgunj, Kathmandu. 3. Professor & Head of Dept., Dept. of ORL and Head & Neck Surgery, TUTH, Maharajgunj, Kathmandu. 4. Assoc. Professor, Dept. of ORL and Head & Neck Surgery, TUTH, Maharajgunj, Kathmandu. 5. Lecturer, Dept. of ORL and Head & Neck Surgery, TUTH, Maharajgunj, Kathmandu. Address for correspondence : Dr. Naramaya Thapa, Lecturer Nepal Medical College and Teaching Hospital Jorpati, Kathmandu. ORIGINAL ARTICLE Journal of Nepal Medical Association, 2001:40:77-82


INTRODUCTION
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 direct relationship between CSOM and brain abscess. 2 Chronic suppurative otitis media is one of the commonest otolaryngologic problems especially in underdeveloped country like ours.Its high incidence in low socioeconomic status is associated with poor hygiene, overcrowding, ignorance and lack of awareness of disease and its consequences.
Though the incidence of it and its complications has decreased in the Western world, in developing countries the incidence rate is still high.In developed countries the incidence of complications of CSOM has come down to 0.04% of all cases of suppurative ear disease. 3,4In a rural area of India it has found to be 4.26% 5 whereas in Thailand it varies from 6.45-7.60%. 6,7 study has been done in Nepal regarding incidence of complication, types of complication and correlation of different types of complications with types of pathology in CSOM.Therefore the main aim of this study was to evaluate the prevalence of complications, and to correlate types of complications with types of pathology in cases of atticoantral type of CSOM who underwent mastoid exploration in Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu.
Of 300 patients, 233 had cholesteatoma and only 67 had granulation tissue.Of the 233 patients with cholesteatoma, 48 (20.6%) had complications whereas of the 67 patients with granulation tissue, 16 (23.88%)had complications.When tested statistically it was found not to be significant (p=0.3764)(Table III).Of the 48 cases of cholesteatoma with complications, 34 (70.83%) had extracranial complications whereas of the 16 cases of granulation tissue, 14 (87.50%) had extracranial complications.However, statistically it was found not to be significant (p=0.3892)(Table IV).Similarly, out of the 48 patients of cholesteatoma with complications, 14 (29.17%) had intracranial complications whereas of the 16 patients of granulation tissue with complications, only 1(6.26%) had intracranial complication.When tested statistically it was also found not to be significant (p=0.1089)(Table V).Thapa et.al. : Complications of Chronic Suppurative Otitis ... SNHL was found in 2 (5.88%) patients.Facial nerve palsy was found in 1 (2.94%) patient and mastoid abscess and facial nerve palsy and CSF otorrhea was present in another 1 (2.94%) patient.Among intracranial complications brain abscess -6 (42.86%) and meningitis -4 (28.57%) were the commonest.Among brain abscess, 4 (28.87%)patients had cerebellar abscess and 2 (14.29%) patients had temporal lobe abscess.Two (14.29%) patients had presented with subdural empyema.Lateral sinus thrombosis and perisinus abscess was found only in 1 (7.14%) patient each (Table VI).Among granulomatous cases the commonest extracranial complication was same as in cases of cholesteatoma i.e. mastoid abscess/ fistula or Bezold's abscess with 9 (64.28%)patients.Facial nerve palsy in isolation was present in 3 (21.42%)patients.Labyrinthine fistula and facial palsy with profound sensorineural hearing loss were present in 1 (7.14%) patient each.The only intracranial complication found in granulomatous cases was perisinus abscess which was present in 1 patient.Both extra-and intracranial complications (acute mastoiditis, Bezold's abscess and extradural abscess) were present in 1 patient with granulation tissue (Table VII

Table VII. Distribution of complications in patients with granulation tissue
In preantibiotic era the incidence of complications of CSOM was very high.After invention of antibiotics although the incidence has decreased, it is still high in underdeveloped countries like ours.Most of our patients had a single extracranial complication -48 (75%) patients.This is in contrast to other study done in India which reported higher incidence of multiple complications (43.48%) . 5We found that complications were more common in age group of 11-20 years which is consistent with other studies. 5,6,7,8,9The reason behind this may be that this is socially the most active and health conscious age group.Male patients were more than females which is consistent with other studies. 5,10It may be due to male dominating society.
(1998) which also revealed meningitis to be the commonest intracranial complication followed by cerebellar abscess. 10However, in other studies temporal lobe abscess was more common than cerebellar abscess. 1,6is study showed that 75% patients with complications were due to cholesteatoma which is consistent with the study of Gupta et.al. (1996)  which showed 75.74% cases with cholesteatoma. 5 Bluestone also reported that 2/3 of complications were due to cholesteatoma. 1 Extracranial complications were more common in patients with granulation tissue 14 (87.50%) while intracranial complications were more common in patients with cholesteatoma 14 (29.17%).However, when tested statistically it was found not to be significant (p= 0.3764 and 0.1089 respectively).The reason behind this finding may be presence of granulation tissue beneath the epithelium of cholesteatoma though it can occur without cholesteatoma.
Figure 2 -Distribution of Complications

Table IV . Comparison of types of pathology with extracranial complications
).DISCUSSION

exact test: p=0.3892 (not significant)
11Another reason may be association of both types of pathology with infection and inflammatory process where inflammatory cells and various factors such as lymphokinin, prostaglandins and lysozomal enzymes are released which are responsible for bone erosion resulting in complications.Multiple complications (more than one complications) were seen in only 5 (7.81%) patients.However, Gupta et al. reported the incidence of multiple complications being 47.82%.5CONCLUSIONComplications of atticoantral type of CSOM accounts for a high rate of morbidity and mortality in developing countries.Complications were common in males and in young age group(11-20  years).Extracranial complications (75% of the cases) were more common than intracanial complications (23.44%).Acute Mastoiditis/ mastoid abscess and/or fistula were being the commonest extracanial complication.Brain abscess and meningitis were the commonest intracranial complications.Cerebellar abscess was more commom than temporal lobe abscess.General Physicians (GP) as well public at large should be made aware of seriousness of middle ear suppuration as these account for high rate of morbidity and mortality in our country.