Chapter 99: Complications of Acute Otitis Media and Sinusitis

BACKGROUND

Uncomplicated acute otitis media (AOM) and sinusitis are generally managed in the outpatient setting with excellent outcomes. Occasionally, complications from these infections arise, and a subset of these complications requires immediate intervention and hospitalization (Table 99-1). Children with AOM and sinusitis are predisposed to infectious and inflammatory complications because of their close proximity to orbital and parameningeal structures. The separation between these structures and the middle ear or sinuses may be breached by two main mechanisms: (1) direct extension via communication between the middle ear and the mastoid airspace and thin bony walls separating the sinuses from intraorbital area, and (2) hematogenous spread via penetrating veins from infected sinuses or mastoid spaces to the intracranial region.

ACUTE OTITIS MEDIA AND COMPLICATIONS

AOM is defined as inflammation of the mucoperiosteal lining of the middle ear.¹ An upper respiratory tract infection (URI) precedes most episodes of AOM and causes edema and obstruction of the Eustachian tube, which then impedes drainage of middle ear fluid. One-third of all URIs are complicated by AOM.² By age 3 years, 80% of all children will have had at least one episode of AOM, with the peak incidence occurring between 6 and 18 months of age.³ The high risk in this age group is likely due to a combination of narrower and more horizontal positioning of the Eustachian tubes and a relatively immature immune system, thus making them more susceptible to infection.¹ Most episodes of AOM are treated with oral antibiotics in the outpatient setting. For treatment with parenteral antibiotics, a single dose of ceftriaxone eradicates AOM caused by Haemophilus influenzae and penicillin-susceptible Streptococcus pneumoniae. However, for AOM caused by non-penicillin susceptible S. pneumoniae, ceftriaxone administered intramuscularly successfully treated 52% of cases with a single dose and 97% of cases with three doses.⁴

In the postantibiotic era, complications from AOM have decreased significantly. Serious infectious complications are reported in 0.04% to 0.4% of cases.⁵ The sites of these complications include the surrounding bone, middle/inner ear, and intracranial spaces (Table 99-1).

MASTOIDITIS

Background and Pathophysiology

The mastoid is the inferior posterior portion of the temporal bone and consists of air cells separated by bony septa. Although present at birth, the air cells are not fully pneumatized until 2 to 3 years of ...