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Eur Arch Otorhinolaryngol
DOI 10.1007/s00405-008-0707-8
123
OTOLOGY
Complications of chronic otitis media with cholesteatoma
during a 10-year period in Kosovo
A. Mustafa · A. Heta · B. Kastrati · Sh. Dreshaj
Received: 4 December 2007 / Accepted: 30 April 2008
© Springer-Verlag 2008
Abstract We review and discuss the results of treatments
for complications of cholesteatomatous chronic otitis media
(CCOM) in a tertiary health care center. In a retrospective
study, the medical records of patients with complications of
CCOM who had undergone surgical treatment at the ENT
Clinic of the University Clinical Center of Kosovo for the
period 1994–2004 were reviewed. From a total of 1,803
patients suVering from CCOM, in 91 patients, 55 (60.4%)
men and 36 (39.6) women, one or two complications are
recorded. The mean age of the subjects was 30 years, and
the age range was from 1 to 76 years. Extracranial (EC)
complications were observed in 52 cases (57.1%), and
intracranial (IC) complications were seen in 29 patients
(31.9%). Twelve patients (11%) had multiple complica-
tions. For the EC cases, we found that subperiostal mastoi-
dal abscess occurred in 26% of the all patients, facial nerve
palsy was seen in 16.48% and labyrinthine Wstula occurred
in 10%. For the IC cases, meningitis (19.7%) and perisinu-
sal abscess (15.3%) were the most common complications.
The most often isolated pathogen from ear swabs was Pro-
teus mirabilis in 33.3% of cases. The most frequent radio-
logical diagnostic procedures were mastoid tip X-rays,
which were performed in 77% of the patients, and com-
puted tomography in 24%; magnetic resonance imaging was
not performed on any of the patients during the study period.
Patients with EC complications were treated in the ENT
Clinic, whereas patients with IC complications, after oto-
logic surgical procedures, were transferred to the Neurosur-
gery Clinic or to the Clinic for Infectious Diseases. In this
series, three patients (3.3%) died as a result of complica-
tions, while the remaining 96.7% survived. Complications
of COM with cholesteatoma can represent life-threatening
conditions, and close cooperation between otosurgeons, neu-
rosurgeons and infectious disease specialists is mandatory.
Keywords Complications of cholesteatoma ·
Chronic otitis media · Surgical treatment
Introduction
Cholesteatoma is an epithelial-lined growth containing
mainly cellular debris in which cholesterol crystals can
generally be found. Cholesteatomas are benign and occur
mainly in the middle ear and mastoid region, and through
pressure, cause destruction of surrounding structures [1].
Once established in the middle ear, mastoid or petrous
bone, cholesteatoma is a destructive lesion that gradually
expands and destroys adjacent structures, leading to com-
plications. The pathogenesis is diverse, with diVerent path-
ways leading to the same destructive lesion [2]. The
majority view of pathogenesis now favors retraction of
Shrapnel’s membrane or the posterosuperior quadrant of
the pars tensa, which develops into a gradually expanding
cyst containing epithelial debris having locally erosive
properties [3].
Although the incidence of complications due to otitis has
decreased in recent decades, they still pose a challenge for
A. Mustafa (&) · A. Heta
ENT Clinic, University Clinical Center of Kosovo,
rr. Spitalit pn, 10000 Prishtina, Kosovo/UNMIK
e-mail: aziz_mustafa2000@yahoo.com
B. Kastrati
Neurosurgery Clinic, University Clinical Center of Kosovo,
Prishtina, Kosovo/UNMIK
Sh. Dreshaj
Clinic for Infectious Disease,
University Clinical Center of Kosovo, Prishtina, Kosovo/UNMIK
Eur Arch Otorhinolaryngol
123
clinicians, because the complications have an insidious pre-
sentation that is usually hidden by the indiscriminate use of
antibiotics [4]. The objective of surgery for chronic otitis
media with cholesteatoma and chronic otomastoiditis is to
eradicate the disease and create anatomic conditions to pre-
vent recurrence and complications. To achieve this pur-
pose, two surgical techniques exist: canal wall-up (CWU)
and canal wall-down (CWD) mastoidectomies [5].
Complications of CCOM are classiWed as extracranial
(EC) or intracranial (IC). EC complications are recorded
more often than IC complications, but IC complications are
more severe and lethal. Consequently, studying EC and IC
complications is clinically important.
The goal of the present study was to analyze the manage-
ment of complications of cholesteatoma for a 10-year
period at our center retrospectively. Because the University
Clinical Center of Prishtina is the only referral center for
otogenic complications in Kosovo, the incidence of compli-
cations due to cholesteatoma can be estimated accurately.
The present study, which included all patients hospitalized
for complications of cholesteatoma over a 10-year period,
describes the diagnosis and treatment of complications due
to CCOM. In particular, we focus on the cause and duration
of chronic ear signs and symptoms and discuss otosurgical
approaches.
Material and methods
We reviewed the clinical records of patients diagnosed as
having CCOM and treated at the ENT/Head and Neck Sur-
gery Clinic, University Clinical Center, Prishtina, Kosovo,
from January 1994 through December 2003. The diagnosis
of a complication of CCOM was established by experi-
enced otolaryngologists based on the clinical examination,
otomicroscopy and radiology examinations and was con-
Wrmed during the surgical procedures. Cases with COM
without an intraoperative Wnding of cholesteatoma were
excluded from the study.
The demographic data included sex, age and residence
(rural or urban). Signs and symptoms on admission, white
blood count (WBC), erythrocyte sedimentation rate (ESR)
and the results of middle ear aspirate culture obtained on
admission were also recorded. In all cases with a suspected
complication, X-rays of the mastoid were performed, and
occasionally, computed tomography (CT) of the temporal
bone, brain and neck was performed. The surgical proce-
dures were recorded, and materials were harvested for
pathology conWrmation.
With regard to patient consent, we obtained written per-
mission from the clinic director to conduct research on this
topic, because our institution lacks an institutional review
board. In addition, every patient admitted to the clinic must
sign a consent form giving permission to conduct all diag-
nostic and therapeutic procedures, including the publication
of images or other medical records.
Results
During the 10-year period from January 1994 to December
2003, 1,803 patients were admitted with diagnosis of otitis
media. We found that 92% of these patients had COM,
while 8% had acute otitis media. From a total of 1,803
patients, in 272 of them, an intraoperative cholesteatoma is
conWrmed. From this 272 patients with CCOM, 91 (33.5%)
came to the clinic with either one or two complications. We
also found that complications of COM (without cholestea-
toma) occurred in only 6.7% of cases.
The number of patients with complications of cholestea-
toma decreased during the last 5 years of the study period as
shown in Fig. 1. This decrease corresponds to the end of the
military conXict in Kosovo in 1999 and was likely due to the
subsequent rapid reconstruction of the health care system,
which improved primary health care and medical education.
The detailed data of 91 patients with complications of
CCOM included in the study are presented in the Table 1,
where 55 (60.4%) were men and 36 (39.6%) women, that
presents statistically signiWcant diVerence (
2
test = 3.97,
P < 0.05). The mean age was 30 years, with a standard
deviation (SD) of 16.5 years (SD § 16.54), ranging from 1
to 70 years. The percentage of pediatric patients (<15 years
old) was 20.9%. According to residence, urban versus rural,
there were no signiWcant diVerence: 50.5% versus 49.5%
(
2
test = 0.01, P >0.05).
The duration of disease, from the Wrst visit to the ENT
doctor to the moment of surgery, is presented in Table 2.
The mean duration of disease was 8.6 years, with a stan-
dard deviation of 8.9. Only 17.6% of patients carried the
cholesteatoma for less than 1 year. The same percentage of
patients had episodes of exacerbation for more than
Fig. 1 Complications of CCOM by year
13
9
8
9
8
7
10
12
11
4
0
2
4
6
8
10
12
14
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Eur Arch Otorhinolaryngol
123
15 years. Most of the patients (38.5%) carried the choleste-
atoma from 1 to 5 years.
Types of complications of CCOM are shown in Table 3.
EC complications occurred in 52 patients (57.1%), IC com-
plications in 29 (31.9%) and multiple complications
(IC + EC) in 10 patients (11%). In IC group, there were two
cases (2.2%) with multiple complications (IC + EC), con-
sidering sepsis as result of an intracranial complication. For
the EC cases, we found that subperiostal mastoidal abscess
(SMA) occurred in 26% of the all patients, facial nerve
palsy (FNP) was seen in 16.48% and labyrinthine Wstula
occurred in 10%. For the IC cases, meningitis (19.7%) and
perisinusal abscess (15.3%) were the most common com-
plications. In group of multiple complications (IC + EC),
combination of perisigmoid sinus abscess and SMA was
the one that most often occurred (4.4%). Meningitis and
SMA was the second most often occurred one.
Diagnostic procedures applied for this series of patients
was not standardized and diVers from patient to patient. For
some procedures, e. g. CT scans, determinative was avail-
ability. For the period 1994–2003, CT was not available in
our center in all cases and is done only in 24% of cases;
pure tone audiometry can be performed only in conscious
patients. The Table 4 shows the percentage of diagnostic
procedures performed in patients of our series. Laboratory
analyzes, erythrocyte sedimentation rate (ESR) and white
blood count (WBC) was taken in all cases and elevated
values indicated developing complications. In 70.3% of
patients, mastoid tip X-rays were performed; in cases
Table 1 Patient by gender, residence and age
Number N (%) P value
Gender
Men 55 (60.4%) 0.046
Women 36 (39.6%)
Residence
Urban 46 (50.5%) 0.917
Rural 45 (49.5%)
Age (years)
Mean § SD 29.90 § 16.54
Rank 1–70
<15 years 19 (20.9%)
Table 2 Duration of disease (CCOM)
Duration in years Number (N) Percent (%)
<1 16 17.6
1–5 35 38.5
6–10 17 18.7
11–15 5 5.5
>15 16 17.6
No data 2 2.2
Total 91 100.0
Mean 8.6 years
SD 8.9
Table 3 Types of CCOM complications
SMA subperiostal mastoid abscess, FNP facial nerve paralysis
Type of complication Number
(N)
Percent
(%)
Extracranial complications
SMA 24 26.4
FNP 13 14.3
Perilabyrinthine Wstula 9 9.9
Acute mastoiditis 4 4.4
Zygomatitis/perizygomatic abscess 1 1.1
Bezold’s abscess 1 1.1
Total 52 57.1
Intracranial complications
Meningitis 11 12.1
Perisigmoid sinus abscess 10 11.0
Cerebral abscess 3 3.3
Meningoencephalitis 2 2.2
Subdural abscess 1 1.1
Perisigmoid sinus abscess + sepsis 1 1.1
Meningitis + sepsis 1 1.1
Total 29 31.8
Multiple (IC/EC) complications
Perisigmoid sinus abscess + SMA 4 4.4
Meningitis + SMA 2 2.2
Cerebral abscess + FNP 1 1.1
Meningitis + petrositis 1 1.1
Meningitis + FNP 1 1.1
Perisigmoid sinus abscess +
jugular vein thrombophlebitis + SMA
11.1
Total 10 11.0
Total 91 100.0
Table 4 Diagnostic procedures
E
SR erythrocyte sedimentation rate, WBC white blood count, CT com-
puted tomography, PTA pure tone audiometry
Total number of patientsn =91
N %
ESR 91 100.0
WBC 91 100.0
CT 22 24.2
Mastoid X-rays 64 70.3
PTA 44 48.4
Ear swabs 44 48.4
Eur Arch Otorhinolaryngol
123
suspected of IC complications, CT scans were performed.
PTA shows conductive hearing loss in diseased ears.
The microbiology analysis results are shown in Table 5.
Swabs from draining ears, myringotomy incisions or the
mastoid cavity were only taken in 44 patients, and patho-
genic bacteria were isolated in only 33 patients. The most
frequently isolated pathogens were Proteus mirabilis in
33.3%, Staphylococcus aureus in 15% and Pseudomonas
sp. and Proteus vulgaris in 12% of the 44 cases.
The surgical procedures for the treatment of complica-
tions are summarized in Table 6. CWD radical tympano-
mastoidectomy (RTM) was performed in 86.8% of the
patients and was the most frequently applied procedure.
CWU procedures were only applied in 13.2% of the
patients.
The modiWcations of the CWD procedure in each of the
79 applicable cases were diVerent and depended on the
spread of disease and the type of complications. The modi-
Wcations of the CWD procedure are listed in Table 7. The
most common open techniques applied were RTM in
34.2% of the patients, RTM with middle fossa dura expo-
sure in 14% and RTM with lateral sinus exposure in 11.4%.
The end results regarding the management of this series
of patients were the following: seventy-seven patients
(84.6%) were cured and followed as outpatients for at least
1 year. Conversely, 10 patients (11%) were transferred to
other departments, three died and one patient left our
department. In addition, one patient was transferred to the
Abdominal Surgery Department because of acute abdomi-
nal distress. The three patients who died had intracranial
complications: two had meningitis and one had meningitis
and a brain abscess.
Discussion
Adam Politzer in 1869 (published in 1909) clearly identi-
Wed the potential seriousness of otitis media in the preanti-
biotic era based on the anatomic location and boundary
with vital structures by stating that “the temporal bone has
four sides: the outside is bounded by life, from which there
comes the opening of the auditory canal, one form of our
appreciation of what life means; on the other three sides
this bone is bounded by death”. The advent of antimicrobi-
als, an increasing of awareness of physicians and the public
regarding the potential seriousness of disease and diagnos-
tic methods yielding earlier identiWcation and treatment
immensely reduced the incidence of lethal complications
[6, 7].
With regard to the prevalence and incidence of compli-
cations, many studies have counted the prevalence of
patients having COM with cholesteatoma who develop
complications, because calculating the incidence was not
appropriate. The results of large series of patients have
shown a similar rate of otogenic complications compared to
the results of our series. During a 9-year period (1990–
Table 5 Isolated bacteria from ear swabs
Bacteria Number (N) Percent (%)
Proteus mirabilis 11 33.3
Staphyloccocus aureus 5 15.2
Proteus vulgaris 4 12.1
Pseudomonas spp. 4 12.1
Citrobacter 39.1
E
scherichia coli 39.1
Streptoccocus pneumoniae 13.0
Klebsiella pneumoniae 13.0
M
organella morganii 13.0
Total 33 100.0
Table 6 Surgical procedures applied in patients with complications
Surgical procedure Number (N) Percent (%)
Radical tympano-mastoidectomy 79 86.8
Simple mastoidectomy +
tympanoplasty
66.6
Mastoidectomy 5 5.5
Antrotomy 1 1.1
Total 91 100.0
Table 7 The modiWcations of CWD procedures applied in 79 patients
with cholesteatoma complications
R
TM radical tympano-mastoidectomy, MFDE middle fossa dura expo-
sure, SSE sigmoid sinus exposure, TOT tympanoplasty in open tech-
nique
CWD procedure Number (N) Percent (%)
RTM 27 34.2
RTM + MFDE + SSE 12 15.2
RTM + MFDE 11 13.9
RTM + SSE 9 11.4
RTM + labyrinthine Wstula closure 7 8.9
ModiWed RTM 3 3.8
Revision RTM 3 3.8
RTM + facial canal plasty 2 2.5
TOT 1 1.3
TOT + craniotomy 1 1.3
RTM + perizygomatic
abscess incision
11.3
RTM + SSE + Bezold’s
abscess evacuation
11.3
RTM + Middle fossa
extradural abscess evacuation
11.3
Total 79 100.0
Eur Arch Otorhinolaryngol
123
1999), of 2,890 patients with acute and chronic otitis
media, Osma et al. found 93 cases involving complications,
which consisted of 57 IC cases (59%) and 39 EC cases
(41%), suggesting that 3.22% of all patients with middle
ear infections develop a complication [8]. Kangsaranak
et al. reviewed 17,000 patients with COM and found 102
cases with IC and EC complications; they calculated the
prevalence of complications as 0.69% among populations
with suppurative COM [9]. This same group reviewed
another series of 24,321 patients from a 13-year period and
found 87 cases with 140 IC complications; they calculated
a prevalence of 0.36% for IC complications [10]. As a com-
parison, we found complications in 5% of the cases in our
series (91 out of the 1,803 patients with acute and chronic
otitis media). Our prevalence was high because our series
consisted of inpatients. If we had included the outpatients
with COM, we would likely have obtained a much lower
prevalence that was similar to the results in the literature.
The highlight of our results is the Wnding that CCOM
developed complications in 33.5% of the cases in our
patient series, whereas COM without cholesteatoma devel-
oped complications in only 2% of the cases.
The duration from the onset of disease to the appearance
of complications was important in our work. In our series, the
mean duration of disease was 8.6 years. More than 62% of
the patients reported a duration of 1–15 years, while 17% had
duration of less than 1 year, which was similar to the percent-
age of patients with disease duration of more than 15 years.
Studies on the complications of cholesteatoma have
found diVerent percentages of the men-to-women ratio. In
the series of Osma et al. involving 93 patients [8], the
authors found a signiWcant diVerence in the men-to-women
ratio of 2:1. In contrast, Keles et al. in a series of 51 patients
did not Wnd a signiWcant diVerence in the men-to-women
ratio, observing that 57% of the patients were men and 43%
were women [11]. In our series, of the 91 patients with
complications from cholesteatoma, we found that 60%
were men and 40% were women.
Complications due to cholesteatoma can occur in
patients of all ages, from infants to older adults [8–12]. In
our series, the age structure of the patients was diVerent,
with a slight domination in the 11- to 20-year-old group.
The mean age was 30 years, and the patients ranged in age
from 1 to 70 years.
COM is a suppurative bacterial infection, and its causa-
tive agents can be isolated using ear swabs. This is impor-
tant because primary surgical therapy must always be
complemented with antibiotic therapy chosen according to
the microbiology lab results. In a meta-analysis of seven
publications, of a total of 280 patients, Dhooge et al. found
that Streptococcus pneumoniae was the most commonly
isolated causative agent, occurring in 23% of cases. Staphy-
lococcus coagulase-positive bacteria were seen in 19% of
cases. Streptococcus -hemolyticus group A was seen in
16% of cases, and Haemophilus inXuenzae was detected in
2% of the cases. They also found that 20% of cases did not
show pathogenic bacteria in the cultures [13]. Other studies
have suggested that Pseudomonas aeruginosa is the leading
causative pathogen in COM with cholesteatoma [14, 15]. In
our series, material for microbiology analyses was only
taken from 33 patients, and the most frequently isolated
bacterial agent was from the Proteus group as follows: Pro-
teus mirabilis
from 33% of the swabs, Staphylococcus
aureus from 15%, Proteus vulgaris from 12% and Pseudo-
monas spp. from 12%. Streptococcus pneumoniae was only
isolated from 3% of the swabs. Antibiotic therapy in cases
with microbiology lab results is determined by an antibio-
gram, whereas antibiotic therapy is determined by empiri-
cal evidence in cases without lab results. In cases with
meningitis, therapy is given after consultation with an
infectious disease specialist.
Although the clinical history and clinical exam play
important roles in the diagnosis of complications, the main
diagnostic tool is clinical imaging. The gold standard is CT,
because this imaging provides a good view of bony struc-
tures; magnetic resonance imaging (MRI) is better for the
visualization of soft tissue pathologic changes. According
to the protocols of many centers, the suspicion of a compli-
cation necessitates a CT scan within the Wrst 24 h of admit-
tance, in coronal and axial cuts at 1-mm slices, using a high
resolution of 30–50 mA.
When an intracranial complication is suspected, a con-
trast CT scan must be performed. MRI T-1- and turbo T-2-
weighted scans allow better visualization of brain soft tis-
sue and blood vessels in coronal and axial sections with or
without contrast [16]. The sensitivity of CT in the current
diagnosis of intratemporal complications is reported to be
87–100% [17, 18]. In our series, the majority of patients did
not receive CT scans for the diagnosis of complications,
because these devices were not prevalent in Kosovo in the
late 1990s. Temporal bone plain X-rays were applied in
77% of the patients in our series, and CT scans were only
applied in 24%. MRI was not applied to any patient. The
other diagnostic procedures included laboratory Wndings
(ESR, WBC) and the results of lumbar puncture.
A wide range of surgical techniques are used for the
treatment of complications due to cholesteatoma, but the
only eVective treatment is surgery. For EC complications,
otosurgeons must be fully trained to deal with all possible
complications and to adapt the approach and surgical
method to achieve a clean and dry ear for a long time dur-
ing the follow-up. For IC complications, close cooperation
between otosurgeons and neurosurgeons is mandatory [19].
In recent publications, the authors have agreed that oto-
genic meningitis must be treated with middle ear surgery
(mastoidectomy, simple or radical) in combination with
Eur Arch Otorhinolaryngol
123
antibiotics. For lesions located adjacent to the dura or teg-
mental area, such as extradural abscesses and sigmoid sinus
thrombosis, mastoidectomy performed by an otosurgeon is
the only necessary approach. For deep cerebral and cerebel-
lar abscesses, craniotomy performed by a neurosurgeon
working with otosurgeons is the treatment of choice [20].
In our series, all patients with EC complications were
treated in the ENT Clinic by a senior otosurgeon. No deaths
were recorded among the EC complications group. The IC
complications group was treated primarily in the ENT
Clinic with mastoidectomy alone or in combination with
sigmoid sinus exploration in cases with thrombosis of the
sigmoid sinus. Patients with deep cerebral abscesses were
treated surgically twice: Wrst by mastoidectomy in the ENT
Clinic and second by craniotomy in the Neurosurgery
Clinic. Three deaths occurred in this group: two patients
with otogenic meningitis and one with a cerebral abscess
died, representing a mortality rate of 3.3% among the
patients with complications.
Conclusions
• Patients having COM with cholesteatoma develop
complications more often than patients having COM
without cholesteatoma; so the management of patients
with cholesteatoma must be a priority for the ENT
health care system.
• The treatment of the complications due to cholestea-
toma is surgical, and trained otosurgeons must be ready
to perform all needed interventions.
• Complications of COM with cholesteatoma represent
life-threatening conditions, and close cooperation
among otosurgeons, neurosurgeons and infectious dis-
ease specialists is mandatory.
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