Incidental mastoid opacification in children on MRI

The Role of Imaging Modalities in Diagnosis and Outcome of Otitis Media with Effusion in Cochelear Implant Candidates

OBJECTIVE

We investigated the accuracy of imaging modalities in diagnosis and outcome of otitis media with effusion by correlating the imaging findings with the preoperative otomicroscopic examinations, tympanometric results, and intraoperative findings in patients who underwent cochlear implant surgery.

METHODS

The results of the preoperative physical examination and intraoperative findings of patients younger than 18 years who underwent cochlear implant surgery at a single tertiary institution were recorded from their medical charts. Tympanometries, which were performed in maximum 1 week prior to imaging modalities, were analyzed. The high resolution computed tomography of temporal bone and magnetic resonance imaging of internal acoustic meati findings were reviewed. The mastoid cavity and middle ears were evaluated separately.

RESULTS

The data comprising of 280 ears were evaluated. The correlation between imaging findings and both physical examination and tympanometries were statistically significant (p = 0.000). The intraoperative findings supported this correlation.

CONCLUSIONS

Our study showed that imaging modalities might detect the middle ear and mastoid cavity effusions. The severity of these changes may differ according to the severity of disease.

Pediatric head and neck emergencies

PURPOSE

Head and neck emergencies in children are frequent cause of visits to the hospital. Imaging plays a critical role in the management of these patients. This review article aims to familiarize radiologists with the common clinical presentations encountered, imaging characteristics of nontraumatic pediatric head and neck emergencies, and improve their ability to recognize associated complications as well as be aware of common mimics.

METHODS

We researched our database for commonly encountered nontraumatic head and neck emergencies in children. A literature search was done to compare and complete the list of conditions to be discussed in this review.

RESULTS

The review was organized according to anatomical location of the emergent condition. Relevant anatomy has been discussed along with clinical presentation, imaging characteristics and complications. We have presented common mimics with each set of disorders. Key imaging characteristics have been delineated using radiology images.

CONCLUSION

Familiarity with the known complications of head and neck emergencies allows the radiologist to actively search for such findings, encourage early institution of appropriate therapy, and improve outcomes.

The Prevalence of Incidental Mastoid Opacification and the Need for Intervention: A Meta-Analysis

OBJECTIVES/HYPOTHESIS

The increasing use of cross-sectional imaging has led to the predicament of incidental mastoid opacification (IMO). We investigated the prevalence of IMO and the clinical need for ENT assessment or intervention when identified.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The PRISMA statement standards were used to search electronic databases including Medline, Embase, PubMed, and Web of Science. The selection criteria were mastoid opacification found on computed tomography (CT) or magnetic resonance imaging (MRI) as incidental findings.

RESULTS

A total of 16 studies were identified for qualitative analysis and 15 for quantitative analysis, mainly retrospective. The pooled prevalence of IMO in 246,288 patients was 8.4% (95% CI 5.5-12.0). The prevalence of IMO was significantly higher in studies with children (17.2%, 95% CI 10.9-24.6) than those with adults (6.1%, 95% CI 3.3-9.6); smaller sample size studies (12.4%, 95% CI 8.1-17.3) compared to larger sample size studies (4.1%, 95% CI 1.5-7.8); and when IMO was detected by viewing images (14.5%, 95% CI 9.9-19.8) compared to reading reports (3.5%, 95% CI 1.3-6.6). Imaging modality was not a significant moderator due to similar IMO rate on CT (8.6%, 95% CI 1.8-19.7) and MRI (10.4%, 95% CI 4.9-17.6). Nine studies reported on clinical outcomes of patients with IMO, and none reliably reported any cases of clinical mastoiditis.

CONCLUSIONS

The term "mastoiditis" on radiology reports based on IMO does not indicate a clinical diagnosis of mastoiditis, although the current body of evidence is limited. Otolaryngology review is suggested if clinical correlation detects otological signs or symptoms.

LEVEL OF EVIDENCE

NA. Laryngoscope, 2021.

Mastoid effusion on temporal bone MRI in patients with Bell's palsy and Ramsay Hunt syndrome

This study aimed to investigate the incidence of mastoid effusion on temporal bone magnetic resonance imaging (MRI) in patients with Bell’s palsy (BP) and Ramsay Hunt syndrome (RHS), and evaluate the usefulness of mastoid effusion in early differential diagnosis between BP and RHS. The incidence of mastoid effusion on 3.0 T—temporal bone MRI, which was conducted within 10 days after the onset of acute facial nerve palsy, was compared between 131 patients with BP and 33 patients with RHS. Findings of mastoid cavity on temporal bone MRI were classified into three groups as normal mastoid, mastoid effusion, and sclerotic change, and the incidence of ipsilesional mastoid effusion was significantly higher in RHS than BP (P < 0.001). Tympanic membrane was normal in 7 of 14 RHS patients with mastoid effusion, and injected without middle ear effusion in 7 patients. This study highlights significantly higher incidence of ipsilesional mastoid effusion in RHS than BP, and suggests that the presence of mastoid effusion may provide additional information for differential diagnosis between RHS and BP.

Incidental mastoid opacification on computed tomography in the pediatric population

OBJECTIVES

Incidental mastoid opacification (IMO) is a common radiologic finding and source of referral to otolaryngologists. Our objectives were to: 1) determine the rate of IMO in our pediatric population; 2) identify those with clinical mastoiditis; and 3) identify factors necessitating an otolaryngology consultation.

METHODS

This was a retrospective chart review at an academic, tertiary, pediatric hospital in an urban setting. Pediatric patients with the keyword 'mastoid' on a computed tomography (CT) scan report were reviewed. The effect of age, gender, season and the use of contrast media on the rate of IMO was also analyzed. Chi-square analysis was used to compare the significance of categorical frequencies.

RESULTS

The rate of IMO in our cohort was 14.2% (164/1157). In children <8 years of age, the IMO rate was 22.0% compared to 5.6% in children 8-17 years of age (p < .001). The IMO rate in male children was 16.6% compared to 11.0% in female children (p = .007). There was no statistically significant higher rate of IMO during winter (15.1%) compared to summer (9.0%) and in CT scans with contrast (16.0%) compared to without contrast (14.0%). Our department of otolaryngology was formally consulted in 3% (5/164) of IMO cases. None of those patients had clinical mastoiditis.

CONCLUSIONS

This is the largest study identifying IMO on CT and in children to date. Although the overall rate of IMO in the pediatric population is 14.2%, it is rarely clinically significant.

Acute Otitis Media and Associated Complications in United States Emergency Departments

OBJECTIVE

Complications due to acute otitis media (AOM), while rare, are associated with significant morbidity and are not well characterized from an epidemiological perspective. We analyze the pattern of presentation and emergency department (ED) utilization in patients with AOM and associated complications.

STUDY DESIGN

Retrospective analysis of the Nationwide Emergency Department Sample (NEDS) from 2009 to 2011.

SETTING

Emergency Department.

PATIENTS

Patients who presented with a primary diagnosis of AOM or acute mastoiditis.

INTERVENTION

Diagnostic.

MAIN OUTCOME MEASURES

NEDS was queried for patient encounters with a diagnosis of AOM or acute mastoiditis based on ICD-9 codes. Complications of severe infection, including petrositis, Gradenigo's syndrome, facial paresis, labyrinthitis, meningitis, intracranial abscess, venous sinus thrombosis, and cerebrospinal fluid leak, were assessed. Weighted estimates for demographics, types of complications, socioeconomic status, and trends over time were extracted.

RESULTS

A weighted total of 5,811,127 ED visits were identified. The majority of patients were less than 18 years old (79.9%) with an average age of 10.1 years. Most were discharged (99.4%). There were 15,243 (0.26%) patients who presented with a complication. The most common complications were acute mastoiditis (0.16%), labyrinthitis (0.06%), and facial paresis (0.03%). Compared with patients with uncomplicated AOM, patients with complicated AOM were older (37 vs. 10-yr old), insured by Medicare (18% vs. 2.1%), and more likely to be admitted (43.6% vs. 0.4%) (p < 0.0001, for all comparisons).

CONCLUSIONS

ED visits related to AOM or mastoiditis are common and complications are rare. An in-depth analysis on a national level is useful for assessing healthcare utilization trends.

Incidental finding of mastoid opacification in computed tomography imaging of the asymptomatic paediatric population

Background

Acute mastoiditis is a clinically diagnosed suppurative infection of the mastoid air cells and is the most common complication of acute otitis media. Opacification of the mastoid air cells is a commonly reported radiological finding and patients are often erroneously diagnosed with acute mastoiditis when this is present.

Objectives

This study aimed to quantify incidental findings of mastoid opacification in the asymptomatic paediatric population and contribute to the epidemiological data.

Method

A retrospective cohort study was conducted of all paediatric patients who underwent relevant computed tomography imaging for a non-otological indication.

Results

Data were collected from 767 patients in total. Mastoid opacification was reported in 82 patients. The prevalence was highest in patients aged zero to one year (n = 25, prevalence = 20.3 per cent), followed by those aged two to three years (n = 17, prevalence = 19.5 per cent).

Conclusion

Mastoid opacification is a common incidental finding in the asymptomatic paediatric population, with prevalence rates between 5 per cent and 20 per cent depending on age. The prevalence peaks in patients aged zero to four years (19–20 per cent) and is inversely correlated with increasing age.

Otitis, Sinusitis, and Mastoiditis

Otitis, sinusitis, and mastoiditis represent a range of common upper respiratory tract infections that are more common in children than in adults. The clinical presentation of otitis varies based on the anatomic site of disease. Acute otitis media and otitis media with effusion are infections of the middle ear, and otitis externa is infection of the external auditory canal. Otitis is one of the most common infections seen in young children. Each case represents an opportunity to practice precise diagnostic skills and to practice judicious antibiotic use. Sinusitis, while also relatively common, may present with nonspecific signs and symptoms. An accurate diagnosis requires a complete history and careful physical examination to help distinguish between viral rhinosinusitis, a condition that is usually self-limiting, and bacterial rhinosinusitis, a condition that requires treatment with antibiotics. Mastoiditis is a less common condition that can occur as a complication of otitis media. Prompt recognition and appropriate antibiotic treatment, often in combination with surgical debridement, is required to prevent further spread of the infection and the development of secondary complications.

Incidental mastoid effusion diagnosed on imaging: Are we doing right by our patients?

OBJECTIVES/HYPOTHESIS

To investigate whether radiologist-produced imaging reports containing the terms mastoiditis or mastoid opacification clinically correlate with physical examination findings of mastoiditis. Additionally, to investigate whether and how often otolaryngology was unnecessarily consulted and inappropriate antibiotic therapy was initiated.

STUDY DESIGN

Retrospective chart review within a large community hospital setting.

METHODS

A retrospective review of 160 patients who had imaging tests performed for nonotolaryngology indications from January 2011 to March 2017 at our facility. Indications, patient demographics, otolaryngology consultations, and new antibiotics started were recorded. Physical examinations were documented.

RESULTS

Physical examination revealed that only 14 of 160 patients (8.8%) had clinical evidence of otologic disease. However, of the 160 patients meeting the inclusion criteria, 18 (11.3%) received an otolaryngology consultation, and 18 (11.3%) had antibiotics started. Eleven of the 18 patients in each group (61.1%) had a normal physical examination, two (11.1%) had serous otitis media, one (5.6%) had chronic otitis media, and four (22.2%) had acute otitis media. No patients were found to have clinical mastoiditis. χ² analysis revealed no significance in the radiologic diagnosis of mastoiditis versus mastoid opacification in relation to physicians requesting otolaryngology consultations (P = .241) or starting patients on antibiotics (P = .951).

CONCLUSIONS

This study highlights the prevalence of incidental but clinically insignificant opacification of the mastoid cavity. We believe that nonotolaryngology physicians are, overall, competent to correlate such radiologic findings clinically and to prevent unnecessary consultations and inappropriate treatment, which add significant costs to our overstretched healthcare system.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:852-857, 2019.

Fluid signal in the mastoid is a common incidental finding on MRI of the brain

Incidental findings are common on patients undergoing magnetic resonance imaging (MRI) of the brain. Fluid signal in the mastoid can be such an incidental finding on MRI of the brain. In only a small number of patients, this relates to inflammatory disease of the middle ear or mastoid. In a small retrospective study, the prevalence of this finding has been studied. Fluid signal in the mastoid was found in 21 out of 84 patients (25%). Only in two patients MRI revealed a cause for the mastoid fluid (mastoid osteolysis in a patient with metastatic breast cancer and presumed recurrent cholesteatoma in another patient). Two patients reported about longstanding presbyacusis. At the initial examination, none of the patients reported symptoms of an inflammatory otological disease, and clinical examination was unremarkable in all patients. In conclusion, fluid signal in the mastoid seems to be a frequent incidental finding in asymptomatic patients. A diagnosis of mastoiditis should only be made if there are distinct clinical findings.

Incidental mastoiditis on magnetic resonance imaging scans: clinical relevance and cost implications

Objectives

To determine: (1) the incidence of incidental ‘mastoiditis’ reported on magnetic resonance imaging scans performed in patients with asymmetrical sensorineural hearing loss and/or unilateral tinnitus; (2) how many of those patients have actual otological pathology and/or require treatment; and (3) the financial implications of such a reporting practice.

Method

Retrospective case series.

Results

Between October 2015 and November 2016, 500 patients underwent magnetic resonance imaging of the internal auditory meatus to rule out cerebellopontine angle lesions. There was an incidental finding of increased mastoid signalling in 5.8 per cent (n= 29), of which 20.7 per cent (6 of 29) were reported as bilateral cases. The diagnosis of ‘mastoiditis’ was found in 39.7 per cent (29 of 73). None of these patients had any pathology identified clinically. Other significant pathology was identified in a further 8.8 per cent (n= 44).

Conclusion

The diagnosis of mastoiditis is primarily clinical. An incidental finding of high signalling in the mastoid region on magnetic resonance imaging is highly unlikely to represent actual clinical disease. In patients who are scanned for other reasons and who do not complain of otological symptoms, such findings are unlikely to require otolaryngology input.

Presenting features and imaging in childhood acute myeloid leukemia with central nervous system involvement

Central nervous system (CNS) involvement in childhood acute myeloid leukemia (AML) can manifest as leukemic cells in the cerebrospinal fluid, a solid CNS tumor, or as neurological symptoms. We evaluated the presenting symptoms and neuroimaging findings in 33 of 34 children with AML and CNS involvement at diagnosis in the period 2000-2012 in Sweden, Finland, and Denmark. Imaging was performed in 22 patients, of whom 16 had CNS-related symptoms. Seven patients, including all but two with facial palsy, had mastoid cell opacification, considered an incidental finding. The frequent involvement of the mastoid bone with facial palsy warrants evaluation in larger series.

Does incidental mastoid opacification on computerized tomography necessitate referral to ENT?

OBJECTIVE

The prevalence of incidental temporal bone disease on magnetic resonance imaging has been widely reported in the medical literature. Despite this, there currently is little evidence regarding incidental otological disease on computerized tomography (CT). Thus, the study aimed to review the CT prevalence of asymptomatic adult ear disease and evaluate the appropriateness of ear, nose, and throat (ENT) referral following its discovery.

STUDY DESIGN

Retrospective observational study of 468 CT scans.

METHODS

All CT head scans performed between January 2015 and January 2016 containing the keyword mastoid in the radiological report initially were recruited for the study. Scans performed in the pediatric population following head trauma or for otological indications were excluded, leaving 468 eligible radiological images. The presence of prior otological disease or referral subsequently was established using electronic patient records.

RESULTS

Mastoid and/or middle ear opacification was noted to be present in 62 patients (13%). Of these patients, 10 subsequently were found to have prior otological intervention or review. Following exclusion of these patients, the rate of incidental temporal bone disease was recorded as 11%.

CONCLUSION

Data from this study suggests that incidental findings in an asymptomatic individual do not necessitate referral or further intervention. Furthermore, it is the author's recommendation that radiological findings be closely correlated with clinical examination to reduce false diagnosis and inappropriate referral to ENT.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2860-2865, 2017.