Indications for surgery in acute mastoiditis and their complications in children

Surgical management of mastoiditis with intratemporal and intracranial complications in children. Outcome, complications, and predictive factors

INTRODUCTION

Intratemporal or intracranial complications of acute mastoiditis are often of significant severity, can be life-threatening, and require prompt and usually aggressive treatment. This study focused on analyzing the outcomes and complications of different surgical techniques used in intracranial and intratemporal complications of acute mastoiditis, the most common complication of acute otitis media.

METHODS

A retrospective study of pediatric patients with mastoiditis with intratemporal and intracranial complications was designed at the Niño Jesús University Children's Hospital in Madrid, Spain, from 2005 to 2021.

RESULTS

Of 417 patients with mastoiditis, 112 patients developed intratemporal and intracranial complications, with subperiosteal abscess being the most frequent complication. The most frequently isolated pathogens were Streptococcus pneumoniae, Streptococcus pyogenes, and Fusobacterium necrophorum. The most used surgical technique was myringotomy with placement of transtympanic drainage, in 86.6% of all cases. In patients with intracranial complications, neurosurgical procedures were necessary for 19.2%, with craniotomy with mastoidectomy being the most frequent. Most of the cases evolved favorably, and only 5.4% of the patients required surgical reintervention, being more frequent in intratemporal complications. In terms of complications, we found cases of neutropenia in 3.6%, neurological sequelae in 5.4%, and permanent hearing loss in 2.7%.

CONCLUSIONS

There was a favorable evolution with a low incidence of reoperation and sequelae within our series. The surgical technique of choice correlated with the severity of the complication. If the mean size of the abscess exceeds 20 mm, incision and drainage, along with myringotomy and tube placement, should be considered as the initial treatment. Closed mastoidectomy should be reserved for deteriorating of clinical evolution or acute mastoiditis with intracranial complications. Intracranial and multiple concomitant complications were associated with a more extended hospital stay, ICU occupancy, neurosurgical intervention, and risk of neurological sequelae and neutropenia. Conversely, intratemporal complications may result in permanent hearing loss.

Management of otogene extracranial complications in children and adolescents: report of 35 cases over 10 years

OBJECTIVE

Medical management of exocranial otogenic complications represents a challenge for a medical system of a country in general, especially for ENT services. The goal of this study is to find some answers on demographic data, clinical symptoms and signs, diagnostics, and especially therapy for these complications in young patients.

METHOD

The study is retrospective, performed in the ENT clinic of the University Clinical Center of Kosova in Prishtina and covers 10 years (from 01.06.2000 to 01.06.2010) and includes all young aged patients (1-18 years) hospitalized because of exocranial otogenic complications.

RESULTS

From a total of 35 patients, male were 22 (63%) and females 13 (37%). The commonest complications were: mastoiditis in 18 (51.4%) and subperiosteal mastoidal abscess in 12 cases (34%) than rarest complications were: Bezold's abscess in 2 cases, facial nerve paresis, labyrinthitis, and combined complication one case each. Diagnostics of these cases were based on the clinical appearance, laboratory analyses, and clinical imaging. Treatment of these patients was surgical, medical, and combined: 3 of the medical therapy only (intravenous antibiotics), and 32 others were treated surgically: cortical mastoidectomy in 16 (45%) of cases, mastoidectomy and aeration tube insertion in 6 (17%) and antrotomy in 3 (8.5%) of cases. None of these series of patients died and none of them had permanent sequels.

CONCLUSION

Timely diagnostics and adequate treatment of exocranial otogenic complications made it possible that our results can be comparable with the results of other referent centers cited in the recent literature.

Pediatric temporomandibular joint (TMJ) arthritis, an elusive complication of acute mastoiditis

INTRODUCTION

Septic arthritis of the Temporomandibular joint (TMJ) is a rare complication of acute middle ear infection. Presentation is elusive and could be easily missed. Often diagnosis is made only with consequential development of TMJ ankylosis. This study intends to characterize patients and course of disease and suggest a diagnostic and therapeutic strategy.

METHODS

Retrospective review of all children diagnosed with TMJ arthritis and/or TMJ ankylosis secondary to acute middle ear infection, treated in a tertiary pediatric medical center between the years 2005 and 2021.

RESULT

Seven patients were identified with otogenic TMJ arthritis. Median age at presentation was 1.14 years (IQ range 1.1-1.5). All seven were diagnosed with acute mastoiditis. CT scans demonstrated TMJ related collections in 5/7 and intracranial complications in 3/7. Treatment included cortical mastoidectomy for 5/7. One patient had a concomitant surgical washout of the TMJ. Two patients had drainage only of subperiosteal collections. Six of the seven patients went on to develop TMJ ankylosis that presented within a median of 2.8 years (IQ range 2.6-3.9) after the episode of acute mastoiditis. All six patients presented with trismus and facial growth anomalies, and all but one required surgery to release the ankylosis.

CONCLUSION

Otogenic TMJ arthritis develops mostly in young children with acute mastoiditis and intratemproal and/or intracranial suppuration. Imaging is helpful in making the diagnosis, with TMJ related collections on CT being the most common finding. TMJ ankylosis can develop within a few years and present with trismus and abnormal facial growth. Cortical mastoidectomy does not seem to prevent ankylosis. It remains unclear whether focused treatment to the TMJ or physiotherapy could be beneficial in that.

Management of Acute Complicated Mastoiditis: A Systematic Review and Meta-analysis

BACKGROUND

The objective of our study was to evaluate the efficacy of treatment options for the most frequently reported complications of acute mastoiditis in the English literature. PubMed, EMBASE, and The Cochrane Library were searched from database inception through March 29, 2019.

METHODS

Two independent reviewers (M.R.K., K.S.) evaluated search results for study inclusion. References cited in publications meeting inclusion criteria were reviewed. Twenty-three included studies were published from 1998 through 2018. Treatment efficacy was determined by comparing the change in number of complication subtypes in each treatment subgroup (medical, conservative, or surgical) from admission to discharge (range: 5-30 days) or postdischarge follow-up (range: 1-27.5 months) with a random effects model.

RESULTS

Among 733 identified articles, 23 met inclusion criteria. Of the 883 included patients, 203 were managed medically (23%), 300 conservatively (34%) and 380 surgically (43%). Conservative patients had more extracranial complications (ECC, P = 0.04) and intratemporal complications (IT, P = 0.04) at follow-up compared with medical patients. Medical patients had more total number of complications (TNC, P = 0.03), ECC (P = 0.02), and IT (P = 0.01) at discharge compared with surgical patients. Conservative patients had more of all complications except intracranial/extracranial abscess and "other" at discharge and follow-up compared with surgical patients.

CONCLUSIONS

There were larger reductions in TNC, ECC, and IT at discharge and follow-up among surgical patients compared with medical and conservative patients. There were greater reductions in TNC, ECC, IT, intracranial complications, subperiosteal abscess and lateral sinus thrombosis at discharge and follow-up among surgical patients compared with conservative patients.

Bacterial meningitis complicated by cerebral venous thrombosis

Introduction

Community-acquired bacterial meningitis may be complicated by cerebral venous thrombosis (CVT), but this has not systematically been studied.

Methods

We evaluated clinical characteristics and outcome of CVT in adults with community-acquired bacterial meningitis in a prospective nationwide cohort study of bacterial meningitis (2006–2018) in the Netherlands.

Results

CVT occurred in 26 of 2220 episodes with bacterial meningitis (1%). The diagnosis of CVT was made on the day of presentation in 15 patients (58%) and during hospital stay in 11 patients after a median of 6 days (IQR 2–7). Sinusitis or otitis was present in 16 of 24 patients (67%). Patients with CVT presented more often in a coma than those without CVT (53 vs. 18%; P = 0.001) and the clinical course was more often complicated by focal neurologic deficits (58 vs. 22%; P < 0.001). Twelve patients of 26 (46%) had parenchymal lesions on neuroimaging, of whom two (8%) were specific for CVT. The transverse sinus was most frequently thrombosed (18 of 26; 69%). Streptococcus pneumoniae was the most common causative pathogen, occurring in 17 of 26 patients (65%). Eleven patients (44%) received anticoagulant therapy with heparin and none of them developed intracerebral hemorrhage during admission. Unfavorable outcome, as defined as a score on the Glasgow Outcome Scale <5, occurred in 14 of 26 patients (54%) and 4 patients (15%) died.

Discussion and conclusion

CVT is a rare complication of bacterial meningitis and mainly occurs in patients with coma, ear, nose and throat infections, and focal neurologic deficits.

Pediatric otogenic cerebral venous sinus thrombosis: a case report and a literature review

Background

Cerebral venous sinus thrombosis in children is a rare but potentially fatal complication of acute mastoiditis, one of the most common pediatric infectious diseases. Due to its subtle clinical presentation, suspicion is essential for a prompt diagnosis and appropriate management. Unfortunately, no standard treatment options are available. To discuss the possible clinical presentation, microbiology, and management, we here report the case of a child with otogenic cerebral venous sinus thrombosis and perform a literature review starting from 2011.

Case presentation

The child, a 10-months-old male, presented clinical signs of right acute otitis media and mastoiditis. Brain computed tomography scan detected right sigmoid and transverse sinus thrombosis, as well as a subperiosteal abscess. Fusobacterium necrophorum and Haemophilus Influentiae were detected on cultural sampling. A multidisciplinary approach along with a combination of medical and surgical therapy allowed the patient’s full recovery.

Conclusion

Cerebral venous sinus thrombosis is a rare but severe complication of acute otitis media and mastoiditis. The management of this pathological condition is always challenging and an interdisciplinary approach is frequently required. Current therapeutic options include a combination of medical and surgical therapy. A patient-centered approach should guide timing and treatment management.

The National Landscape of Acute Mastoiditis: Analysis of the Nationwide Readmissions Database

OBJECTIVE

To determine risk factors for readmission, prolonged length of stay, and discharge to a rehabilitation facility in patients with acute mastoiditis. Trends in treatment and complication rates were also examined.

STUDY DESIGN

Retrospective cohort study.

SETTING

Nationwide Readmissions Database (2013, 2014).

PATIENTS

Pediatric and adult patients in the Nationwide Readmissions Database with a primary diagnosis of acute mastoiditis.

INTERVENTIONS

Medical treatment, surgical intervention.

OUTCOME MEASURES

Rates of and risk factors for readmission, prolonged length of stay, and discharge to a rehabilitation facility. Procedure and complication rates were also examined.

RESULTS

Four thousand two hundred ninety-five pediatric and adult admissions for acute mastoiditis were analyzed. The overall rates of readmission, prolonged length of stay, and discharge to a rehabilitation facility were 17.0, 10.4, and 10.2%, respectively. Children 4 to 17 years of age had the highest rates of intracranial complications, and children ≤3 years were most likely to undergo operative intervention. Any procedure was performed in 31.2% of cases, and undergoing myringotomy or mastoidectomy was associated with lower rates of readmission but higher rates of prolonged length of stay. Those with intracranial complications and subperiosteal abscesses had the highest surgical intervention rates.

CONCLUSIONS

Readmission, prolonged length of stay, and discharge to a rehabilitation facility are common in patients with acute mastoiditis with various sociodemographic and disease-related risk factors. While once a primarily surgical disease, a minority of patients in our cohort underwent procedures. Undergoing a surgical procedure was protective against readmission but a risk factor for prolonged length of stay.

Acute mastoiditis in children

Acute mastoiditis is the most common complication of acute otitis media. Although rare, the disease is carefully studied by otolaryngologists because it usually affects very young children with severe clinical course and sometimes causes serious complications. Most important risk factors are the young age (often>2 years), high fever, alteration of the laboratory findings (very high values of WBC count, absolute neutrophil count and C-reactive protein), while less important are previous antibiotic therapy or previous middle ear infections. The main pathogen of the acute mastoiditis is Streptococcus pneumoniae, followed by Streptococcus piogenes, Haemophilus influentiae, and Staphylococcus aureus. The finding of Pseudomonas aeruginosa is not uncommon, but often its presence is often considered a contamination or simultaneous infection. The complications can be extracranial (subperiosteal abscess, Bezold's abscess); intratemporal (facial nerve palsy, labyrinthitis) and intracranial (subdural abscess). The complications have often a very serious clinical course and potentially life-threatening. Antibiotic therapy is the main treatment in not complicated forms. Considering the prevalence of Streptococcus pneumoniae, cephalosporins are the antibiotic of choice, but they have to be administrated intravenously in hospitalized patients. Combinations with other antibiotic are suggested when multibacterial flora is present. In complicated forms of acute mastoiditis, the antibiotic treatment can be particularly important, in combination with other specific drugs (i.e. anticoagulants and/or corticosteroids). Surgical treatments, such as incision of abscesses, mastoidectomy, and neurosurgical procedures, are sometimes performed in combination with medical therapy in very severe complications. Data from our experience are briefly reported.

Gradenigo's syndrome with abscess of the petrous apex in pediatric patients: what is the best treatment?

BACKGROUND

Gradenigo's syndrome is defined by the classic clinical triad of ear discharge, trigeminal pain, and abducens nerve palsy. It has become a very rare nosological entity after the introduction of antibiotics, so that has been defined as the "forgotten syndrome." However, the underlying pathological process (apical petrositis) still represents a life-threatening condition that shall be immediately recognized in order to address the patient to the proper therapy. The therapy itself may be an argument of discussion: on a historical background ruled by surgery, reports of successful conservative antibiotic treatment have risen in recent years.

METHODS AND RESULTS

We reported a case of Gradenigo's syndrome in a child with an abscess of the left petrous apex and initial involvement of the carotid artery. After multidisciplinary evaluation, we decided to encourage conservative treatment, until complete regression was observed.

DISCUSSION

The available literature of the last 10 years was reviewed, with particular attention to the presence of an apical abscess and the therapeutic approach. The principles of management with regard to conservative therapy versus surgical indications are therefore examined and discussed.

Therapeutic approach to pediatric acute mastoiditis – an update

Introduction

Acute mastoiditis remains the most common complication of acute otitis media. It may rarely appear also in cochlear implant patients. However, the treatment recommendations for this disease are not precisely defined or employed, and in the current literature the differences regarding both the diagnosis and management are relatively substantial.

Objective

The aim of this study was to determine a standard and safe procedure to be applied in case of pediatric acute mastoiditis.

Methods

A retrospective chart review of 73 patients with 83 episodes of acute mastoiditis hospitalized at our tertiary-care center between 2001 and 2016 was conducted. Bacteriology, methods of treatment, hospital course, complications, and otologic history were analyzed. Based on our experience and literature data, a protocol was established in order to standardize management of pediatric acute mastoiditis.

Results

All the patients treated for acute mastoiditis were submitted to an intravenous antibiotic regimen. In the analyzed group pharmacological treatment only was applied in 11% of children, in 12% myringotomy/tympanostomy was added, and in the vast majority of patients (77%) mastoidectomy was performed. In our study recurrent mastoiditis was noted in 8% of the patients. We also experienced acute mastoiditis in a cochlear implant child, and in this case, a minimal surgical procedure, in order to protect the device, was recommended.

Conclusions

The main points of the management protocol are: initiate a broad-spectrum intravenous antibiotic treatment; mastoidectomy should be performed if the infection fails to be controlled after 48 h of administering intravenous antibiotic therapy. We believe that early mastoidectomy prevents serious complications, and our initial observation is that by performing broad mastoidectomy with posterior attic and facial recess exposure, recurrence of acute mastoiditis can be prevented.

Acute mastoiditis: 20 years of experience with a uniform management protocol

OBJECTIVES

To characterize the clinical presentation of pediatric patients who, upon AM diagnosis, also had imaging-diagnosed ICCs (ID-ICCs); to define the group of AM patients at risk of developing ID-ICCs; and to update knowledge about organisms causing AM.

STUDY DESIGN

Analysis of all AM patients admitted between 1997 and 2018 and treated according to an obligatory protocol including both brain imaging and sampling for bacterial culture upon clinical diagnosis of AM.

RESULTS

Of 166 admitted patients (0.5-19 years old) 22 (13%) already had ID-ICCs. In patients who, on admission, had already received antibiotics for acute otitis media (AOM) and also had CRP (C-reactive protein) levels above 93.5 mg/L, the risk of ID-CC was increased by 22.5-fold (P < 0.0001). Bacterial culture results were available for all patients and were positive in 115 (69%). Organisms most commonly found in patients without prior antibiotic treatment were group A Streptococcus pyogenes (53%), Streptococcus pneumoniae (23%), and Haemophylus influenzae (11%), while with prior antibiotic treatment they were Fusobacterium necrophorum (21%), Streptococcus pyogenes (18%) and Pseudomonas aeruginosa (18%).

CONCLUSIONS

Since the risk of ID-ICC in patients with the abovementioned CRP and prior antibiotic treatment was significantly higher than in the others, these high-risk patients should undergo diagnostic imaging on admission. Antibiotic treatment prior to AM development may promote growth of non-AOM pathogen.

Safety and postoperative adverse events in management of acute mastoiditis in children - 30 Day NSQIP outcomes

OBJECTIVE

To examine preoperative risk factors, postoperative 30-day outcomes and adverse events of acute mastoiditis using a national pediatric surgical database.

METHODS

We explored our objectives using a cross-sectional analysis of a hospital-based reporting system database. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) pediatric database was used to identify surgical encounters for the treatment of acute mastoiditis from 2012 to 2015. Patient demographics, co-morbidities, laboratory values, surgical details, complications, and outcomes were tabulated. Linear regression was used to determine predictors of prolonged hospital stay based on pre-operative, surgical and outcome variables.

RESULTS

113 patients with acute mastoiditis were identified from with mean age of 7.8 years. Mastoidectomy was the most common index procedure performed (44; 34%). Average hospital stay length was 5.2 days. No patients died within 30 days. 4 (3.1%) patients required readmission, and 9 (6.9%) required unplanned subsequent operative procedures. Pre-operative presence of sepsis or systemic inflammatory response syndrome (SIRS; p = 0.03), and unplanned additional procedures were associated with a prolonged hospital stay (p = 0.03), but age, gender, race, and pre-operative morbidities were not (p > 0.05).

CONCLUSIONS

Contemporary surgical management of acute mastoiditis in children appears to be safe. Mortality is rare and has been potentially eliminated as a complication. Rates of pre-operative systemic infection were very high, despite current antibiotic utilization trends. Opportunities for quality improvement exist to investigate how to decrease rates of preoperative sepsis, limit readmissions, and unplanned re-operations. The role of mastoidectomy appears prominent, as it was used in about two-thirds of cases.

LEVEL OF EVIDENCE

4.

Early signs and symptoms of intracranial complications of otitis media in pediatric and adult patients: A different presentation?

OBJECTIVES

The aim of this study was to review the clinical presentation and early signs and symptoms of otogenic intracranial complications (OIC) in children and adults.

METHODS

retrospective chart review. The medical records of all children and adults admitted in our center with OIC during the period 2008-2017 were reviewed. Data concerning clinical presentation, treatment and outcomes were reviewed and analyzed.

RESULTS

We included 47 patients with OIC: 21 children (range 1-13 years) and 26 adults (range 22-71 years). We included more patients with acute otitis media than with chronic otitis media (children 5% adults 19%, all with cholesteatoma). In children; the most common OIC was central cerebral venous thrombosis. In both children and adults; otogenic symptoms such as otalgia and otorrhea were present. Children presented more frequently with headache and nausea. Adults presented more frequently with decreased consciousness. Hearing loss was the most common long-term sequel. Three adults died.

CONCLUSIONS

In our series, we found that OIC in children present as 'mimicking meningitis' (e.g. nausea and vomiting). Adults on the other hand have a clinical presentation 'mimicking stroke' (e.g. neurological deficits and decreased level of consciousness). In children, sinus thrombosis was observed more frequently than in adults. Despite the low mortality rate, death still occurs. Long -term sequelae most frequently include hearing loss in children as well as in adults.

Outpatient management of pediatric acute mastoiditis

OBJECTIVE

Evaluate the Montreal Children's Hospital experience with outpatient management of uncomplicated acute mastoiditis with parenteral antibiotic therapy alone and determine if it is a safe alternative to inpatient management.

SUBJECTS AND METHOD

A retrospective review of pediatric patients diagnosed with acute mastoiditis at a tertiary care pediatric hospital between 2013 and 2015 was performed. Patients with syndromes, immunodeficiency, cholesteatoma, chronic otitis media, cochlear implant in the affected ear, or incidental mastoid opacity were excluded.

RESULTS

56 children age 6 months to 15 years old were treated for acute mastoiditis, including 29 hospitalizations and 27 outpatients. Patients managed as outpatient with daily intravenous ceftriaxone had a 93% cure rate. Eighteen hospitalized and one outpatient had complications of acute mastoiditis. Children with complications were more likely to be febrile (p = 0.045). Two patients failed outpatient therapy and were admitted; one for myringotomy and piperacillin-tazobactam treatment and one required a mastoidectomy. 4/27 children treated as outpatient underwent myringotomy and tube insertion, 2 underwent myringotomy and tube along with admission and 21 did not require tube insertion. The average total duration of intravenous antibiotic therapy was respectively 4.9 and 18.9 days in the outpatient and hospitalized group. The average duration of admission was 5.9 days.

CONCLUSION

Outpatient medical therapy of uncomplicated pediatric mastoiditis is safe, successful, and efficient. Benefits include efficient use of surgical beds, cost savings and patient and family convenience. Careful patient selection and close monitoring are keys for successful outcome.

Management of paediatric acute mastoiditis: systematic review

Background:

Acute mastoiditis remains the commonest intratemporal complication of otitis media in the paediatric population. There has been a lack of consensus regarding the diagnosis and management of acute mastoiditis, resulting in considerable disparity in conservative and surgical management.

Objectives:

To review the current literature, proposing recommendations for the management of paediatric acute mastoiditis and appraising the treatment outcomes.

Method:

A systematic review was conducted using PubMed, Web of Science and Cochrane Library databases.

Results:

Twenty-one studies were included, with a total of 564 patients. Cure rates of medical treatment, conservative surgery and mastoidectomy were 95.9 per cent, 96.3 per cent and 89.1 per cent, respectively.

Conclusion:

Mastoidectomy may be the most definitive treatment available; however, reviewed data suggest that conservative treatment alone has high efficacy as first-line treatment in uncomplicated cases of acute mastoiditis, and conservative therapy may be an appropriate first-line management when treating acute mastoiditis.

Current concepts in the pathogenesis and treatment of chronic suppurative otitis media

Otitis media (OM) is an inflammation of the middle ear associated with infection. Despite appropriate therapy, acute OM (AOM) can progress to chronic suppurative OM (CSOM) associated with ear drum perforation and purulent discharge. The effusion prevents the middle ear ossicles from properly relaying sound vibrations from the ear drum to the oval window of the inner ear, causing conductive hearing loss. In addition, the inflammatory mediators generated during CSOM can penetrate into the inner ear through the round window. This can cause the loss of hair cells in the cochlea, leading to sensorineural hearing loss. Pseudomonas aeruginosa and Staphylococcus aureus are the most predominant pathogens that cause CSOM. Although the pathogenesis of AOM is well studied, very limited research is available in relation to CSOM. With the emergence of antibiotic resistance as well as the ototoxicity of antibiotics and the potential risks of surgery, there is an urgent need to develop effective therapeutic strategies against CSOM. This warrants understanding the role of host immunity in CSOM and how the bacteria evade these potent immune responses. Understanding the molecular mechanisms leading to CSOM will help in designing novel treatment modalities against the disease and hence preventing the hearing loss.

Diseases of the middle ear in childhood

Middle ear diseases in childhood play an important role in daily ENT practice due to their high incidence. Some of these like acute otitis media or otitis media with effusion have been studied extensively within the last decades. In this article, we present a selection of important childhood middle ear diseases and discuss the actual literature concerning their treatment, management of complications and outcome. Another main topic of this paper deals with the possibilities of surgical hearing rehabilitation in childhood. The bone-anchored hearing aid BAHA(®) and the active partially implantable device Vibrant Soundbridge(®) could successfully be applied for children. In this manuscript, we discuss the actual literature concerning clinical outcomes of these implantable hearing aids.

Two cases of acute mastoiditis with subperiosteal abscess

The incidence of mastoiditis in pediatric age has consistently increased over the last two decades due to increase of antibiotic-resistant bacteria. Compared to young patients, occurrence of acute otitis media complications such as acute mastoiditis and subperiosteal abscess is relatively low in adults. Various treatments for acute mastoiditis with subperiosteal abscess such as tympanostomy tube insertion, intravenous antibiotics, and postauricular incision and drainage have avoided the morbidity and necessity of mastoid surgery. Recently, many studies have indicated mastoidectomy only in cases of severe complications or failure of disease improvement after antibiotic treatment and myringotomy. In this report, we present two cases of successful treatment of subperiosteal abscess and discuss the management of acute mastoiditis with subperiosteal abscess in both child and adult.

Bilateral acute mastoiditis and subperiosteal abscesses in a child managed by simultaneous bilateral mastoid surgery

Objective:

We report a case of bilateral acute mastoiditis and subperiosteal abscesses successfully managed with simultaneous surgery.

Method:

A case report and literature review are presented.

Results:

A two-year-old boy presented with fever, otalgia, otorrhoea and bilateral protruding ears. He was treated for 72 hours with intravenous antibiotics but failed to improve. Computed tomography confirmed bilateral mastoid abscesses with destruction of the mastoid cortex. Bilateral drainage of the subperiosteal abscesses and bilateral cortical mastoidectomies were carried out. Post-operatively, he recovered well, and free field audiometry showed a normal hearing threshold of 20 dB across all test frequencies.

Conclusion:

This is only the second reported case of bilateral mastoiditis and subperiosteal abscesses. This case illustrates the use of bilateral cortical mastoidectomy in the successful management of this condition following failed antibiotic therapy, and highlights important management considerations.

Algorithmic management of pediatric acute mastoiditis

OBJECTIVE

Today, no uniformly accepted diagnostic and therapeutic criteria have been established for the management of pediatric acute mastoiditis. The aim of this study is determine the efficacy and safety of an algorithmic approach for treating pediatric acute mastoiditis.

METHODS

The medical records of all children (n=167) with a diagnosis of AM admitted in our center during the period 2002-2010 were retrospectively studied. Data concerning medical history, symptomatology, laboratory and imaging findings, presence of complications, treatment methods and final outcomes were reviewed and analyzed. Parenteral antibiotics and myringotomy were applied to all children on the day of admission. Initial surgical approach also included drainage or simple mastoidectomy for subperiosteal abscesses and simple mastoidectomy for children suffering from intracranial complications. Finally, simple mastoidectomy was performed as a second line treatment in children showing poor response to the initial conservative approach.

RESULTS

All children were cured after a mean hospitalization of 9.8 days. The rate of intracranial complications at admission was 6.5% and the overall rate of the use of mastoidectomy 42%. Following the presented treatment scheme in all cases, no child developed additional complications while in-hospital and under treatment or after discharge.

CONCLUSIONS

Although simple mastoidectomy represents the most reliable and effective surgical method to treat acute mastoiditis, a more conservative approach consisting of adequate parenteral antibiotic coverage and myringotomy can be safely adopted for all children suffering from uncomplicated acute mastoiditis. Non-responsive cases should undergo simple mastoidectomy within 3-5 days in order to avoid further in-hospital acquired complications. Simple mastoidectomy should also be performed in every case of unsuccessful subperiosteal abscess drainage or presence of intracranial complications.

Acute mastoiditis in children: a retrospective study of 188 patients

OBJECTIVE

The aim of this study is to define the clinical and bacteriological characteristics of acute mastoiditis (AM) in children in order to optimize diagnostic work-up and treatment.

METHODS

In this retrospective study, 188 children between 3 months and 15 years of age (15±24 months; median±SD) were referred to our pediatric ENT emergency center for AM during a 7-year period (December 2001-January 2008).

RESULTS

Fifty seven percent were male and 43% were female. Clinical follow-up duration was 3.9±0.7 months (mean±SEM). The incidence of AM remained stable during the whole study period. Microbiological samples (n=236) were negative in 33% of cases. The most frequently isolated germs were Streptococcus pneumoniae (51%), Streptococcus pyogenes (11.5%), Anaerobes (6.5%), and coagulase-negative Staphylococcus (6.5%). Paracentesis, puncture of retro auricular abscess under local anesthesia, and peroperative samples all contributed to isolate the involved germ(s). All the patients were hospitalized and received intravenous antibiotics, and 36.2% (n=68) underwent surgery. Several surgical procedures were necessary in 4 cases (2.1%). AM recurrences requiring a second hospitalization were observed in 8 patients (4.3%). The only observed complication was lateral sinus thrombosis (n=6; 3.2%). Surgical failures, requiring more than one surgical procedure, were more frequent in case of: (i) presence of Anaerobes (p≤0.001) or Gram-negative bacteria (p≤0.05) in microbiological samples; (ii) surgical drainage without mastoidectomy (p≤0.001). Recurrences were more frequent in AM due to Streptococcus pneumoniae.

CONCLUSIONS

Based on our findings and on literature data, a protocol was established in order to standardize the management of pediatric AM in our center. The mains points are: no systematic surgery; if surgery is indicated, it must encompass a mastoidectomy; broad-spectrum intravenous antibiotic treatment covering the most commonly involved germs (3rd generation cephalosporin) and secondarily adapted to the results of microbiological samples. If the infection is not controlled after 48 h of intravenous antibiotherapy, a mastoidectomy had to be performed.

[Acute mastoiditis in the pneumococcal vaccine era]

INTRODUCTION AND OBJECTIVES

Acute mastoiditis is the most common complication of acute otitis media. Recent studies have noticed an increase in cases. The goal of this study was to review acute mastoiditis cases diagnosed in children younger than 14 years old.

MATERIAL AND METHODS

A retrospective study of all patients under 14 years old admitted with a diagnosis of mastoiditis between 1996 and 2008 was performed. Epidemiological, laboratory and clinical variables were analysed.

RESULTS

Sixty-one charts were reviewed. The mean age was 28 months; 55.7% of the patients were male. Most cases were in the autumn and winter; 79% occurred from 2002 to 2008. Most cases (82%) had antecedents of an upper airway catarrhal process and 60.7% had a clinical diagnosis of acute otitis media. Prior antibacterial agent therapy had been administered in 55.7% of the cases. Culture of middle ear effusions was performed in 48 patients, revealing Streptococcus pneumonia in 39.7%, Haemophilus influenzae in 2%, Staphylococcus aureus in 12.5% and Pseudomonas aeruginosa in 8.3%. Cultures were sterile in 18 patients (37.5%). Of the pneumococcal isolates, 26.2% were resistant to penicillin or third generation cephalosporins. Most cases (93.4%) responded well to antibacterial therapy alone or with myringotomy. There were complications in 7 patients (11.5%). Mastoid surgery was performed in 4 patients.

CONCLUSIONS

Acute mastoiditis shows a rising incidence in recent years. The most commonly isolated form is the pneumococcus, the high rates of antibiotic resistance in our study being notable. Treatments with antibiotics alone or in combination with myringotomy are effective in less severe forms.

[Acute mastoiditis: experience in a tertiary-care center in the South of Spain during 1999-2008 period]

INTRODUCTION

An increase in both the incidence and severity of acute mastoiditis (AM) has been recently recorded in many different geographical areas. Causes remain unclear. This study aims to evaluate our clinical and epidemiological data in paediatric patients with AM and to compare them with recent reports.

MATERIAL AND METHODS

Retrospective chart review of 145 patients diagnosed of AM from 1999 to 2008 in our tertiary-care centre, including clinical, epidemiological, microbiological, treatment and outcome data.

RESULTS

The annual incidence showed a changeable trend throughout the study period. The average number of cases was 14.5 cases per year, with a median age of 3 years, and 57.9% males. A total of 53.8% received pre-admission oral antibiotics, mainly beta-lactamics. Most frequent presenting clinical findings were fever (77.9%), ear displacement (73.8%), otalgia (71.7%), and postauricular swelling (70.3%). Microbiological cultures were performed in 53 cases; S. pneumoniae was the most isolated microorganism. CT scans were performed in 56.6% cases. All patients received parenteral antibiotic treatment with a median duration of treatment of 5 days. Surgery was performed on 32.6%. Complications were seen in 20% of patients: 13.1% had extracranial complications, and 8.2% had intracranial complications. A significant increase in intracranial complications was detected in the second half of the study period.

CONCLUSIONS

A changeable trend in the annual incidence of AM throughout the time of study was observed. A higher proportion of intracranial complications was detected in the last five years of the study period.

Mastoid subperiosteal abscess as a first sign of unnoticed cholesteatoma in children

AIM

To present children who underwent mastoidectomy for congenital cholesteatoma presented as a subperiosteal abscess.

RESULTS

All seven children (age range 7-14 years, six boys) presented with retroauricular swelling, erythema and fluctuation in the mastoid area, and one child also had a mastoid-cutaneous fistula. Five children had otorrhoea, while the other two had normal-appearing tympanic membranes. None of the children had a history of middle ear disease. Four children were treated with antibiotics for a recent episode of otitis media prior to admission. The main findings at surgery were pus, granulations and erosion of the mastoid cortex. Pseudomonas aeruginosa and Proteus sp. were isolated from the abscess in two patients, and the other five cultures were negative. All the patients demonstrated some degree of hearing impairment after surgery.

CONCLUSION

Surgical eradication of a mastoid SA in older children is essential as it may be the first indication of an underlying CC.

Mastoiditis in a paediatric population: a review of 11 years experience in management

OBJECTIVE

This study explores the experience at Sydney Children's Hospital (SCH) managing children with acute mastoiditis and establishes a robust treatment algorithm.

METHODS

Retrospective review of all patients admitted to SCH with an ICD-10 coding of "Mastoiditis" from 1 January 1996 through 31 December 2006 inclusive. Criteria assessed included demographic characteristics, clinical features, symptom duration and treatment initiated by the general practitioner. The results of investigations at SCH were reviewed including white blood cell count, microbiology and imaging. The presence of complications was determined and the results of medical and surgical treatment were assessed.

RESULTS

Seventy-nine episodes of acute mastoiditis were managed in 76 patients. Treatment prior to SCH was commenced by the family practitioner or district hospital doctor in 53/79 patients. The mean duration of community initiated treatment before presentation to SCH was 3.7 days. In 33 episodes a previous history of acute otitis media was noted (42%). In the remaining 46 episodes (58%) mastoiditis was the initial diagnosis. Complications were found in 30 episodes (38%) and 36 episodes (46%) required surgical treatment.

CONCLUSIONS

Mastoiditis often develops rapidly but may be treated very effectively. The potential for significant morbidity remains high but excellent outcomes can be expected for those who are managed without delay. Children with acute mastoiditis should be managed in centres where timely and complete medical and surgical treatment is available.

Lateral sinus thrombosis in the pediatric population: multiple presentations for a potentially lethal disease

Lateral sinus thrombosis complicating head and neck infections is a rare but potentially life-threatening condition.We report 4 pediatric cases of lateral sinus thrombosis occurring in different settings (2 patients with acute otitis media, 1 patient with chronic otitis media, and another with acute tonsillitis) to emphasize the nonspecific clinical presentation of this complication. In all our cases, early diagnosis was missed.Keeping a high index of suspicion when dealing with these infections is a reasonable approach.

Preoperative and postoperative intracranial complications of acute mastoiditis

OBJECTIVES

We determined the clinical characteristics and treatment outcomes of an unusual cluster of intracranial complications seen in acute mastoiditis (AM).

METHODS

We performed a retrospective review of pediatric patients treated for AM in a tertiary care hospital from March 2006 to March 2007.

RESULTS

Eleven children, 6 months to 10 years of age (mean age, 3.8 years), were treated for AM confirmed by computed tomography, which identified asymptomatic intracranial complications in 8 of the 11 patients: these were sigmoid sinus thrombosis (4 patients), epidural abscess (4), perisigmoid abscess or bony erosion (2), and tegmen mastoideum dehiscence (1). All patients required operative intervention with tympanomastoidectomy, although only 2 patients required neurosurgical intervention, consisting of evacuation of epidural abscess and sigmoid sinus thrombosis, respectively. Cultures yielded routine organisms and 1 multidrug-resistant strain of Streptococcus pneumoniae. One patient developed reaccumulation of the subperiosteal abscess that required revision mastoidectomy, and another patient developed postoperative sigmoid sinus thrombosis.

CONCLUSIONS

Although uncommon, intracranial complications of AM may present without clinical signs or symptoms. Computed tomography of the temporal bone with contrast is essential for identifying asymptomatic complications. Mastoidectomy remains the mainstay of surgical treatment. Neurosurgical intervention and anticoagulation may be avoided with protracted postoperative intravenous antibiotics. Postoperative vigilance is crucial, as complications may evolve despite aggressive therapy.

Common respiratory infections diagnosed in general practice

Acute respiratory infections are one of the most common causes for presentation to a general practitioner. The range of symptoms associated with each infection can be wide ranging in both presentation and severity, depending on age of the patient, underlying co-morbidities and other confounding factors. In this chapter we describe the most common respiratory infections ranging from relatively mild infections such as the common cold, through to more serious presentations including pneumonia. Data are presented from a general practitioner morbidity surveillance system based in England and Wales. Each acute respiratory syndrome is described in respect of seasonality, secular trends and microbiological aetiology providing an insight into the complex nature of these acute respiratory episodes. The more serious endpoints of acute respiratory infections are hospitalisation and death. Many acute respiratory infections are mild in nature and generally self-limiting and therefore do not commonly require further medical interventions. However, despite major advances in the prevention and treatment of acute respiratory infections in recent years, hospitalisation and deaths continue to exert pressures on national health resources and provide an economic burden in countries across the world on an annual basis.

[Complications of acute mastoiditis in children]

OBJECTIVE

The incidence of complications resulting from acute otitis media has significantly decreased since the introduction of antibiotics. The use of antibiotics has lead to decrease in the complications of acute mastoiditis as well as the mortality of the disease. The purpose of the study was to review our experience in the diagnosis and treatment of complications of acute mastoiditis in children. Study design. Retrospective clinical study.

MATERIAL AND METHODS

We present a retrospective study of 70 children with extracranial and intracranial complications of acute mastoiditis who were treated in the period from 1968 to 2006 at Department of Otolaryngology, Medical University of Gdansk. Their treatment has been documented with long period of otologic follow-up.

RESULTS

Extracranial complications occurred in 41 (30.4%) of treated acute mastoiditis cases, and subperiostal abscess was the commonest one in 37 (90.2%) patients. Intracranial complications occurred in 29 (21.4%) of acute mastoiditis cases and facial paralysis was the commonest one in 14 (40.0%) cases, followed by sigmoid sinus thrombosis and perisinus abscess. Ear cultures grew in patients with otogenic complications, the most often Staphylococcus aureus, Streptococcus sp. and Pseudomonas aeruginosa were found. Mastoidectomy with myringotomy resolved the disease in 46 (65.7%) children, only myringotomy in 6 (8.6%) and canal wall down mastoidectomy in 18 (25.7%) children. Complete resolution was achieved in all cases.

CONCLUSION

The persistent othorrea, otalgia and headache, prolonged high fever, neurological signs were the most common symptoms associated with the development of intracranial complications of acute mastoiditis in children. Computed tomography and MRI are necessary tools for diagnosis and surgery planning in every case of latent mastoiditis. Antibiotic treatment of acute mastoiditis does not prevent otogenic complications. Extracranial or intracranial complications of acute mastoiditis need surgical treatment and prolonged antibiotic therapy. The present study found evidence for decreased incidence of mastoiditis and their suppurative complications during last years.

Acute mastoiditis in children: the "Ferrara" experience

OBJECTIVE

This study aims to investigate the clinical features and outcomes of acute mastoiditis in children referred to the ENT/Audiology Department of the University of Ferrara from January 1994 to December 2005. It also aims to discuss risk factors and to find predictors for surgery.

METHODS

A retrospective study on case sheets of children with an acute mastoiditis diagnosis was carried out. Fifty-five cases fulfilled the inclusion criteria: they presented otoscopical evidence of acute otitis media and inflammatory findings of the mastoid area such as post-auricular swelling, redness or tenderness, protrusion of the auricle and/or radiological findings.

RESULTS

Twenty-six patients were only treated with antibiotic therapy, tympanocentesis alone was performed in 11 cases; in 5, a ventilation tube was positioned. Mastoidectomy was performed in 13 patients. The group who underwent mastoidectomy had a median hospital stay of 15 days (5-54), in this group were found the following complications: 1 meningitis, 1 meningo-encephalitis, 1 lateral and sigmoid sinus thrombosis, 1 facial palsy.

CONCLUSION

the incidence of otomastoiditis does not seem to be decreasing, on the contrary, in some countries, it seems to be on the increase. Our experience cannot confirm a real increase of the incidence but we noted periodic variations during the time of observation. It is important, that careful attention is paid to the clinical assessment of children who are 2-years old or under, as they seem to be more exposed to the risk of clinical complications; therefore, it is highly recommended that the otologist and the paediatrician collaborate closely.

What is new in otitis media?

The "wait and see" approach in acute otitis media (AOM), consisting of postponing the antibiotic administration for a few days, has been advocated mainly to counteract the increased bacterial resistance in respiratory infections. This approach is not justified in children less than 2 years of age and this for several reasons. First, AOM is an acute inflammation of the middle ear caused in about 70% of cases by bacteria. Redness and bulging of the tympanic membrane are characteristic findings in bacterial AOM. Second, AOM is associated with long-term dysfunction of the inflamed eustachian tube (ET), particularly in children less than 2 years of age. In this age group, the small calibre of the ET together with its horizontal direction result in impaired clearance, ventilation and protection of the middle ear. Third, recent prospective studies have shown poor long-term prognosis of AOM in children below 2 years with at least 50% of recurrences and persisting otitis media with effusion (OME) in about 35% 6 months after AOM. Viruses elicit AOM in about 30% of children. A prolonged course of AOM has been observed when bacterial and viral infections are combined because viral infection is also associated with ET dysfunction in young children. Bacterial and viral testing of the nasopharyngeal aspirate is an excellent tool both for initial treatment and recurrence of AOM. Antibiotic treatment of AOM is mandatory in children less than 2 years of age to decrease inflammation in the middle ear but also of the ET particularly during the first episode. The best choice is amoxicillin because of its superior penetration in the middle ear. Streptococci pneumoniae with intermediary bacterial resistance to penicillin are particularly associated with recurrent AOM. Therefore the dosage of amoxicillin should be 90 mg/kg per day in three doses. In recurrent AOM with beta-lactamase-producing bacilli, amoxicillin should be associated with clavulanic acid at a dose of 6.4 mg/kg per day. The duration of the treatment is not established yet but 10 days is reasonable for a first episode of AOM. OME may be a precursor initiating AOM but also a complication thereof. OME needs a watchful waiting approach. When associated with deafness for 2-3 months in children over 2 years of age, an antibiotic should be given according to the results of the bacterial resistance in the nasopharyngeal aspirate. The high rate of complications of tympanostomy tube insertion outweighs the beneficial effect on hearing loss. The poor results of this procedure are due to the absence of effects on ET dysfunction. Pneumococcal vaccination has little beneficial effects on recurrent AOM and its use in infants needs further studies. Treatment with amoxicillin is indicated in all children younger than 2 years with a first episode of AOM presenting with redness and bulging of the tympanic membrane. Combined amoxicillin and clavulanic acid should be given in patients with beta-lactamase-producing bacteria. The duration of treatment is estimated to be at least 10 days depending on the findings by pneumo-otoscopy and tympanometry. Bacterial and viral testing of the nasopharyngeal aspirate is highly recommended particularly in children in day care centres as well as for regular follow-up. The high recurrence rate is due to the long-lasting dysfunction of the eustachian tube and the immune immaturity of children less than 2 years of age.