1
|
Bridwell RE, Koyfman A, Long B. High risk and low prevalence diseases: Acute mastoiditis. Am J Emerg Med 2024; 79:63-69. [PMID: 38368849 DOI: 10.1016/j.ajem.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/20/2024] Open
Abstract
INTRODUCTION Acute mastoiditis is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of mastoiditis, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Acute mastoiditis most commonly affects pediatric patients and is a suppurative infection of the mastoid air cells. It is often associated with otitis media, and common bacteria include Streptococcus and Staphylococcus. History and examination may reveal tympanic membrane erythema, pinna protrusion, postauricular erythema, mastoid tenderness with palpation, external canal swelling, otorrhea, fever, and malaise. The disease should be suspected in those who fail treatment for otitis media and those who demonstrate the aforementioned abnormalities on examination and systemic symptoms. Laboratory analysis may reveal evidence of systemic inflammation, but a normal white blood cell count and other inflammatory markers should not be used to exclude the diagnosis. Computed tomography (CT) of the temporal bones with intravenous contrast is the recommended imaging modality if the clinician is unsure of the diagnosis. CT may also demonstrate complications. Treatment includes antibiotics such as ampicillin-sulbactam or ceftriaxone as well as otolaryngology consultation. Complications may include subperiosteal and intracranial abscess, deep neck abscess, facial nerve palsy, meningitis/encephalitis, venous sinus thrombosis, and seizures. CONCLUSIONS An understanding of acute mastoiditis can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
Collapse
Affiliation(s)
- Rachel E Bridwell
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| |
Collapse
|
2
|
Ziv O, Sapir A, Leibovitz E, Kordeluk S, Kaplan DM, El-Saied S. Post-operative clinical course in children undergoing mastoidectomy due to complicated acute mastoiditis. Eur Arch Otorhinolaryngol 2021; 279:3891-3897. [PMID: 34714371 DOI: 10.1007/s00405-021-07149-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/19/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE To determine the immediate post-operative course and outcome of pediatric patients with complicated acute mastoiditis (CAM) following surgical treatment. METHODS A retrospective chart review of children diagnosed with CAM who underwent mastoid surgery during 2012-2019 in a tertiary care university hospital. 33 patients, divided into 2 groups: 17 patients with sub-periosteal abscess (SPA) alone-single complication group (SCG) and 16 patients with SPA and additional complications: sigmoid sinus thrombosis (SST), peri-sinus fluid/abscess, epidural/subdural abscess, and acute meningitis-multiple complications group (MCG). RESULTS 33 patients belong to the SCG 17(51%) and 16(49%) belonged to the MCG, respectively. 6/17(35.3%) SCG patients experienced POF vs. 12/16(75%) in the MCG (P = 0.012). At post-operative day 2 (POD2), 10/13(77%) febrile patients belonged to MCG and 3/13(23%) to SCG (P = 0.013). POF was recorded until POD6 in both groups. Seven patients, all from MCG with POF, underwent second imaging with no new findings; a total of 18 positive cultures were reported. Fusobacterium necrophorum counted for 8/18(44.5%) of all positive cultures, 7/9(77.8%) in the MCG vs. 1/9(11.1%) in the SCG, P = 0.004. Streptococcus pneumoniae was reported only in SCG (5/9, 55.5%, vs. 0/9, P = 0.008). CONCLUSION Post-mastoidectomy fever due to CAM is not unusual and seems to be a benign condition for the first 5-6 days, following surgery. MCG patients are more prone to develop POF. F. necrophorum is more likely to be associated with MCG, and S. pneumoniae is common in SCG patients.
Collapse
Affiliation(s)
- Oren Ziv
- Department of Otolaryngology-Head and Neck Surgery, Ben-Gurion University, Beer-Sheva, Israel.,ENT Department, Soroka University Medical Center, 151, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Aviad Sapir
- Department of Otolaryngology-Head and Neck Surgery, Ben-Gurion University, Beer-Sheva, Israel. .,ENT Department, Soroka University Medical Center, 151, Beer Sheva, Israel. .,Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel.
| | - Eugene Leibovitz
- Pediatric Infectious Disease Unit, Ben-Gurion University, Beer-Sheva, Israel.,ENT Department, Soroka University Medical Center, 151, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Sofia Kordeluk
- Department of Otolaryngology-Head and Neck Surgery, Ben-Gurion University, Beer-Sheva, Israel.,ENT Department, Soroka University Medical Center, 151, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Daniel M Kaplan
- Department of Otolaryngology-Head and Neck Surgery, Ben-Gurion University, Beer-Sheva, Israel.,ENT Department, Soroka University Medical Center, 151, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Sabri El-Saied
- Department of Otolaryngology-Head and Neck Surgery, Ben-Gurion University, Beer-Sheva, Israel.,ENT Department, Soroka University Medical Center, 151, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| |
Collapse
|
3
|
Temporal Trends and Regionalization of Acute Mastoiditis Management in the United States. Otol Neurotol 2021; 42:733-739. [PMID: 33481546 DOI: 10.1097/mao.0000000000003050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe demographics and to analyze temporal trends in the inpatient management of acute mastoiditis admissions. STUDY DESIGN Cross-sectional analysis. SETTING National Inpatient Sample, 2002-2014. PATIENTS 26,072 nonelective inpatient admissions with primary diagnosis of acute mastoiditis. INTERVENTION Myringotomy, mastoidectomy, or no procedure. MAIN OUTCOME MEASURES We described the patient- and hospital-level demographics of acute mastoiditis admissions and the frequency of complications. We evaluated the percentage of patients requiring surgical management. Binary logistic regression was performed to determine whether there was a significant increase in the percentage of patients treated at academic institutions. RESULTS The majority of patients were ≤40 years old (64.9%) and Elixhauser comorbidity index ≥4 (57.4%); 23.3% (SE 0.8%) presented with complications associated with acute mastoiditis, the most common of which was a subperiosteal abscess (11.5%, SE 0.7%). Among all admissions, 30.9% (SE 1.1%) underwent myringotomy, 13.8% (SE 0.8%) required both myringotomy and mastoidectomy. On multivariate analysis, there was a statistically significant increase in the percentage of mastoiditis admissions to teaching hospitals for all admissions (OR 1.55 [CI 1.22-1.97], p < 0.001) and even more evident for cases with associated complications (OR 1.85 [CI 1.21-2.83], p = 0.004). CONCLUSIONS AND RELEVANCE A sizeable percentage of patients with acute mastoiditis present with complications which may require surgical intervention. From 2002 to 2014, inpatient care of acute mastoiditis became increasingly regionalized to teaching hospitals, suggestive of increased specialization within certain facilities. This trend may have significant impacts on the cost and subsequent quality of care provided to these patients.
Collapse
|
4
|
Acute mastoiditis: 20 years of experience with a uniform management protocol. Int J Pediatr Otorhinolaryngol 2019; 125:187-191. [PMID: 31369930 DOI: 10.1016/j.ijporl.2019.07.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/06/2019] [Accepted: 07/14/2019] [Indexed: 12/16/2022]
Abstract
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.
Collapse
|
6
|
Abstract
PURPOSE OF REVIEW Over recent years, there has been a marked increase in the number of centres delivering paediatric outpatient parenteral antimicrobial therapy (pOPAT). Various factors have fuelled this drive, including the significant economic pressures faced by high-income countries to contain the cost of healthcare, resulting in a significant reduction of in-patient beds over the past 20 years. It is essential that pOPAT services have formal clinical governance structures in place to ensure the safe and effective management of children being ambulated on intravenous antibiotics. They also require oversight of antimicrobial decisions by a medically qualified infection specialist to ensure that the principles of antimicrobial stewardship are adhered to. This review aims to provide an evidence-based framework for delivering pOPAT services. RECENT FINDINGS There is increasing data supporting the implementation of admission avoidance strategies for children with cellulitis and pyelonephritis. In addition, recent data supports the management of a subset of children with febrile neutropenia within pOPAT services. Above all, there is a clear recognition that embedding antimicrobial stewardship within pOPAT services reduces duration of intravenous antibiotics (IVAbs) and improves patient management. pOPAT services are safe, cost-effective and associated with high levels of parent/patient satisfaction. Further research is required to develop risk prediction models for children being considered for pOPAT. Further data about the use of elastomeric devices in children and the acceptability of parental administration of IVAbs are also required.
Collapse
Affiliation(s)
- Sanjay Patel
- Department of Paediatric Infectious Diseases & Immunology, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Mailpoint 43, Tremona Road, Southampton, SO16 6YD, UK. .,NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK. .,NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| | - Helen Green
- Department of Paediatric Infectious Diseases & Immunology, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Mailpoint 43, Tremona Road, Southampton, SO16 6YD, UK
| |
Collapse
|
7
|
Tritt A, Kay-Rivest E, Paradis T, Duval M. Daily outpatient intravenous antibiotic therapy for the management of paediatric periorbital cellulitis, a retrospective case series. Clin Otolaryngol 2019; 44:273-278. [PMID: 30638306 DOI: 10.1111/coa.13284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/26/2018] [Accepted: 01/05/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate whether outpatient treatment of periorbital cellulitis with daily administration of intravenous antibiotics and physician evaluation is an effective and safe alternative to admission. DESIGN A retrospective chart review study of paediatric patients treated on an outpatient basis for periorbital cellulitis at a tertiary children's hospital between 2013 and 2015 was performed. Children were assessed day by a paediatrician to monitor for resolution of symptoms or complications. SETTING The Montreal Children's hospital, a tertiary care centre. PARTICIPANTS Children diagnosed with an uncomplicated periorbital cellulitis secondary to an acute sinusitis or upper respiratory tract infection. MAIN OUTCOME MEASURES The number of days of intravenous antibiotics, complications or need for subsequent admission. Complications were defined as formation of an abscess or phlegmon confirmed on computerised tomography scan, worsening or recurrent persistent cellulitis, failure to improve on intravenous antibiotics, and intracranial complications. RESULTS Sixty-six children with a diagnosis of uncomplicated periorbital cellulitis secondary to sinusitis who received intravenous antibiotics via medical day hospital and who fit the inclusion criteria were identified. The mean duration of intravenous antibiotic therapy was 4.1 days. All children received ceftriaxone, with one patient also receiving cefuroxime. Two of 66 patients developed complications; one patient required admission for failure to improve/subperiosteal phlegmon and later underwent functional endoscopic sinus surgery, and one patient developed an eyelid abscess that did not require admission. No patients developed severe neurological or visual deficits. CONCLUSIONS Outpatient intravenous therapy with daily reassessment by a physician may be a safe alternative to admission in select cases of periorbital cellulitis without systemic signs of illness.
Collapse
Affiliation(s)
- Ashley Tritt
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Emily Kay-Rivest
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Tiffany Paradis
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Melanie Duval
- Department of Otolaryngology, McGill University, Montreal, Quebec, Canada
| |
Collapse
|