Acute mastoiditis: predictors for surgery

Emerging Clinical Features of Acute Mastoiditis in Israel: A Registry Based Cohort

BACKGROUND AND OBJECTIVES

Acute mastoiditis (AM) is a severe infection in the young population, with possible life-threatening complications. This study aimed to characterize AM presentation, symptoms and signs, complications, and management, over a period of 10 years.

METHODS

This large-scale population-based cohort studied "Clalit Health Care" records, to include patients <18 years diagnosed with AM, hospitalized between the years 2008-2018. After validation, we investigated clinical symptoms and signs, pneumococcal vaccination status, complications, laboratory and microbiological parameters, imaging, antibiotic treatment and surgical interventions.

RESULTS

AM was diagnosed in 1189 patients, mean age of 2.71 years and 591 (49.71%) were female. Most presented with protrusion of pinna (83.1%), retro auricular redness (73.5%) and fever (71.8%). Patients <2 years of age had more symptoms (3.8 ± 1.4, opposed to 3.6 ± 1.5, P = 0.006) and showed higher white blood cell count and C-reactive protein values. Local and intracranial complications occurred in 233 (20.8%) and 75 (6.5%) patients, respectively. Complications were associated with increased white blood cell count and C-reactive protein and related to bacterial type, specifically Fusobacterium necrophorum ( P < 0.0001), for which 50% had an intracranial complication. Between the years 2008-2018, Streptococcus pneumoniae -positive cultures decreased (30.9% to 10.3%, P > 0.0001) as opposed to group-A Streptococcus (10.9% to 30.9%, P = 0.002).

CONCLUSIONS

This study shows a difference in AM appearance in the <2 years population and the association between white blood cell count, C-reactive protein and microbiology results with the occurrence of a complication. This may play a role in the management process, such as imaging and intervention needs. Although performed during the pneumococcal vaccine era, the disease microbiology was shown to change significantly throughout the study.

Retrospective study of acute mastoiditis in children in Spain attended in a Pediatric Emergency department

OBJECTIVE

To analyze the cases of acute mastoiditis, characteristics, management and complications in children attended in the emergency department.

METHODS

Retrospective study of acute mastoiditis in a Spanish tertiary hospital over a 6-year period (2018-2023).

RESULTS

One hundred two episodes of acute mastoiditis were analyzed (54% males, median age 1.8 years). Microorganisms were isolated in one third of cases, mainly Streptococcus pyogenes (64% of ear secretion cultures). Complications occurred in 27.5%, primarily subperiosteal abscess. A younger age, absence of vaccination schedule, previous history of otitis, cochlear implant carriers or white blood cell counts and C-reactive protein levels were not associated with complications. Complicated cases had longer hospitalizations. Treatment included antibiotics, corticosteroids, and surgery in 50% of cases.

CONCLUSIONS

This study shows an increase of acute mastoiditis during 2023, with a relevant role of S. pyogenes. A younger age, absence of vaccination, personal history of otitis or cochlear implant, blood cell counts and C-reactive protein levels were not associated with complications.

Pediatric Acute Mastoiditis: Our Experience in a Tertiary Care Center

Introduction

Acute mastoiditis (AM) is a common intra-temporal complication of acute otitis media (AOM) and is more commonly seen in children. Occasionally, it presents as the first sign of ear disease. This study aimed to evaluate the clinical course of AM and determine therapeutic options for pediatric patients presenting with AM.

Methods

This was a prospective, observational study conducted on patients with AM presenting at a tertiary center during one year period. Convenience sampling was employed and 79 pediatric patients (18 years or below) were recruited for the study. Data on the demographic profile of patients, the treatment offered, duration of hospital stay, and outcome were analyzed.

Result

In our study, 62% were male patients (n = 49) and 38% (n = 30) were females. The mean age of patients was 9.32 ± 5.3 years and a history of AOM was present in 60 (75.9%). On admission, the most common presentation was post-auricular inflammation (100%) followed by otalgia (79.7%), fever (59.5%), aural protrusion (54.4%), and otorrhoea (51.9%). Culture reports were available for 54 (68.4%) patients and 30 (38%) grew organisms. The cultured organisms were Streptococcus pneumonia (20.3%), Pseudomonas aeruginosa (10.1%), Streptococcus pyogenes (3.8%), and Staphylococcus aureus (3.8%). Most patients were managed conservatively (n = 66, 83.5%) whereas surgery was performed in 16.5% (n = 13) patients. The mean hospital stay was 5.58 ± 1.99 days. The need for surgical management was significantly associated with age >5 years (p = 0.006), history of AOM (p = 0.026) and the presence of complications (p = 0.012). Subperiosteal abscess (SA) was present in 21 (26.6%) patients and one had facial palsy. SA along with AM had a mean hospital stay of 8.5 ± 0.77 days compared to 4.94 ± 1.43 days in case of isolated AM (p < 0.001) and the mean age of presentation in SA with AM was 11.97 ± 5.13 years compared to 8.29 ± 5.14 years in case of isolated AM (p = 0.006). All patients recovered and were followed up to three months with no recurrence, complications, or sequelae.

Conclusion

Most of the cases of acute mastoiditis follow previous AOM episodes. With early recognition and effective treatment, the prognosis is good.

Evidence of otitis media and mastoiditis in a Medieval Islamic skeleton from Spain and possible implications for ancient surgical treatment of the condition

OBJECTIVE

To evaluate lesions on a cranium from the Iberian Peninsula and assess its medico-historical and paleopathological significance.

MATERIALS

The skeletal remains of a juvenile individual found in a Medieval Islamic grave (10th -16th century) in Eastern Spain.

METHODS

Macroscopic examination of the left and right temporal bones, binocular microscopy, X-ray, and Scanning Electron Microscopy - Energy Dispersive X-ray Spectroscopy (SEM-EDS) were performed.

RESULTS

A sub-oval perforation superior to the right mastoid process and pathological changes on the right temporal bone were identified. SEM-EDS confirmed the presence of copper in the surrounding area of the perforation.

CONCLUSIONS

The observed pathological changes are most likely compatible with otitis media and subsequent mastoiditis. The sub-oval perforation could be interpreted either as an abscess or as evidence of a surgical procedure (mastoidectomy) or a combination of both; and the Cu traces may be the result of an associated object or, possibly, the application of a plaster with copper acetate used as medical treatment.

SIGNIFICANCE

This case contributes to the paleopathological record and the interpretation of similar cases, and also helps in the understanding of medical care and treatment in Medieval Islam.

LIMITATIONS

The lack of similar pre-modern cases of surgical intervention limits comparability to clinical cases. Suggestion for further research: Exploration into indicators of health care in past populations.

Cranial Rhabdomyosarcoma Masquerading as Infectious Mastoiditis: Case Report and Literature Review

BACKGROUND

Rhabdomyosarcoma originating in the mastoid is rare and may be misdiagnosed as an infectious mastoiditis due to overlapping clinical and imaging features. We aimed to identify distinguishing characteristics to facilitate earlier diagnosis and treatment.

METHOD

Here we describe a case report and a systematic review of 23 reports describing previous cases of mastoid rhabdomyosarcoma. We compare these patients to a systematic review of patients with infectious mastoiditis and identify distinguishing clinical features.

RESULTS

A total of 43 patients with rhabdomyosarcoma of the mastoid were identified and compared with patients with mastoiditis. Rhabdomyosarcoma patients were more likely to present with a mass (86%) or cranial nerve dysfunction (83.7%), while mastoiditis patients were more likely to have fever (72.4%), pain (48.2%), and present at a younger age (4.4 vs. 6.1 years). The average lifespan with rhabdomyosarcoma of the mastoid was 7.1 months after diagnosis, with 41.7% of patients alive at the time of report.

CONCLUSIONS

Based on abstracted and aggregated information, we identified unique features observed more frequently in each of rhabdomyosarcoma and mastoiditis. These predictive features allow for the differentiation of each diagnosis and avoid the delay of proper treatment.

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.

Acute Mastoiditis in Children: Is Computed Tomography Always Necessary?

Objectives

Acute mastoiditis (AM) is the most common intratemporal complication of acute otitis media in children. In the past decade, reports have indicated a rise in the incidence of AM in the pediatric population. A parallel rise in the use of computed tomography (CT) imaging has occurred. The rise in the use of CT scanning in the pediatric population, entraining with it a rise in pediatric brain irradiation, has led us to question the necessity of using CT for pediatric patients with AM.

Methods

We reviewed the medical files of pediatric patients who had AM in the years 2005 through 2007.

Results

Fifty patients were identified. The gender distribution was equal, and the ages ranged from 4 months to 12 years. Of the 46 patients who were admitted to our institution “de novo,” only 2 underwent CT scanning on admission, and 4 other patients had CT performed during hospitalization. The majority of patients (92%) with AM did not have a CT scan performed and were treated conservatively with no complications.

Conclusions

In most pediatric patients, CT does not seem to be indispensable in the diagnosis of AM. Conservative therapy and close follow-up seem to suffice for most.

Postauricular Needle Aspiration of Subperiosteal Abscess in Acute Mastoiditis

To test the hypothesis that subperiosteal abscess, a complication of acute mastoiditis, can be treated equally well by needle aspiration as by cortical mastoidectomy, we performed a retrospective analysis of 78 pediatric patients hospitalized between 1995 and 2003 and performed an analysis of published data on types and outcomes of treatment approaches for acute mastoiditis. Postauricular pus aspiration resolved the subperiosteal abscess in 14 of 17 patients. The length of the hospital stay of patients who underwent aspiration was shorter than that of patients who underwent cortical mastoidectomy. We conclude that postauricular pus aspiration, a simple and minimally invasive procedure, is an effective treatment modality for subperiosteal abscess. Mastoidectomy should be reserved for nonresponsive cases or those with more serious complications. Broad-spectrum antibiotics, myringotomy with daily toilet of the ear, and postauricular aspiration, when required, minimize the indications for surgery and reduce the hospital stay.

Complications of Mastoiditis in Children at the Onset of a New Millennium

The aim of the present study was to review our recent experience in the diagnosis and treatment of acute mastoiditis and its complications in a single tertiary-care, university-affiliated pediatric center. Ninety-eight children with 101 episodes of acute mastoiditis were included in the study. The mean interval from onset of illness to mastoiditis was 4.5 days. Ear cultures most often grew Streptococcus pneumoniae and Pseudomonas aeruginosa (23.7% each). Complications occurred in 15.8% of episodes. The only factor differentiating children with and without complications was white blood cell count. These findings indicate that acute mastoiditis not only is a complication of prolonged infection of the middle ear, but may also present as an acute infection of the mastoid bone that can progress within 48 hours. The complication rate remains high, and antibiotic treatment at the onset of symptoms does not prevent complications. A high white blood cell count on admission may serve as a predictive factor of complicated cases.

Acute mastoiditis in children: a 10-year retrospective and validated multicenter study

BACKGROUND

Conservative treatment of acute otitis media may lead to more complications. This study evaluates changes in incidence, the clinical and microbiological findings, the complications and the outcome of acute mastoiditis in children in a country employing conservative guidelines in treating acute otitis media.

METHODS

All admitted children (0-15 years) diagnosed with acute mastoiditis during the period from 1998 to 2007 in eastern Denmark (population 2.2 million) were identified. Patient files were retrieved and reviewed; the data were entered into a database.

RESULTS

The average incidence of admitted children with acute mastoiditis was 4.8/100,000 children per year (95% CI were ± 0.03 -0.04), and there was no change in the incidence during the 10-year period. Of the 214 children included (mean age 2.1 years, range 0.3-13.1, median 1.3 years), 100% presented with protrusion of the pinna and 95% with retroauricular swelling and redness, whereas 32% had a retroauricular abscess. Mastoidectomy had been performed in children with a retroauricular abscess. Thirty-one percent had a ventilation tube inserted. The remaining group was treated with antibiotics and analgesics, and 86% also had a myringotomy performed. Streptococcus pneumoniae and group A streptococci were the bacteria most commonly cultured, 94% being susceptible to penicillin. The complication rate was low at 1.9%. All children included were initially admitted; no patients were outpatients.

CONCLUSIONS

The incidence of acute mastoiditis is stable in eastern Denmark where conservative management guidelines for treating acute otitis media are used. Bacterial resistance toward penicillin is low (6%), complications are rare and the treatment outcome is good. Furthermore, no severe complications after treatment were observed.

Acute mastoiditis--the role of radiology

Acute mastoiditis is a commonly occurring condition in children and adults, and one that most radiologists will come across at some point during their on-call duties. Acute mastoiditis is usually clinically apparent. However, the complications, especially the intracranial ones, can be more insidious and may have fatal consequences. Therefore, it is imperative that the radiologist is well versed in identifying these. Local spread of infection from the mastoids and middle ear cleft may occur via four routes: bone erosion, thrombophlebitis, periphlebitis, and via the anatomical pathways. The role of radiology is largely to demonstrate the complications of mastoiditis, which can be clinically occult and are often serious; this article will highlight these complications.

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.

Clinical, laboratory, and microbiological differences between children with simple or complicated mastoiditis

OBJECTIVE

To assess clinical, laboratory, and microbiological differences between children with simple and complicated mastoiditis.

PATIENTS AND METHODS

Data on all children who were hospitalized at a tertiary center for acute mastoiditis over a 5-year period were collected from the computerized files. Findings were compared between those with simple mastoiditis vs. cases with intra- or extra-cranial complications.

RESULTS

Of the 308 children with acute mastoiditis, 55 (17.9%) had complicated disease. This group was characterized by a significantly higher maximal fever at presentation and higher absolute neutrophil count and C-reactive protein level than the children with simple disease. There was no statistically significant between-group difference in age, history of otitis media, prior antibiotic treatment, days of illness before presentation, absolute leukocyte count, and platelet count. No difference was detected between the groups in the penicillin and ceftriaxone susceptibility of the Streptococcus pneumoniae isolates.

CONCLUSION

High-grade fever, high absolute neutrophil count, and high C-reactive protein level may serve as clinical and laboratory markers of complicated mastoiditis. Children with these findings warrant close follow-up and perhaps, earlier surgical intervention.

Conservative management of acute mastoiditis in children

OBJECTIVE

To review the current management of acute mastoiditis with critical emphasis on the role of myringotomy.

DESIGN

A retrospective chart review.

SETTING

Tertiary-care, university affiliated children's hospital.

PATIENTS

One hundred and forty-four consecutive children hospitalized for acute mastoiditis between the years 1991 and 2002.

INTERVENTIONS

All children were treated with parenteral antibiotics (conservative management). Myringotomy was performed at the discretion of the otolaryngologist on-call.

MAIN OUTCOME MEASURES

Comparing outcomes of children with or without myringotomy regarding hospital stay, complications and the need for surgical interventions.

RESULTS

Myringotomy was performed in 34.6% of episodes. The children who underwent myringotomy were found to be significantly younger (22.4 compared to 28.8 months, p=0.028) and had more complications (n=17 vs. n=8, p<0.001). Complications overall occurred in 16.3% of episodes. Performing myringotomy had no significant effect on the duration of hospital stay. Children pretreated with antibiotics underwent significantly less myringotomies p=0.027. There were no significant differences between children who underwent myringotomy and those who did not with regard to WBC count, or ESR.

CONCLUSIONS

These findings suggest that myringotomy may not be required in all cases of acute mastoiditis. Parenteral antibiotics is sufficient in most cases. Criteria for myringotomy may include a younger age. Conservative management resulted in good outcomes in this series.

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.

Acute mastoiditis in Norway: no evidence for an increase

OBJECTIVE

In a large Norwegian newspaper in November 2005, an otolaryngologist at Rikshospitalet claimed that the increasing number of children hospitalized for acute mastoiditis was worrying and questioned the restrictive use of antibiotics in Norway. Based on latter he recommended that all children below age 2 with symptoms of uncomplicated acute otitis media should receive antibiotics. Our purpose was to incidence variation and characteristics of acute mastoiditis in children.

METHODS

Registry based study with complete data on hospitalization for acute mastoiditis and cortical mastoidectomy in Norway during 1999-2005.

RESULTS

Three hundred and ninety-nine Norwegian children aged 0-16 years were included. The incidence of acute mastoiditis in children below 2 ranged from 13.5 to 16.8 per 100,000 during the study period. Corresponding numbers for children 2-16 years were 4.3-7.1 per 100,000 children. No incidence increase was found during the study period. Age-specific incidence revealed a peak during the second and third year of life, and acute mastoiditis was most common in boys. Cortical mastoidectomy was equally common in the young and older age group, 22% received surgery. For children aged 2 and above, significantly fewer children were hospitalized for acute mastoiditis media during the period July, August and September.

CONCLUSION

Despite the introduction of restrictive Norwegian guidelines for antibiotic treatment of acute otitis media in children aged 1 year and above, our data did not give evidence for an increase in acute mastoiditis. Except for the high incidence of acute mastoiditis in young children, hospitalization characteristics were remarkably similar in children below and above 2 years.

The Binax NOW test as a tool for diagnosis of severe acute otitis media and associated complications

The diagnosis of acute otitis media (AOM) is often difficult, depending heavily on the experience and skills of the examiner. However, it is important to identify episodes of AOM that involve the risk of complications and to treat these episodes appropriately. The present study was performed in order to evaluate the use of a rapid antigen assay for Streptococcus pneumoniae, the Binax NOW test, as a diagnostic tool in patients with severe AOM and associated complications. The study included 70 patients with 74 episodes of AOM, 18 of them with complications. Cultures, Binax NOW tests, and a PCR assay were performed on nasopharyngeal secretions, middle ear fluid, and in some cases mastoid bone, cerebrospinal fluid, and urine. According to culture and PCR of the middle ear fluid, 30 (41%) of the episodes were caused by S. pneumoniae. The Binax NOW test was positive in 24 of these episodes (80%). It identified pneumococcal AOM independent of antibiotic treatment, and it was easily adapted to bone tissue. The test yielded sensitivity, specificity, and positive and negative predictive values for middle ear specimens of 85%, 100%, 100%, and 89%, respectively. The corresponding positive and negative values for predicting the bacterial etiology with nasopharyngeal secretions were 51% and 75%. This study showed that the Binax NOW test is a useful diagnostic tool for patients with severe AOM with or without complications.

Indications for surgery in acute mastoiditis and their complications in children

OBJECTIVE

To review the clinical charts of 45 paediatric patients treated for acute otomastoiditis at the ORL Department of the University of Brescia (Italy) between January 1994 and March 2005 and to discuss the diagnostic workup and the outcome of treatment.

METHODS

Twenty-six males and 19 females were admitted with acute mastoiditis and subperiosteal abscess. Thirteen of them (28.9%) presented an intracranial complication. Only three of them were not operated upon; one received a ventilation tube (VT); all the others underwent a mastoidectomy within 48-72 h. Twenty out of 32 uncomplicated mastoiditis were treated conservatively and the remaining 12 underwent myringotomy+/-VT, associated with a mastoidectomy in 9 cases.

RESULTS

Antibiotics alone or with VTs achieved a full recovery in 28 out of 32 uncomplicated cases. Mastoidectomy resolved the disease in 13 patients (9 with complications). In severe complications, a canal wall down (CWD) (n=2) or an intact canal wall (ICW) mastoidectomy (n=7) were preferred, based on the extent of the lesions and the degree of hearing loss. All children recovered completely at 1 year follow-up. In the uncomplicated cases that were operated upon, the mean hospital stay was 7.8 days (versus 4.3 days for the conservative group). In children with intracranial complications the mean hospital stay was 12.8 days, significantly less than the four non-surgical patients, who remained hospitalized for an average of 18 days.

CONCLUSION

Acute mastoiditis can fully recover with conservative treatment or myringotomy+VTs. Immediate surgical treatment is indicated for intracranial complications, if the neurological conditions are not critical. A simple mastoidectomy+/-tympanoplasty is warranted in: (1) exteriorization, if the child is older than 30 months or >15 kg of weight, (2) intracranial complications (combined with a neurosurgical procedure as needed) and (3) cholesteatoma or granulation tissue.

[Acute mastoiditis in children. A retrospective study and literature review]

OBJECTIVE

To review our experience and results in the diagnosis and treatment of acute mastoiditis, a pathology with an increasing incidence in the recent years.

METHODS

The study reviewed 49 pediatric patients diagnosed and treated of acute mastoiditis between 1994 and 2003 in our hospital. We summarize epidemiologic, laboratory and clinical features.

RESULTS

The mean age was 2.5 years. Seventy-five percent of cases were in autumn and winter months and nearly twenty-five percent had been diagnosed in the last year. S. pneumoniae was the most commonly isolated pathogen (28.6%), although a sterile result was the most frequent (38.1%). Twenty-four patients (48.9%) required surgical treatment. Only five patients (10.2%) developed complications.

CONCLUSIONS

Acute mastoiditis is a pathology with an important incidence and is generally the consequence of an untreated otitis or an insufficient treatment. Due to the low number of complications, we can not estimate through statistical analysis valid markers like predictors for complication.

Mastoid subperiosteal abscess: a review of 51 cases

OBJECTIVE

To present a large study on subperiosteal abscess (SA) that represents the most frequent complication of acute mastoiditis.

METHOD

A retrospective study was conducted on 49 patients who underwent mastoidectomy for SA.

RESULTS

The patients ranged in age from 8 months to 21 years. Two patients were re operated on the same side due to recurrent abscess. Forty-five percent of the patients were treated using antibiotics at home and 58.8% of patients had no history of middle ear infection prior to admission. CT underestimated abscess in two patients who were operated on based on their clinical signs. Perisinus abscess was drained during mastoidectomy in one child. Purulent discharge was obtained from the abscess in 41 cases. The most common isolated pathogens were Streptococcus pyogenes and Staphylococcus aureus. Cholesteatoma was found during mastoidectomy in six patients (11.3%). Twenty-four patients (49%) developed postoperative sequela including various middle ear infections, mastoiditis, recurrent SA and impaired hearing.

CONCLUSIONS

Mastoid SA is a unilateral mainly children's disease that can recur. Cholesteatoma can associate the abscess and could be found in older children and recurrent abscess. High morbidity rate requires long-term follow-up for these patients.

Acute mastoiditis and osteomyelitis of the temporal bone

OBJECTIVE

Acute mastoiditis becomes clinically significant when infection spreads through the periosteum and induces periosteitis. This study describes an atypical complication of acute mastoiditis: osteomyelitis of the temporal bone.

PATIENTS AND METHODS

The study sample included all patients admitted for acute mastoiditis between September 2001 and December 2003 who had symptoms, signs and imaging findings of osteomyelitis of the temporal bone beyond the mastoid area. The files were reviewed for diagnosis, work-up, radiographic findings and treatment.

RESULTS

The study group included 6 of the 120 patients treated for acute mastoiditis. In four children (66%), the diagnoses of acute otitis media and acute mastoiditis were made simultaneously at admission. Ear cultures yielded coagulase-positive Staphylococcus in three patients, Bacteroides in two, multiple organisms in two, S. pneumoniae in one, and no growth in two. Complications were suspected if there was a lack of improvement in symptoms and signs, or in cases of skin involvement over the temporal bone beyond the area of the mastoid in accordance with imaging findings. Computerized tomography demonstrated temporal bone absorption beyond the mastoid area (squama and/or petrous bones) in all children, suspected sinus vein thrombosis in two, and suspected epidural abscess in one. All children were treated with at least cortical mastoidectomy and insertion of ventilation tubes. Revision mastoidectomy was performed in three children in whom no improvement was noted and imaging suggested other complications.

CONCLUSION

The present study describes an unusual complication of acute mastoiditis-osteomyelitis of the temporal bone beyond the mastoid framework. The disorder is characterized by a failure to respond both locally and systemically to accepted medical and surgical therapy, persistent fever and high levels of inflammatory markers, and computerized tomography findings of temporal bone destruction. Treatment includes broad-spectrum antibiotics and at least cortical mastoidectomy. Prognosis is good.

Mastoidectomy for Acute Otomastoiditis: Our Experience

We conducted a retrospective study of 53 mastoidectomies in 51 patients with acute otomastoiditis. In 26 cases (49.1%), surgery had been performed within 48 hours of the development of symptoms. The most common complication of acute otomastoiditis was subperiosteal abscess, which occurred in 37 cases (69.8%). Intracranial complications were seen in 6 cases (11.3%). The most common pathogens isolated from subperiosteal abscesses, the mastoid cavity, and intracranial collections were Streptococcus spp and Staphylococcus aureus. In 14 cases (26.4%), conservative treatment failed to cure acute otomastoiditis; such cases should raise a suspicion of a subperiosteal abscess, an underlying cholesteatoma, or an infection caused by gram-negative bacteria. Upon hospital admission, patients should receive antibiotics that are effective against both gram-positive and gram-negative organisms. Patients with intracranial complications or facial nerve paralysis may require a combination of two or more antibiotics. Long-term follow-up is highly recommended.

Diagnosis and management of acute otitis media

This evidence-based clinical practice guideline provides recommendations to primary care clinicians for the management of children from 2 months through 12 years of age with uncomplicated acute otitis media (AOM). The American Academy of Pediatrics and American Academy of Family Physicians convened a committee composed of primary care physicians and experts in the fields of otolaryngology, epidemiology, and infectious disease. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to AOM. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific definition of AOM. It addresses pain management, initial observation versus antibacterial treatment, appropriate choices of antibacterials, and preventive measures. Decisions were made based on a systematic grading of the quality of evidence and strength of recommendations, as well as expert consensus when definitive data were not available. The practice guideline underwent comprehensive peer review before formal approval by the partnering organizations. This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

Indications for mastoidectomy in acute mastoiditis in children

The objective of this study was to identify clinical features of acute mastoiditis in children that are indicative of the need for mastoidectomy. We performed a retrospective chart review of 40 children (20 male, 20 female) between 2 months and 12 years 9 months of age with a diagnosis of acute mastoiditis who were managed in our institution between July 1998 and June 2002. All patients received intravenous antibiotics; this was the only treatment in 14 patients (35%). Tympanostomy tubes were inserted in 22 patients, together with postauricular needle aspiration in 12 (30%), and incision and drainage of subperiosteal abscess in 10 (25%). Mastoidectomy was performed in 4 cases (10%), and cholesteatoma was found in 3. One other child was subsequently found to have cholesteatoma. We conclude that children who present with acute mastoiditis should undergo mastoidectomy if cholesteatoma is clinically suspected, or if extratemporal suppurative complications have occurred.

Bacteriology of mastoid subperiosteal abscess in children

OBJECTIVE

Subperiosteal abscess (SA) is the most frequent complication of acute mastoiditis (AM). Of pathogens cultured from the external auditory canal or middle ear during myringotomy, 15% may be different from microorganisms isolated from the SA. We suggest, therefore, that only cultures obtained from the abscess cavity can truly reflect the bacteriology of this complication of AM. The purpose of our study was to analyze the infectious agents which cause SA and mastoid cortex erosion in children.

MATERIAL AND METHODS

The medical records of 35 children who underwent mastoidectomy for SA between May 1984 and April 2002 were evaluated.

RESULTS

Mastoid cortex erosion was found at surgery in 72.7% of abscesses Purulent discharge was obtained from the SA cavity in 28 cases. The commonest pathogens isolated in these cases, as well as in 18 cases of mastoid cortex erosion, were Staphylococcus aureus and Streptococcus pyogenes, followed by Streptococcus pneumoniae. Hemophilus influenzae, Pseudomonas aeruginosa, Escherichia coli and Klebsiella pneumoniae. Sterile culture was found in 25% of cases.

CONCLUSIONS

Mastoid SA is a unilateral disease that can recur. Early administration of anti-Staphylococcus medications should be considered for patients with SA as a complication of AM.

Computed tomographic versus surgical findings in complicated acute otomastoiditis

Computed tomography (CT) plays an important role in planning surgery in cases of complicated middle ear infection. The purpose of this study was to determine, by comparison of radiologic and surgical findings, the diagnostic value of CT in complicated acute otomastoiditis. The study group consisted of 37 patients without a history of chronic ear disease. In this study, CT enabled correct diagnosis of 26 of 27 cases (96%) of subperiosteal abscess, 17 of 18 cases (94%) of mastoid cortex erosion in patients with subperiosteal abscess, and several intracranial complications, including epidural abscess, subdural empyema, and perisinus abscess. The CT scan produced overdiagnosis in some cases: sigmoid sinus thrombosis in 1 patient, mastoid cortex erosion in 2 children with subperiosteal abscess, and bone erosion toward the posterior cranial fossa in 1 patient with meningitis. My findings suggest that subperiosteal abscess is a disease of young children; however, when it develops in an older child, cholesteatoma should be suspected. Furthermore, acute mastoiditis complicated with facial nerve paralysis may be associated with cholesteatoma in 66% of cases. My experience showed that CT had a sensitivity of 97% and a positive predictive value of 94% in the diagnosis of complicated acute otomastoiditis.

The laws of acute otitis media

One key to successfully navigating the quagmire of otitis media is to understand otitis media and share that understanding with parents. The Laws of Otitis Media can be useful in this endeavor. Another key to success is to help parents understand that they and their child's physician are partners in the goal of preventing AOM as much as possible, and treating episodes as precisely as possible when they occur. Parents need to know that AOM usually occurs at < 3 years of age and most normal children experience some AOM. The number of AOM episodes depends on a combination of inherited factors that are compounded by immature immunity and anatomy plus the degree of exposure to provoking respiratory pathogens. A firm understanding of the difference between AOM and OME makes it simpler to withhold antibiotics for OME; and understanding that infrequent AOM usually gets well without antibiotics also may reduce some of parents' anxieties. Parents of patients with frequent AOM deserve more guidance about the need for more potent antibiotics and the reduced expectations for cure despite use of appropriate antibiotics. Clinicians need to share with parents the fact that most information about antibiotics and AOM comes from studies sponsored by pharmaceutical companies, with the goal of optimizing the chance that the company's drug would appear to be a good choice. Therefore, only by understanding critical study-design characteristics that ensure fair and proper comparison, will the clinician (or parent using the Internet) be able to decide which drugs are best. Because there are so few well-designed studies, pharmacodynamics has become an alternative method to decide which drugs are best. Practitioners may need to rely on an expert to help interpret the application of pharmacodynamics to local AOM pathogens. While shorter courses of antibiotics are attractive from the compliance and perhaps even the reduction of resistance perspective, failure rates will be higher in young children with tough-to-treat AOM. Further, some of the better tasting or more convenient drugs turn out to be less effective in these same hard-to-treat patients. To further minimize parental anxiety, clinicians should share the fact that it is very rare to see severe complications or lifelong hearing problems due to AOM that is reasonably managed. This is important because the available tools to prevent AOM are limited in number and efficacy. The Laws of AOM can be a basis for busy practitioners to establish a structure for constructively sharing information and responsibility with parents concerning AOM.

Acute mastoiditis in a Norwegian population: a 20 year retrospective study

We have retrospectively examined the nature of acute mastioditis (in western Norway) during a 20 year period (1980-2000). Sixty-one cases of AM were identified in 57 patients with a mean age of 3.6 years. We found no significant change in the incidence of AM during the last 20 years. Seven patients were treated solely with intravenous antibiotics and myringotomies. Fifty patients also underwent cortical mastoidectomy, four cases with bilateral surgery. Antibiotic treatment was given to 31 of the patients before admission to hospital and this group had a significant longer duration of symptoms (12.4 days) compared to untreated patients (7.3 days). Streptococcus pneumoniae was the most common organism recovered from patient cultures. Surgery was found to correlate to patients with retroauricular fluctuation or to children with at least two of the three clinical signs: protrusion of the ear, retroauricular oedema and swelling of the ear canal. Our data show that clinical examination only reveal 50% of the cases with surgically proven retroauricular subperiostal abscess. We therefore recommend a CT scan of patients treated conservatively.

Prevention of acute mastoiditis: fact or fiction?

Acute mastoiditis is the most common complication of acute otitis media (AOM). In recent years routine antibiotic treatment for acute middle ear infections was questioned and even abandoned in some countries. The goal of our study was to investigate the influence of antibiotic treatment on the occurrence and clinical outcome of acute mastoiditis and to analyze the bacteriological findings. A retrospective case record study of 48 patients with 50 episodes of acute mastoiditis hospitalized at our tertiary-care center between 1992 and 1999 was performed. Twenty-three patients (48%) received antibiotic treatment before admission whereas 25 (52%) did not. The group of patients without antibiotic pretreatment were younger (mean, 6 years) than patients with antibiotics (mean, 18 years) and their referral was delayed. The most common isolated single pathogen was Streptococcus pneumoniae. All pneumococci were sensitive to penicillin. Acute mastoiditis may be the first clinical sign of a middle ear infection, especially in very young children. Adequate antibiotic pretreatment cannot invariably prevent the development of acute mastoiditis even in the absence of penicillin resistant pathogens.