Acute mastoiditis in children: review of the current status

Intracranial complications of acute mastoiditis: Surgery not always necessary

INTRODUCTION

Acute mastoiditis (AM) can rapidly become life-threatening with various intracranial complications. The standard care includes antibiotics, mastoidectomy, and drainage. Reports show varying preferences for conservative and surgical treatments, with a more conservative approach gaining popularity. In this study we aim to evaluate the presenting symptoms, management and outcomes of patients presenting with intracranial complications secondary to acute mastoiditis.

METHODS

Retrospective review for all children admitted for acute mastoiditis for 12 years period (January 2010-December 2021). Children who had mastoiditis associated with intracranial complications were included in the study. STROBE guidelines were followed in this study.

RESULTS

23 patients were diagnosed with acute mastoiditis with intracranial complications. The mean age was 2.1 years. The most common presenting sign was fever, followed by otalgia. The most common pathogens were Fusobacterium necrophorum and Streptococcus pneumoniae. The most common intracranial complication was sinus vein thrombosis (SVT) affecting 13 patients. Eventually, 10 patients underwent cortical mastoidectomy during 1-6 days upon admission, with an average of 3.2 days. During the follow-up period patients were monitored for clinical progression. Patients who did not show clinical improvement such as persistent fever, worsening symptoms, or the presence of neurological symptoms were treated surgically. The length of stay was an average of 15.5 days overall, with no significantly longer hospital stay in patients who were treated surgically compared to patients who were treated conservatively (17.1 days vs. 14.2 days, P = .26).

CONCLUSION

Intracranial complications of acute mastoiditis remain a significant challenge. Selected patients with intracranial complications can be treated conservatively with close monitoring, without increasing the risk of immediate or long-term complications. Initial antimicrobial treatment should cover anaerobic bacteria, as it correlates with severe complications.

Increase in acute mastoiditis at the end of the COVID-19 pandemic

PURPOSE

Common respiratory infections were significantly reduced during the COVID-19 pandemic due to general protective and hygiene measures. The gradual withdrawal of these non-pharmaceutical interventions (NPI) was associated with a notable increase in these infections, particularly in pediatric and adult otorhinolaryngology. The aim of this retrospective monocentric study was to evaluate the impact of NPI during the COVID-19 pandemic on the incidence and severity of acute mastoiditis (AM).

METHODS

Pre-pandemic clinical data of AM cases from 2011 to 2019 were compared with infection counts from January 2020 to June 2023 for seasonal periodicity, age-specific differences, pathogens, and complication rates in a German third-level hospital.

RESULTS

Out of 196 patients with AM 133 were children, the majority between 1 and 5 years of age. Complications of AM, such as meningitis, brain abscess, and sinus vein thrombosis, were more common in adults (87%) than in children (17%). Morbidity and mortality rates were similar before, during and after the pandemic. Pneumococci were the most common pathogen in both age groups, with a post-pandemic cumulation of Streptococcus pyogenes infections in children. While pre-pandemic cases clustered in spring, seasonality was absent in all age groups during the main phase of the pandemic. The cessation of NPI caused a steep rise in AM cases in both age groups starting from December 2022.

CONCLUSION

NPI during the COVID-19 pandemic reduced the incidence of AM. Their reversal led to a substantial increase in the incidence of AM during the post-pandemic period, which may be due to a general increase in viral respiratory infections and an insufficiently trained immune system.

High risk and low prevalence diseases: Acute mastoiditis

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.

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.

Acute otitis media-related facial nerve palsy in a child: a case report and a literary review

BACKGROUND

Acute otitis media has become a rare cause of facial palsy in children. A high index of suspicion is essential to achieve the diagnosis and to properly treat this condition to avoid permanent neurological sequelae.

CASE PRESENTATION

A case of acute otitis media-related facial nerve palsy in an 18 months-old child is described and a review of the recent literature about the clinical presentation, diagnosis, and management of this condition is performed.

CONCLUSIONS

Facial paralysis is an uncommon complication of acute otitis media that requires appropriate care. As highlighted in our report, the treatment of facial nerve palsy secondary to otitis media should be conservative, using antibiotics and corticosteroids. The role of antiviral is still a matter of debate. Myringotomy and a ventilation tube should be added when spontaneous perforation of the tympanic membrane is not present. More aggressive surgical approach should be considered only when there is no significant improvement.

Sex and Gender Differences in Bacterial Infections

There is a growing awareness of the importance of sex and gender in medicine and research. Women typically have stronger immune responses to self and foreign antigens than men, resulting in sex-based differences in autoimmunity and infectious diseases. In both animals and humans, males are generally more susceptible than females to bacterial infections. At the same time, gender differences in health-seeking behavior, quality of health care, and adherence to treatment recommendations have been reported. This review explores our current understanding of differences between males and females in bacterial diseases. We describe how genetic, immunological, hormonal, and anatomical factors interact to influence sex-based differences in pathophysiology, epidemiology, clinical presentation, disease severity, and prognosis, and how gender roles affect the behavior of patients and providers in the health care system.

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.

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.

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.

Otogenic cerebral venous thrombosis in children: A review of 16 consecutive cases

OBJECTIVES

Management of otogenic cerebral venous thrombosis (OCVT) is controversial. Despite the modern antibiotic era OCVT still represents a potential life-threatening condition. This study aims to report the clinical presentation and management in a series of children with OCTV. The coexisting intracranial complications (ICC), the extent of the surgical treatment and the role of hypocoagulation were the analysed outcomes.

MATERIAL AND METHODS

Retrospective chart review of patients aged less than 16 years and consecutively treated for OCVT at a tertiary university hospital between January 2007 and March 2015.

RESULTS

Sixteen children with ages ranging between 25 months and 16 years (9 girls/7 boys) with OCVT were identified. Acute otitis media was the causative factor in the majority of cases (n = 13). The remaining cases resulted from chronic otitis media with cholesteatoma (COMC). Eleven patients were under antibiotic therapy prior to admission. Other ICC were simultaneously present: intracranial abscess (n = 6); otitic hydrocephalus (n = 3); and meningitis (n = 1). Thrombus extension correlated with the presence of additional ICC (p = 0.035). Treatment in all cases comprised of broad-spectrum antibiotics, mastoidectomy, and long-range hypocoagulation with warfarin. Transtympanic ventilation tubes were inserted in all cases but one with COMC. Perioperative sigmoid sinus exposure was performed in seven patients, with drainage of perisinus empyema in three cases. Five children underwent simultaneous craniotomy for intracranial abscess drainage. Follow-up imaging performed in 12 cases revealed partial or complete recanalization in three and seven cases, respectively. After a mean hypocoagulation duration of nine months, no hemorrhagic or major neurologic complications were observed.

CONCLUSIONS

The clinical course of OCVT can be masked by previous antibiotic therapy. As such, a high suspicion index is needed for diagnosis. Simultaneous ICC appears to be more frequently found if an extensive thrombosis was present. The high recanalization rate in this series with low morbidity and no mortality can be obtained with a timely combination of antibiotics, mastoidectomy with transtympanic tube insertion and hypocoagulation. However, the decision to start hypocoagulation and its duration should be undertaken on an individual basis owing the possible adverse effects. Prospective and case-control studies are still needed to better clarify the role of the hypocoagulation treatment in OCVT.

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.

Acute Otitis Media and Acute Coalescent Mastoiditis

Acute otitis media is a frequent manifestation of otitis media, mainly during the early childhood. The multifactorial pathogenesis and risk factors are exposed along with its most microbiological agents. The clinical manifestations and their differential diagnoses are presented. General concepts and different actual guidelines of the treatment are described, also the efficient preventive measures are proposed.

The second main issue of this chapter is to deal with the complications of acute otitis media, especially the acute coalescent mastoiditis, that is the most common suppurative complication of AOM. The pathogenesis of coalescent acute mastoiditis, its epidemiology, risk factors and the microbiological agents are presented. The clinical features and differential diagnosis are described, as the specific imaging findings. Complications of acute coalescent mastoiditis are typically the subperiosteal abscess, due to the cortical bony necrosis of the mastoid and its septa, or the intracranial spread of the infection (meningitis, intracranial abscesses and venous sinus thrombosis).

The general concept of management is exposed, with emphasis on the antimicrobial treatment and the different surgical options.

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.

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.

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.

Facial Nerve Paralysis in Acute Suppurative Otitis Media-Management

Facial paralysis is a rare complication of acute suppurative otitis media which requires early detection and appropriate care. We hereby report a case which we managed conservatively with good outcome. Following our experience and review of literature on the subject, antibiotic therapy and corticosteroid therapy, with or without myringotomy were found to be the first-line procedures. Surgery should be employed in case of acute or coalescent mastoiditis, suppurative complications and lack of clinical regression.

Management of acute complicated mastoiditis at an urban, tertiary care pediatric hospital

OBJECTIVES/HYPOTHESIS

To describe the presentation and management of acute complicated mastoiditis in children.

STUDY DESIGN

Retrospective case series.

METHODS

An analysis of pediatric patients with acute complicated mastoiditis treated at an urban, tertiary care children's hospital from 2007 to 2014 was performed.

RESULTS

Forty-eight patients presented with a total of 67 complications of acute mastoiditis. Mean age at presentation was 4.8 years (range = 0.1-15.3 years). The most common complications were subperiosteal abscess (n = 22, 45.8%), epidural abscess (n = 16, 33.3%), and sigmoid sinus thrombosis (n = 14, 29.2%). The most common pathogens isolated included Streptococcus pneumoniae (n = 14, 29.2%) and group A streptococcus (n = 10, 20.8%). Multidrug resistance was not associated with complication type. Surgical management included myringotomy ± tympanostomy tube placement in 46 (95.8%) patients (the only surgery in 10), drainage of subperiosteal abscess without mastoidectomy in 18 (37.5%) patients, and mastoidectomy in 21 (43.8%) total patients. Patients presenting with intracranial complications were the most likely to undergo a mastoidectomy. Anticoagulation was used in the management of nine of 14 (64.3%) patients presenting with sigmoid sinus thrombosis. Neurosurgical interventions (n = 7, 14.6% patients) were primarily performed to manage increased intracranial pressure.

CONCLUSIONS

Subperiosteal abscess was the most common complication of acute mastoiditis, and when occurring as the sole complication was successfully managed with antibiotics and surgical intervention that did not include mastoidectomy. Epidural abscess and sigmoid sinus thrombosis were more prevalent than reported in prior series and were managed more aggressively. These patients were more likely to need neurosurgical interventions.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2321-2327, 2017.

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.

Incidental mastoid opacification in children on MRI

BACKGROUND

The opacification the mastoid cavity is frequently reported by radiologists on cross-sectional imaging done for non-otological indications. It is well known that presence of fluid the mastoid does not amount to mastoiditis. This study seeks to provide an evidence-based confirmation of this known finding.

OBJECTIVE

The purpose of our study was to determine the prevalence of mastoid opacification in children undergoing outpatient brain MRI examination.

MATERIALS AND METHODS

Our study included 515 outpatient children who had brain MRI for indications other than mastoiditis or otitis media from January 2014 to March 2014. Children with history of skull base trauma or radiation were excluded. The age range was 15 days to 18 years. The overall prevalence of mastoid opacification was determined using one sample proportion and exact 95% Clopper-Pearson confidence intervals. The prevalence of mastoid opacification was analyzed based on gender, age and presenting symptoms using chi-square test of association.

RESULTS

One hundred ten children (21.4%) had mastoid opacification. Younger patients tended to have higher opacification rates with the prevalence in children younger than 1 year of age and between 1 and 2 years of age as high as 41.7% (20/48) and 47.5% (38/80), respectively.

CONCLUSION

The diagnosis of mastoiditis in children should not be based upon a radiologist's report of finding fluid or mucosal thickening in the mastoid air cells as incidental opacification the mastoid is seen frequently.

Diagnosis and management of acute mastoiditis in a cohort of Italian children

OBJECTIVE

The Italian Society for Pediatric Infectious Diseases created a registry to determine the management of pediatric acute mastoiditis (AM) in Italy.

METHODS

A cross-sectional survey of paediatricians was conducted to evaluate hospitalization due to AM in Italian pediatric wards between 1 January 2002, and 31 December 2013.

RESULTS

A total of 913 children (561 males, 61.4%) were included in this study. The annual number of AM cases significantly increased during the study period (30 in 2002 and 98 in 2013) but only among older children (≥ 4 years old; p = 0.02). AM complications occurred in 69 (7.6%) of the children and sequelae were observed in 13 (1.4%) patients.

CONCLUSION

The annual number of pediatric AM cases admitted to Italian pediatric wards increased in the past few years; this increase was strictly age-related. The risk of severe AM complications appeared relatively low, and most AM cases could be treated conservatively.

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.

Infants under the age of six months with acute mastoiditis. A descriptive study of 15 years in Sweden

OBJECTIVE

To investigate the occurrence, clinical signs and outcome of acute mastoiditis in infants under the age of 6 months in Sweden between the years 1993-2007.

METHODS

All ENT departments in Sweden reported children 0-5 months treated for acute mastoiditis 1993-2007 and all records were reviewed. The clinical course and various characteristics were recorded.

RESULTS

Seventeen young infants with acute mastoiditis were identified. Three patients had suffered acute otitis media earlier, otherwise the children were previously healthy. Preceding the episode of acute mastoiditis, the children had an upper respiratory tract infection or fever for seven days in mean (median three days) and the mean number of days with ear-symptoms was three days (median two days). Three patients were treated with antibiotics prior to admittance. Almost all children presented with clear retroauricular signs with protruding ear and redness behind the ear. The children were hospitalised for six days (mean and median). Eight patients (47%) suffered from a subperiosteal abscess. All but one patient underwent surgery: myringotomy (13); incision or punction of the mastoid (5); mastoidectomy (3). Streptococcus pneumoniae was the most frequent bacterium identified in cultures. No intracranial complications or other severe complications were found.

CONCLUSION

Acute mastoiditis is extremely rare in infants under the age of 6 months. The patients in this study did not have any predisposing diseases. An upper respiratory tract infection had preceded the episode of acute mastoiditis for some time in the majority of cases, but the time from first ear symptoms to hospitalization was very short. Acute mastoiditis is a potentially life-threatening disease, but the timely administration of intravenous antibiotics and surgical intervention prevented the occurrence of severe complications in these young infants.

[Facial nerve paralysis secondary to acute otitis media]

OBJECTS

To discuss clinical presentation and therapeutic approaches of facial paralysis in acute otitis media.

METHODS

We present five cases of facial palsy in children with acute otitis media managed in our ENT department during a period of 12 years (2001-2012).

RESULTS

The mean age was 14.2 years; sex ratio was 0.66. All patients presented with a facial asymmetry, but only 3 of them had otalgia before the onset of facial asymmetry. The facial palsy delay was 3.3 days. The ear examination showed that the tympanic membrane was congestive in 4 patients, associated with a bulging in 2 patients, and a small perforation in one patient. Our patients presented grade III to IV initial facial palsy according to House and Brackmann staging. Computed tomography scan revealed a dehiscence of the bony facial canal in one patient. Antibiotic therapy associated with intravenous corticosteroids was administered in all patients. All patients underwent a facial kinesis therapy. A progressive improvement of facial palsy was observed in 4 patients and complete recovery of facial function in one case.

DISCUSSION

Conservative treatment associating intravenous antibiotic and corticosteroids with or without myringotomy is the standard approach.

The management of acute mastoiditis in children with cochlear implants: saving the device

OBJECTIVE

Early treatment of profound bilateral sensorineural hearing loss with cochlear implantation has become routine, resulting in an increased proportion of children implanted at younger ages. These children are at a relatively high risk for acute otitis media (AOM), and are more likely to develop mastoiditis in the implanted ear. Despite the significant risks associated with mastoiditis, including compromise of the implant, there are no specific guidelines on the management of this population. We propose a treatment algorithm emphasizing early but conservative operative intervention.

METHODS

A retrospective chart review included eight patients, who experienced mastoiditis, in the context of cochlear implantation at our center from August 2005 to November 2012. During this period 806 implant surgeries were completed.

RESULTS

The median age at which mastoiditis occurred was 37 months, and the mean time from implantation to mastoiditis was 9.56 months. All patients underwent drainage of the middle ear in conjunction with intravenous antibiotics, and two additionally underwent post-auricular incision and drainage.

DISCUSSION

Recent mastoidectomy may be a risk factor for the development of a post-auricular abscess in children, who develop AOM following cochlear implantation. A treatment algorithm was developed, which emphasizes early operative drainage in conjunction with aggressive antibiotic therapy. Conclusions A consistent approach to the management of mastoiditis in children with cochlear implants has not been established. Rapid initiation of aggressive antibiotic therapy and a low threshold for conservative operative intervention results in effective resolution of infection while allowing preservation of the implant.

Facial palsy complicated by masked otomastoiditis in a 3-month-old infant

BACKGROUND

The most common cause of facial palsy is idiopathic or Bell's palsy. Although uncommon in the postantibiotic era, otomastoiditis should receive more attention as a cause of facial palsy, especially in young children. Delay of identification and treatment may result in permanent neurological sequelae.

OBJECTIVES

To describe a 3-month-old infant eventually diagnosed with masked otomastoiditis with initial presentation of facial palsy.

CASE REPORT

We report a case of facial palsy complicated by masked otomastoiditis in a 3-month-old male infant. The facial palsy completely recovered after parenteral antibiotics and myringotomy.

CONCLUSION

We use this case to emphasize that otomastoiditis should be considered in the differential diagnosis of young children with facial palsy. Diagnosis may be difficult as signs and symptoms of otitis media in young children are often nonspecific and subtle, particularly in infants. Early diagnosis and careful investigation of middle ear regions should be performed to avoid permanent sequelae.

Otorrhea as a sign of medical treatment failure in acute otitis media: two cases with silent mastoiditis complicated with facial palsy

We report two children with otitis media who developed facial palsy despite prompt antibiotic therapy. Brain images revealed silent mastoiditis. Persistent otorrhea may be a cautious sign of medical treatment failure or complication of acute otitis media, including mastoiditis or facial palsy. Delayed identification of coexisting mastoiditis or hesitation over surgical intervention may lead to treatment failure and complications. Adequate intravenous antibiotics and myringotomy provide reasonable and appropriate management to prevent permanent sequelae.

What effect has pneumococcal vaccination had on acute mastoiditis?

BACKGROUND

Streptococcus pneumoniae is a frequent cause of acute mastoiditis. Despite the recent (2005) introduction of pneumococcal vaccination, mastoiditis incidence and severity may be increasing. This study aimed to assess the incidence, severity and microbiology of acute mastoiditis over an 11-year period.

METHODS

Retrospective review of paediatric acute mastoiditis cases seen at our institution (2000-2010), comparing patients seen prior to vaccination introduction (period one, 2000-2004), around the time of vaccine introduction (period two, 2005-2007) and post-vaccination (period three, 2008-2010).

RESULTS

We reviewed 84 children. In periods one, two and three, respectively: mean annual case load was 8.4, 5 and 9 children; pneumococcal isolates were seen in 40.5, 6.7 and 29.6 per cent of cases; highest recorded fever was 38.6, 38.9 and 38.2°C and highest leukocyte count 18.9, 15.0 and 15.6 × 109/l; incidence of intracranial complications was 11.9, 0 and 7.4 per cent; mean duration of intravenous antibiotics was 6.0, 4.1 and 4.2 days; proportion treated surgically was 71.4, 60.0 and 48.1 per cent; and mean length of in-patient stay shortened.

CONCLUSION

Pneumococcal mastoiditis admission rates appeared to fall when vaccination was introduced, with concomitant reduction in overall mastoiditis incidence and intracranial complications; subsequently, however, admission rates rapidly returned to pre-vaccination levels.

Acute mastoiditis in children aged 0-16 years--a national study of 678 cases in Sweden comparing different age groups

OBJECTIVE

To compare the characteristics of acute mastoiditis in children in different age groups in order to identify risk groups and risk factors for acute mastoiditis.

METHODS

Records for all children aged 0-16 years treated for acute mastoiditis during 1993-2007 at 33 Ear, Nose and Throat departments in Sweden were reviewed retrospectively according to defined criteria for acute mastoiditis.

RESULTS

A total of 678 cases fulfilled the inclusion criteria. Acute mastoiditis was most common in children younger than two years of age and this group was characterized by less prior history of other diseases and ear diseases, fewer visits to health care centers and less antibiotic treatment before admission, shorter duration of symptoms before admission, hospitalization for fewer days and lower frequency of complications and mastoidectomies. These children also showed a higher incidence of clinical findings, increased inflammatory markers such as fever and heightened counts of C-reactive protein and white blood cells compared with older children. They also tested positive for significantly more samples of Streptococcus pneumoniae while the older children more often exhibited growth of Streptococcus pyogenes or Pseudomonas aeruginosa or no microbial growth.

CONCLUSIONS

The characteristics of pediatric acute mastoiditis differed significantly between age groups. Acute mastoiditis was most common in children younger than two years of age. They showed more rapid progress of symptoms and more distinct signs of acute mastoiditis. This is probably the reason why parents rapidly seek medical care for small children and hospital treatment thus starts earlier in the youngest children, which may in turn explain the excellent outcome. This study showed that younger children have neither more severe acute mastoiditis nor more complications than older ones. The differences between age groups suggest that there are distinctions in the pathophysiology behind the onset and course of acute mastoiditis in younger and older children.

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 in Sweden 1993-2007--no increase after new guidelines

OBJECTIVE

To study whether the incidence and characteristics of acute mastoiditis in children changed in Sweden following the introduction of new guidelines for diagnosis and treatment of acute otitis media advocating "watchful waiting" as an option in children 2-16 years of age with uncomplicated acute otitis media.

METHODS

The records for all patients treated for mastoiditis during 1993-2007 at all Ear, Nose and Throat departments in Sweden were reviewed retrospectively according to defined criteria for acute mastoiditis. In this study the data from children aged 0-16 years were analyzed and compared 71/2 years before and 71/2 years after the introduction of the new guidelines in 2000.

RESULTS

A total of 577 cases aged 0-16 years fulfilled the inclusion criteria during the whole study period. Cases involving cholesteatoma were excluded. The number of children affected by acute mastoiditis did not increase after the introduction of new guidelines. Acute mastoiditis was most common in children younger than two years of age. The proportion of acute mastoiditis increased after 2000 in the group aged 2-23 months although they were not affected concerning treatment by the new guidelines. No decrease was found in the frequency of prehospital antibiotic treatment among the children admitted with acute mastoiditis, and no increase was seen in the duration of ear symptoms before hospital admission, duration of hospital stay, or in the frequency of complications or mastoidectomies, after the introduction of the new guidelines in either group of children.

CONCLUSIONS

The incidence of acute mastoiditis in children in Sweden did not increase following the introduction of new guidelines in 2000 for the diagnosis and treatment of acute otitis media. This is despite the fact that a significant decrease in antibiotic prescriptions for otitis media has been reported during the same time period. The characteristics of acute mastoiditis reflecting severity of illness did not change over time. Acute mastoiditis was most common and increased after 2000 only in children younger than two years of age in which antibiotics were still recommended in all cases of acute otitis media.

Intratemporal complications from acute otitis media in children: 17 cases in two years

BACKGROUND

To describe the clinical features of intratemporal complications of acute otitis media (AOM) in children, a retrospective study was carried out for two years.

METHODS

We considered acute mastoiditis, presence of postauricular swelling, erythema and tenderness and anteroinferior displacement of the auricle; labyrinthitis, presence of vestibular symptoms (spontaneous nystagmus and ataxia with or without vomiting; and facial nerve palsy, absence or decreased motility in hemiface. All children underwent otomicroscopy for evidence of coexistent or recent AOM. Cultures were obtained by tympanocentesis and myringotomy, drainage of subperiosteal abscess or from granulation tissue during tympanomastoidectomy.

RESULTS

From January 2008 to December 2009, 17 patients fulfilled the entry criteria. Median age: 54.2 months. Of the 17 cases, 30% were infants younger than twelve months and most were boys (70.6%). 8/17 were receiving antimicrobial treatment. Diagnoses included 9/17 (52.9%) acute mastoiditis, 7/17 (41.2%) labyrinthitis and 1/17 (5.9%) facial nerve palsy. Intracranial complications were present in 17.6%. All required intravenous antimicrobial treatment. Myringotomy was performed in 16/17, drainage of subperiosteal abscess in 3/17 and tympanomastoidectomy in 2/17. Bacteriology was positive in 9/17 cases, isolating Streptococcus pyogenes (S. pyogenes) in 44% of patients. Secuelaes: One unilateral sensorineural hearing loss.

CONCLUSIONS

Acute mastoiditis is the most common complication. Labyrinthitis was diagnosed in 41.2% of cases. S. pyogenes was prevalent in these serious invasive infections in our area. Associated intracranial complications were present in 17.6% cases. Resolution of AOM complications required surgical procedures in all cases (myringotomy, drainage of subperiosteal abscess or tympanomastoidectomy).

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.

Shifting trends: mastoiditis from a surgical to a medical disease

OBJECTIVE

The aim of this study is to review the outcome of pediatric patients suffering from acute mastoiditis treated conservatively and to correlate this to the evolution of our understanding of the shift in which mastoiditis has been transformed from a surgical to a medial disease.

METHODS

We performed a retrospective review patient files hospitalized in our tertiary-care center between 2005-2008. We examined the data concerning the infection which included: presenting signs/symptoms, prior otologic history, treatment (including both surgical and conservative) prior to hospitalization and during hospitalization, computed tomography (CT), hospital duration, complications and overall outcome. This data was analyzed and compared between different patients who underwent different treatment strategies.

RESULTS

Fifty-one patients were included in this retrospective review. Initially, forty-nine patients admitted to our hospital were treated conservatively. This treatment included intra-venous antibiotics, myringtomy and if needed subperiosteal abscess incision and drainage. Only 2 patients underwent CT scanning on admission. Further on, during hospitalization 4 additional patients underwent CT scanning due to continued fever or progression of local disease. All four CT scans showed no intra-cerebral complications, and so all continued with conservative treatment.

CONCLUSION

Most cases of acute mastoidits may be treated with a conservative therapy regime. This regime, in our opinion, should include three branches: the first intravenous antibiotic therapy using a broad spectrum antibiotic. The second is myringotomy and the third branch is incision and drainage of subperiosteal abscess when needed.

Loss of the group A Streptococcus regulator Srv decreases biofilm formation in vivo in an otitis media model of infection

Group A Streptococcus (GAS) is a common causative agent of pharyngitis, but the role of GAS in otitis media is underappreciated. In this study, we sought to test the hypothesis that GAS colonizes the middle ear and establishes itself in localized, three-dimensional communities representative of biofilms. To test this hypothesis, the middle ears of chinchillas were infected with either a strain of GAS capable of forming biofilms in vitro (MGAS5005) or a strain deficient in biofilm formation due to the lack of the transcriptional regulator Srv (MGAS5005 Δsrv). Infection resulted in the formation of large, macroscopic structures within the middle ears of MGAS5005- and MGAS5005 Δsrv-infected animals. Plate counts, scanning electron microscopy, LIVE/DEAD staining, and Gram staining revealed a difference in the distributions of MGAS5005 versus MGAS5005 Δsrv in the infected samples. High numbers of CFU of MGAS5005 Δsrv were isolated from the middle ear effusion, and MGAS5005 Δsrv was found randomly distributed throughout the excised macroscopic structure. In contrast, MGAS5005 was found in densely packed microcolonies indicative of biofilms within the excised material from the middle ear. CFU levels of MGAS5005 from the effusion were significantly lower than that of MGAS5005 Δsrv early during the course of infection. Allelic replacement of the chromosomally encoded streptococcal cysteine protease (speB) in the MGAS5005 Δsrv background restored biofilm formation in vivo. Interestingly, our results suggest that GAS naturally forms a biofilm during otitis media but that biofilm formation is not required to establish infection following transbullar inoculation of chinchillas.

Acute mastoiditis in southern Sweden: a study of occurrence and clinical course of acute mastoiditis before and after introduction of new treatment recommendations for AOM

Watchful waiting was recommended as an option for uncomplicated episodes of acute otitis media in Sweden in the year 2000. Concern was raised that these recommendations would lead to a higher incidence of acute mastoiditis. The aim of this study was to map the occurrence, treatment policy and the clinical course of mastoiditis before and after the new treatment recommendations were introduced. Included in the study were all patients (adults and children) who were admitted to two ENT departments in southern Sweden for acute mastoiditis from 1996 to 2005. A total of 42 cases of mastoiditis were identified: 23 during the first period of 1996-2000 and 19 during 2001-2005. Mastoidectomy was performed in 14 patients during the first period and in 8 during the second period. As much as 39% of mastoiditis patients received antibiotics before hospital care, but had no improvement. There was no indication that the number of patients with acute mastoiditis was increasing after new treatment recommendation of AOM. There was no increase in the occurrence of mastoidectomy. Severe complications of mastoiditis were rare. Although there were potentially threatening complications of mastoiditis in the study, these did not lead to sequelae. It is important to follow up the consequences when treatment recommendations of AOM are changed.