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

Clinical Characteristics and Treatment Experiences of Pediatric Acute Mastoiditis and Its Complications at the University Tertiary Care Center in the 10-Year Prevaccinal Period

Introduction: We aim to provide an overview of the clinical characteristics and treatment of pediatric acute mastoiditis (AM) and its complications in the prevaccinal pneumococcal period. Materials and methods: Retrospective case series. An analysis of pediatric patients with AM treated at a university tertiary care center from 2008 to 2018 was performed. Results: The research included 121 children, and 27.3% of them had some form of complication. The mean age at presentation of AM was 3.7 years (range = 0-18 years). The most common extracranial complication of AM was a subperiosteal abscess (n = 25, 75.8%) and the most common intracranial complication was meningoencephalitis (n = 2, 6%). The most common pathogen isolated in the complicated AM was Streptococcus pneumoniae (n = 17, 51.5%). A total of 60% of patients reported antibiotic use before hospital admission, mostly third-generation cephalosporins (37.5%). There was a statistically significant difference between age group and occurrence of complications (P = .001). Females had complications more frequently than males (P = .035). There were no statistically significant differences in levels of inflammatory parameters (C-reactive protein and leukocyte count) between patients with or without complications (P = .373 and P = .124; respectively). All patients with complications of AM were surgically treated. Mortality was 0% and all children completely recovered. Conclusion: Extracranial and intracranial complications of AM required surgical treatment and extended antibiotic therapy. Inflammation parameters did not have a predictive role in identifying children with complications of AM. Further investigations will determine whether the introduction of the mandatory pneumococcal vaccine in our country has led to a reduction in the incidence of AM and its complications.

Acute mastoiditis in children: A tertiary care center experience in 2015-2021

Background

Acute mastoiditis is a suppurative infection of mastoid air cells and is the most common intratemporal complication of otitis media.

Aim

This study aimed to evaluate the demographic and clinical characteristics and treatment outcomes of children with acute mastoiditis (AM).

Patients and Methods

We retrospectively reviewed the medical records of hospitalized pediatric patients aged between 1 month and 18 years with a diagnosis of AM between May 2015 and December 2021.

Results

A total of 28 hospitalized children with AM were enrolled in this study, of whom 22 (78.6%) were males and 6 (21.4%) were females with a mean ± standard deviation age of 93.5 ± 53.2 months (range = 6 months-16.1 years). The most common clinical symptoms were postauricular erythema (n = 17, 60.7%), tenderness (n = 16, 57.1%), swelling (n = 14, 50%), fever (n = 14, 50%), and auricular protrusion (n = 7, 25%). Mastoiditis complications occurred in 10 (35.7%) children. The most common extracranial complication was subperiosteal abscess (n = 8, 28.6%). The erythrocyte sedimentation rate (ESR) and the rate of antibiotic use before hospitalization were higher in patients with complicated mastoiditis (P = 0.006 and P = 0.039, respectively). Surgery was performed in 12 (42.9%) patients. Statistically, more surgical interventions were performed in patients who developed complications (P = 0.003).

Conclusion

AM continues as an important disease of childhood. Successful results are obtained with systemic antibiotic therapy and additional surgical intervention as necessary. A careful evaluation of patients with a high ESR and those who received antibiotic therapy before hospitalization is appropriate due to the correlation between these factors and the risk of complication development.

Differences in mastoid and middle-ear cavity opacification in CT between intensive care patients and patients with acute mastoiditis requiring surgical treatment

Purpose

To stratify differences in visual semantic and quantitative imaging features in intensive care patients with nonspecific mastoid effusions versus patients with acute mastoiditis (AM) requiring surgical treatment.

Methods

We included 48 patients (male, 28; female, 20; mean age, 59.5 ± 18.1 years) with mastoid opacification (AM, n = 24; control, n = 24) who underwent clinically indicated cerebral CT between 12/2007 and 07/2018 in this retrospective study. Semantic features described the extend and asymmetry of mastoid and middle-ear cavity opacification and complications like erosive changes. Minimum, maximum and mean Hounsfield unit (HU) values were obtained as quantitative features. We analyzed the features employing univariate testing.

Results

Compared to intensive care patients, AM patients revealed asymmetric mastoid or middle-ear cavity opacification (likelihood-ratio (LR) < 0.001). Applying a dedicated threshold of the extent of opacification, AM patients reached significance levels of LR = 0.042 and 0.002 for mastoid and middle-ear cavity opacification. AM cases showed higher maximum and mean HU values (p = 0.009, p = 0.024).

Conclusions

We revealed that the extent and asymmetry of mastoid and middle-ear cavity opacification differs significantly between AM patients and intensive care patients. Multicenter research is needed to expand our cohort and possibly pave the way to build a non-invasive predictive model for AM in the future.

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.

Complications in Pediatric Acute Mastoiditis: HCUP KID Analysis

OBJECTIVE

A small proportion of children with otitis media develop acute mastoiditis, which has the potential to spread intracranially and result in significant morbidity and mortality. The aim of this study was to evaluate the incidence and management of complications related to pediatric acute mastoiditis using a national database.

STUDY DESIGN

Retrospective review of 2016 Kids' Inpatient Database, part of the Healthcare Cost and Utilization Project.

SETTING

Academic, community, general, and pediatric specialty hospitals in the United States.

METHODS

International Classification of Diseases, Tenth Revision, Clinical Modification code H70.XXX was used to retrieve records for children admitted with a diagnosis of mastoiditis. Data included patient demographics, intracranial infections, procedures (middle ear drainage, mastoidectomy, and intracranial drainage), length of stay (LOS), and total charges.

RESULTS

In total, 2061 children aged ≤21 years were identified with a diagnosis of acute mastoiditis. Complications included subperiosteal abscess (6.90%), intracranial thrombophlebitis/thrombosis (5.30%), intracranial abscess (3.90%), otitic hydrocephalus (1.20%), encephalitis (0.90%), subperiosteal abscess with intracranial complication (0.60%), petrositis (0.60%), and meningitis (0.30%). Children with intracranial abscesses were more likely (P < .001) to undergo myringotomy ± ventilation tube insertion (63.7%), mastoidectomy (53.8%), mastoidectomy with ventilation tube or myringotomy (42.5%), intracranial drainage procedure (36.3%), or all 3 key procedures (15.0%). Children with any type of intracranial complication had a significantly longer LOS (P < .001) and higher total charges (P < .001). Both a diagnosis of bacterial meningitis and undergoing an intracranial drainage procedure (P < .001) contributed significantly to LOS and total charges.

CONCLUSION

Patients with intracranial complications are more likely to undergo surgical procedures; however, there is still wide variability in practice patterns, illustrating that controversies in the management of otitis media complications persist.

Acute mastoiditis in a newborn with 11 days of life: Case report

Acute mastoiditis is a potentially life-threatening complication and extremely rare in children under six months. We herein report the case of a 11-days-old newborn with acute mastoiditis complicated by subperiosteal abscess, submitted to surgical and medical treatment. A transient hypogammaglobulinemia was finally diagnosed and successfully managed without complications. Early recognition of this rare immunological disorder and prompt intervention are critical to prevent further complications.

Acute mastoiditis in children

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

Therapeutic approach to pediatric acute mastoiditis – an update

Introduction

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

Objective

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

Methods

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

Results

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

Conclusions

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

Pediatric recurrent acute mastoiditis: Risk factors and insights into pathogenesis

OBJECTIVES

Recurrent acute mastoiditis is repeatedly reported in the literature, but data to understand the pathogenesis, update treatment recommendations and inform future trials are sparse due to the infrequency of the disease.

METHODS

A retrospective chart review from 2001 to 2016 was conducted including 73 children treated for acute mastoiditis. A follow-up survey was attempted for each patient. Bacteriology, method of treatment, hospital course, complications, and otologic history were analyzed. A chi-squared test, Fisher's exact test and Mann-Whitney U test compared recurrent acute mastoiditis to single acute mastoiditis cases. Additionally, a comprehensive PubMed search and review of world literature addressing recurrent pediatric acute mastoiditis was performed for comparative purposes.

RESULTS

Among 73 children with acute mastoiditis, six (8%) experienced recurrent acute mastoiditis. Streptococcus pneumoniae was the only bacteria isolated in this group. History of recurrent acute otitis media (>4 per year) prior to the first episode of acute mastoiditis was identified in 24% with single episode of acute mastoiditis and 83% with recurrent mastoiditis (p < 0.05). Fewer intracranial/intratemporal complications were identified among recurrent mastoiditis patients (p < 0.05). In a group of patients treated with more extensive surgical communication during mastoidectomy for primary acute mastoiditis (wide mastoidectomy with broad attic exposure and posterior tympanotomy) no recurrence was observed.

CONCLUSION

We identify multiple risk factors associated with recurrence and provide early data supporting anatomic predisposition to the development of recurrent acute mastoiditis. More aggressive opening between the mastoid cavity and middle ear may prevent recurrent acute mastoiditis episodes.

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.

Differentiating between rhinosinusitis and mastoiditis surgery from postmortem medical training: A study of two identified skulls and hospital records from early 20th century Coimbra, Portugal

Differentiating between medical procedures performed antemortem, perimortem or postmortem in skeletal remains can be a major challenge. This work aims to present evidence of procedures to treat rhinosinusitis (RS) and mastoiditis, suggest criteria for the diagnosis of frontal sinus disease, and frame the individuals described in their medical historical context. In the International Exchange collection, the skull (878) of a 24-year-old male, who died in 1933 due to frontal sinusitis and meningitis, presents evidence of a trepanation above the right frontonasal suture, and micro/macroporosity on the superciliary arches. The available Coimbra University Hospitals archives (1913-1939) reported that 46 females and 59 males (aged 15 months-84 y.o., x̄=35.33) underwent surgery to treat RS, primarily by trepanation (94.3%). In a search for similar evidence in the collection, the skull of a 42-year-old female (85), who died in 1927 due to sarcoma in the abdomen, shows four quadrangular holes located above the right supraorbital notch, right and left maxilla, and left mastoid process. The number/location of the holes and cut marks point to postmortem medical training (possible dissection). This paper discusses the value of information from historical contexts to differentiate between surgery and medical training in the paleopathological record.

Acute mastoiditis in children: Middle ear cultures may help in reducing use of broad spectrum antibiotics

BACKGROUND

Acute mastoiditis (AM) is a suppurative infection of the mastoid air cells, representing the most frequent complication of acute otitis media. AM remains an important entity in children due to its potential complications and sequelae. We aim to describe the cases of AM admitted at our department, identify risk factors potentially associated with complications and analyse the changes in clinical approach of AM over time.

METHODS

Case review of clinical files of children admitted with acute mastoiditis from June 1996 to May 2013 at a Lisbon metropolitan area hospital. Data was divided into two groups (prior and after May 2005) in order to evaluate changes in AM approach over the years.

RESULTS

135 AM episodes were included. The median age was 3.8 years and 42% children were less than 24 months of age. Symptoms at presentation included fever (69%), ear pain (56%) and otorrhea (40%). Complications occurred in 22% patients and were more common in children under 24 months (33% vs 15%, p ≤ 0.01). Leukocyte count was significantly higher in children with complications (16.7 vs 14.5 × 10⁹/μL, p ≤ 0.05) as was C-Reactive Protein value (13 vs 6.3 mg/dL, p ≤ 0.001). There was a significant association between the development of complications and C-Reactive Protein value at admission (OR 1.892; IC95%: 1.018-2.493, p ≤ 0.01). The optimal cut-off value was 7.21 mg/dL. Over time there was a significant increase in middle ear cultures obtained by tympanocentesis during surgery (2% vs 16%, p ≤ 0,01) and also a decrease in the use of broad spectrum antibiotherapy as initial treatment (52% vs 25%,p ≤ 0,001).

CONCLUSIONS

Children under 24 months, with high leukocyte count or with high C-Reactive Protein value should be monitored closely since complications tend to be more frequent. A CRP value of 7.21 mg/dL at admission seems to be a good cut-off to monitor children for potential complications. Throughout the period analysed more cultures were performed allowing identification of the pathogens and implementation of appropriate antibiotic therapy.

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.

Subperiosteal abscesses in acute mastoiditis in 115 Swedish children

OBJECTIVES

To study the outcome of different surgical methods of treating subperiosteal abscesses resulting from acute mastoiditis.

METHODS

Medical records for all children from a Swedish retrospective multicentre study, conducted between 1993 and 2007, with acute mastoiditis and subperiosteal abscess, but without predisposing diseases or other complications, were studied. A total of 115 children aged 0-16 years were identified. All patients had received intravenous antibiotics and most had undergone myringotomy.

RESULTS

Thirty-three children had been treated with only minor interventions such as retroauricular needle aspiration and/or incision, while 67 had undergone mastoidectomy. Fifteen had undergone both needle aspiration and mastoidectomy. The group treated with needle aspiration/incision was compared with those treated with mastoidectomy. One of the few significant differences found between the groups was a longer hospital stay in the group that had undergone mastoidectomy.

CONCLUSIONS

Retroauricular needle aspiration and/or incision combined with intravenous antibiotics and myringotomy was an effective first-line treatment for subperiosteal abscesses resulting from acute mastoiditis. In this retrospective study, no greater risk of further complications was seen in this group compared to the group in which mastoidectomy was performed.

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.

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.

Recurrent acute mastoiditis - a retrospective national study in Sweden

CONCLUSIONS

Recurrences were seen in 5% of all patients with acute mastoiditis (AM). Mastoidectomy had been performed in the majority of the patients with recurrences at their first episode of AM. Compared with the group with a single episode of AM, the recurrent group exhibited more subperiosteal and ear canal abscesses, although they were not more severely ill. It appears from this study that previous mastoidectomy itself could predispose patients to recurrent AM (rAM), perhaps due to easier access to the mastoid cavity and/or due to a reduction in mucosal lining.

OBJECTIVE

To retrospectively study the incidence and characteristics of rAM in Sweden.

METHODS

Data from patients with rAM were reviewed and compared with data from patients with a single episode of AM during 1993-2007 in 33 ear, nose and throat departments in Sweden.

RESULTS

Of 798 cases fulfilling the criteria for AM, 36 patients (5%) had experienced one or more recurrences, of which 4 patients (11%) had concurrent cholesteatoma. More than 50% of the patients had their first episode of AM before the age of 2 years. There was a highly significant difference between the two groups concerning the frequency of mastoidectomies and subperiosteal/retroauricular abscesses. However, other clinical characteristics, including severe complications, did not differ significantly. The majority of recurrences were treated conservatively with myringotomy and intravenous antibiotics, and also with aspiration/incision if a subperiosteal/retroauricular abscess was present.

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.

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

Objective:

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

Method:

A case report and literature review are presented.

Results:

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

Conclusion:

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

Algorithmic management of pediatric acute mastoiditis

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acute mastoiditis in children 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.

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.

Bilateral mastoiditis from red tide exposure

BACKGROUND

Bilateral mastoiditis in adults has previously been reported only in association with diabetes mellitus or immunocompromised patients.

OBJECTIVES

To describe a case of bilateral mastoiditis in a healthy adult and to investigate the etiology.

CASE REPORT

A 53-year-old woman presented to the Emergency Department with bilateral otitis externa and mastoiditis after scuba diving during a harmful algal bloom, commonly known as a "red tide." The levels of coliform bacteria recorded at the time and location of her dive exceeded health regulatory limits and correlate with her atypical culture results.

CONCLUSION

Elevated bacterial counts that result from harmful algal blooms may account for this rare infection.

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.

Cost-effectiveness analysis of a universal vaccination programme with the 7-valent pneumococcal conjugate vaccine (PCV-7) in Sweden

The 7-valent pneumococcal conjugate vaccine (PCV-7) has proved to be highly effective against invasive pneumococcal disease and has also provided some protection against all-cause pneumonia and acute otitis media. The objective of this study was to evaluate the projected health benefits, costs and cost-effectiveness of vaccination with the 7-valent conjugated pneumococcal vaccine compared with no vaccination, in all infants in Sweden, taking herd immunity into account. A Markov model was used and a hypothetical birth cohort was simulated for a lifelong perspective. The results show that vaccination of 1 cohort could potentially prevent 9 cases of pneumococcal meningitis, 22 cases of pneumococcal septicaemia, 509 cases of hospitalized pneumonia, 7812 cases of acute otitis media, and 2.7 fatalities, among children 0-4 y of age and 6 episodes of pneumococcal meningitis and 167 cases of pneumococcal septicaemia among adults. The incremental cost per QALY and LY gained was estimated to Euro 29,200 and Euro 51,400, respectively. When herd immunity was accounted for, the cost per QALYand LY gained was estimated to Euro 5500 and Euro 6600, respectively. Thus, the health benefits of a national vaccination programmeme can be achieved within a 'moderate' or 'low' cost per QALY gained.

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.

Cost effectiveness of adding 7-valent pneumococcal conjugate (PCV-7) vaccine to the Norwegian childhood vaccination program

BACKGROUND

Streptococcus pneumoniae is a frequent bacterial cause of serious infections that may cause permanent sequelae and death. A 7-valent conjugate vaccine may reduce the incidence of pneumococcal disease, but some previous studies have questioned the cost-effectiveness of the vaccine. The aim of this study was to estimate costs and health consequences of adding this pneumococcal vaccine to the Norwegian childhood vaccination programme, taking the possibility of herd immunity into account.

METHODS

We developed a simulation model (Markov-model) using data on the risk of pneumococcal disease in Norway, the efficacy of the vaccine as observed in clinical trials from other countries and adjusted for serotype differences, the cost of the vaccine and quality of life for patients with sequelae from pneumococcal disease. The results were expressed as incremental (additional) costs (in euros; euro1.00 approximately NOK8.37), incremental life years and incremental quality adjusted life years. Four different sets of main results are presented: costs and (quality adjusted) life years, with and without indirect costs (the value of lost production due to work absenteeism) and with and without potential herd immunity (i.e. childhood vaccination protects adults against pneumococcal disease).

RESULTS

When indirect costs were disregarded, and four vaccine doses used, the incremental cost per life year gained was euro153,000 when herd immunity was included, and euro311,000 when it was not. When accounting for indirect costs as well, the cost per life year gained was euro58,000 and euro124,000, respectively. Assuming that three vaccine doses provide the same protection as four, the cost per life year gained with this regimen was euro90,000 with herd immunity and euro184,000 without (when indirect costs are disregarded). If indirect costs are also included, vaccination both saves costs and gains life years.

INTERPRETATION/CONCLUSION

In Norway, governmental guidelines indicate that only interventions with cost per life year of less than euro54,000 should be implemented. This implies that four dose vaccination is not cost-effective even if decision makers includes both herd immunity and indirect costs in their decisions. If three doses offer the same protection as four doses, however, vaccination would be cost-saving when indirect costs are included, but not with only herd immunity.

COMMENT

In the autumn of 2005, the Norwegian Government decided to include PCV-7 in the vaccination program. This analysis was used by the Ministry of Health and Ministry of Finance during the decision process.

Complications of acute otitis media in children

The clinical picture and the treatment of acute otitis media (AOM) and its complications have changed during the past decades. The availability of antibiotics has decreased the incidence of complications of AOM significantly. The treatment of complications of AOM is conservative in most cases. Mastoidectomy is needed when abscess-forming mastoiditis or intracranial complications develop. Although intratemporal and intracranial complications of AOM are rare today, they still cause morbidity, and need prompt treatment. Occasionally, permanent damage of the ear leads to hearing loss, vertigo, and sometimes, facial weakness. Antibiotic treatment has decreased the mortality associated with the complications of AOM, but it is still high in countries with developing health care systems. Early diagnosis and effective treatment of the complications are the bases for a good prognosis.

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.

Zygomatic abscess with temporal myositis - a rare extracranial complication of acute otitis media

Acute mastoiditis is the most common complication of acute otitis media (AOM) and its early recognition and management still poses a challenge due to potentially serious consequences. The incidences of extracranial and intracranial suppurative complications of AOM in children have decreased significantly, yet they remain a serious clinical problem, especially when caused by bacteria resistant to antibiotics. The authors presented a case of rare AOM complication - zygomatic abscess with temporal myositis. A 6-year-old boy was admitted to the ENT Department with 4 weeks of ear pain, treated for AOM with cefuroxime axetyl and amoxicilline, with acute mastoiditis and subsequent abscess formation in zygomatic and preauricular region. The inflammatory process spread through anterior air cells to the zygomatic cells leading to a fistula formation in the zygomatic bone and breakthrough into the temporal muscle. The surgical procedures applied were: myringotomy with drainage, cortical mastoidectomy and revision of zygomatic area and treatment with antibiotics (ceftriaxon). Enterococcus faecalis and Streptococcus viridans were found in the culture of middle ear and mastoid effusion. After half a year of follow-up the child had a normal hearing. Severe complications of AOM are rare today. An early diagnosis in order to promote adequate management and prevent inherently suppurative complications is essential.

Incidencia de complicaciones de otitis media

OBJECTIVE

Determine the incidence of otological and endocranial complications of acute otitis media, taking into account previous treatments and the development of complications.

MATERIAL AND METHODS

Retrospective follow-up study between March 1996-2003 including 16 patients: 9 men, 7 women.

RESULTS

Nine patients (56.25%) had intracranial complications and seven otological ones. In the first group, 6 developed meningitis by Streptococcus pneumoniae, one sigmoid sinus thromboflebitis, one multiple abscesses, and one subdural empiema and encephalitis. Otological complications were six acute mastoiditis and the other one a facial paralysis. The child with thromboflebitis underwent mastoidectomy and closed meningeal comunication; 5 of the acute mastoiditis were operated on and the other received traditional treatment. The meningitis received medication. Two died, one because of a subdural empiema and the other due to meningitis.

CONCLUSION

Despite the advances made by antibiotherapy and diagnosis, the complications of otitis media are still frequent. The pediatrician and otorhinolaryngologist should be on the alert for these as well as for Pneumococcus and its high resistance.

Facial nerve paralysis secondary to acute otitis media in infants and children

Nowadays, facial paralysis is an uncommon complication of acute inflammation of the middle ear, with an estimated incidence of 0.005%; it was not so rare in the pre-antibiotic era, occurring in 0.5-0.7% of middle ear inflammatory processes. We would like to highlight this complication of acute otitis media, a common paediatric complaint. We present three new cases of facial palsy in children with acute otitis media and discuss the etiological mechanisms and different approaches to the treatment; a flow chart for facial paralysis in acute otitis media is also presented. Our three patients recovered completely after mastoidectomy (first two cases) and myringotomy with antibiotic therapy (third case). Facial paralysis is an uncommon complication of otitis media which requires appropriate care. Following our experience and revision of literature on the subject, antibiotic therapy and myringotomy are the first-line procedures. Surgery should be employed in case of acute or coalescent mastoiditis, suppurative complications and lack of clinical regression.

Complications of acute otitis media in children in southern Finland

BACKGROUND

The incidence of intratemporal and intracranial complications of acute otitis media (AOM) has decreased and the need for operative treatment is declined in developed countries during the antibiotic era.

OBJECTIVES

To establish the clinical picture, diagnostic procedures, outcome and current treatment of pediatric patients with intratemporal and intracranial complications of AOM.

METHODS

A retrospective chart review with a sent questionnaire. All pediatric patients treated for intratemporal and intracranial complications of AOM over the past 10 years (1990-2000) at the Department of Otolaryngology in the Helsinki University Central Hospital.

RESULTS

During the study period 33 children (incidence 1.1/100,000 per year), aged from 3 months to 14.2 years were treated for intratemporal [97% (32/33)] and intracranial [3% (1/33)] complications of AOM. Facial paresis was found in 9% (3/33) of the patients. The only intracranial complication was an extradural abscess with meningitis. Eighteen patients (55%) were on antibiotic treatment because of AOM prior to the diagnosis of complication. Neither the duration or severity of the signs and symptoms of infection at the time of admittance nor a lack of antibiotic treatment before admittance were statistically significantly associated with the need for mastoidectomy or duration of hospitalization. Streptococcus pneumoniae 25% (8/33) and Pseudomonas aeruginosa 22% (7/33) were the most frequently found bacteria in the culture of middle ear and mastoid effusions. Mastoidectomy was performed on 55% (18/33) of the patients. After half a year of follow-up, all the patients had normal hearing and facial function.

CONCLUSIONS

Severe complications of AOM are rare today in southern Finland and the need for mastoidectomy has declined significantly. With early recognition and effective treatment of complications, the prognosis is good.

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.

Acute mastoiditis in Southern Israel: a twelve year retrospective study (1990 through 2001)

BACKGROUND

Acute mastoiditis is a serious complication of acute otitis media (AOM) and has been increasingly reported in the last decade.

OBJECTIVES

To report the experience accumulated with acute mastoiditis at the Soroka University Medical Center, Beer-Sheva, Israel, in a period of increasing antimicrobial resistance with Streptococcus pneumoniae.

PATIENTS AND METHODS

We reviewed the records of all children with acute mastoiditis hospitalized from 1990 through 2001. Acute mastoiditis was diagnosed when one or more of the physical signs of mastoiditis (swelling, erythema, tenderness of the retroauricular area and anteroinferior displacement of the auricle) were diagnosed in the presence of concomitant or recent (< or =4 weeks) AOM.

RESULTS

One hundred sixteen episodes of acute mastoiditis occurred in 101 children age 2 months to 14 years (median, 25 months; 19% <1 year old). The average yearly incidence was 6.1 cases per 100 000 population <14 years old, with a significant increase in the number of cases during the study period. Acute mastoiditis was the first evidence of AOM in 10 (10%) patients. Fever >38 degrees C and >15,000 WBC/mm3 were present in 67 and 43% of cases, respectively. Irritability, retroauricular swelling, redness and protrusion of the auricle occurred more commonly in patients <3 years old (79, 90, 84 and 76% vs. 28, 42, 45 and 30%, respectively, in patients > or =3 years old; P < 0.002). Computed tomography scans were performed in 54 of 116 (47%) cases and revealed bone destruction in 38 (70%). Periosteal abscess and lateral sinus vein thrombosis were diagnosed in 8 and 2 patients, respectively. Simple mastoidectomy was done in 32 of 116 (28%) cases, after no response to intravenous antibiotics was observed; ventilation tubes were inserted in 12 patients. Cultures were obtained at admission in 83 (72%) episodes (71 by tympanocentesis and 12 from ear discharges). Overall 43 pathogens were isolated: 34 at admission; 14 at surgery; and 5 at both occasions. The most commonly isolated organisms were S. pneumoniae (14 of 43, 33%; 4 penicillin-nonsusceptible), Streptococcus pyogenes (11 of 43, 26%), nontypable Haemophilus influenzae (6 of 43, 14%), Pseudomonas aeruginosa (5 of 43, 12%) and Escherichia coli (4 of 43, 9%). All S. pneumoniae organisms were isolated between 1996 and 2001.

CONCLUSIONS

(1) The incidence of acute mastoiditis in children in Southern Israel is greater than that reported in the literature; (2) a significant increase in the number of cases was recorded during the study period; (3) the clinical picture of acute mastoiditis was more severe in infants and young children; (4) the pathogen distribution in acute mastoiditis differs from that of AOM with significantly higher rates of S. pyogenes and lower rates of nontypable H. influenzae recovery; (5) penicillin-nonsusceptible S. pneumoniae played only a minor role in the etiology of acute mastoiditis in Southern Israel.