Mastoid subperiosteal abscess in children: drainage or mastoidectomy?

Trainee-perceived benefits of a virtual temporal bone competition

OBJECTIVE

To assess the perceived benefits of a novel educational approach for otolaryngology trainees: a virtual reality temporal bone simulator drilling competition.

METHODS

Regional otolaryngology trainees participated in the competition. Drilling activities using the Voxel-Man TempoSurg simulator were scored by experts. Questionnaires that contained questions covering motivators for attending, perceived learning and enjoyment were sent to participants. Agreement with statements was measured on a 10-point Likert scale (1 = strongly disagree, 10 = strongly agree).

RESULTS

Eighteen trainees participated. The most cited reason for attending was for learning and/or education (61 per cent), with most attendees (72 per cent) believing that competition encourages more reading and/or practice. Seventeen attendees (94 per cent) believed Voxel-Man TempoSurg-based simulation would help to improve intra-operative performance in mastoidectomy (mean 7.83 ± 1.47, p < 0.001) and understanding of anatomy (mean 8.72 ± 1.13, p < 0.001). All participants rated the competition as 'fun' and 83 per cent believed the competitive element added to this.

CONCLUSION

The virtual reality temporal bone competition is a novel educational approach within otolaryngology that was positively received by otolaryngology trainees.

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 mastoiditis in infants aged six months or younger

OBJECTIVE

Bibliographic data for the management of acute mastoiditis in infants aged six months or less are very limited. This study investigated the presenting symptomatology, diagnostic and treatment options, and final outcomes in this age group.

METHOD

A retrospective review was conducted of all infants aged six months or less suffering from acute mastoiditis, admitted to our department between 2007 and 2017.

RESULTS

Eleven infants were identified. All of them developed the typical symptomatology of acute mastoiditis, while a higher rate of subperiosteal abscess formation was observed. Imaging was necessary in three cases only. Parenteral antibiotics and myringotomy were applied in all infants. A drainage procedure was also included in the infants with a subperiosteal abscess. Antrotomy was reserved for non-responsive cases. No intracranial complications were observed. All infants were cured without further complications or sequelae.

CONCLUSION

Acute mastoiditis in infants aged six months or less can be safely diagnosed and treated using a standardised algorithmic approach, similar to that used for older children.

Clinical features and management of Luc's abscess: Case report and systematic review of the literature

OBJECTIVES

Luc's abscess is a rare complication of acute otitis media, with a challenging diagnosis and a controversial surgical treatment. The aim of the present study was to review the published literature in order to clarify the clinical features and the surgical management of those patients.

METHODS

A systematic review of the literature was carried out for published reports or case series in English language, describing a temporo-zygomatic (or Luc's) abscess which complicated an acute or chronic otitis media and/or mastoiditis, confirmed through CT scan or MRI of the petrous bone. The collected clinical and radiological data were merged and critically appraised.

RESULTS

Eighteen reports of Luc's abscess were included. Adding our case report, a total of 21 cases were included in the analysis. Abscess drainage plus myringotomy alone vs. abscess drainage plus myringotomy and mastoidectomy were the two surgical management approaches described in the literature. Patients undergoing first line mastoidectomy were successfully treated in all cases, while among those undergoing a more conservative approach, one failure required subsequent mastoidectomy.

CONCLUSIONS

The clinical features of Luc's abscess are rather constant and help in rising the suspicion before the radiological diagnosis. Although cases with associated intra-cranic complications have been reported, the limited existing data do not permit to advocate the mastoidectomy over a more conservative surgical approach. However, the decision to avoid mastoidectomy as the first line surgical treatment should be based on the clinical and radiologic assessment, after an accurate counseling, particularly in the case of a pediatric patient.

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.

Neurological Complications of Acute and Chronic Otitis Media

PURPOSE OF REVIEW

The aim of this study is to discuss the symptoms, diagnosis, and management of the neurologic complications of acute and chronic otitis media.

RECENT FINDINGS

Antibiotic therapy has greatly reduced the frequency of complications of otitis media. However, it is of vital importance to remain aware of the possible development of neurologic complications. There is a trend toward less severe presenting symptoms including otorrhea, headache, nausea, and fever, with altered mental status and focal neurologic deficits presenting later. In order to reduce morbidity, early deployment of a multidisciplinary approach with prompt imaging and laboratory studies is imperative to guide appropriate management. Complications of acute and chronic otitis media may present with neurologic signs and symptoms. It is important to recognize the possible otitic origin of such complications to ensure proper management and to decrease overall morbidity and mortality.

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.

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 Acute Otitis Media and Acute Mastoiditis in Hospitalized Children

Acute otitis media is a common infection in children. Most acute otitis media episodes can be treated at an outpatient setting with antimicrobials, or only expectant observation. Hospital treatment with parenteral medication, and myringotomy or tympanostomy, may be needed to treat those with severe, prolonged symptoms, or with complications. The most common intratemporal complication of acute otitis media is acute mastoiditis. If a child with acute mastoiditis does not respond to this treatment, or if complications develop, further examinations and other surgical procedures, including mastoidectomy, are considered. Since the treatment of complicated acute otitis media and complicated acute mastoiditis differs, it is important to differentiate these two conditions. This article focuses on the differential diagnostics of acute otitis media and acute mastoiditis in children.

Panel 7: Otitis Media: Treatment and Complications

Objective We aimed to summarize key articles published between 2011 and 2015 on the treatment of (recurrent) acute otitis media, otitis media with effusion, tympanostomy tube otorrhea, chronic suppurative otitis media and complications of otitis media, and their implications for clinical practice. Data Sources PubMed, Ovid Medline, the Cochrane Library, and Clinical Evidence (BMJ Publishing). Review Methods All types of articles related to otitis media treatment and complications between June 2011 and March 2015 were identified. A total of 1122 potential related articles were reviewed by the panel members; 118 relevant articles were ultimately included in this summary. Conclusions Recent literature and guidelines emphasize accurate diagnosis of acute otitis media and optimal management of ear pain. Watchful waiting is optional in mild to moderate acute otitis media; antibiotics do shorten symptoms and duration of middle ear effusion. The additive benefit of adenoidectomy to tympanostomy tubes in recurrent acute otitis media and otitis media with effusion is controversial and age dependent. Topical antibiotic is the treatment of choice in acute tube otorrhea. Symptomatic hearing loss due to persistent otitis media with effusion is best treated with tympanostomy tubes. Novel molecular and biomaterial treatments as adjuvants to surgical closure of eardrum perforations seem promising. There is insufficient evidence to support the use of complementary and alternative treatments. Implications for Practice Emphasis on accurate diagnosis of otitis media, in its various forms, is important to reduce overdiagnosis, overtreatment, and antibiotic resistance. Children at risk for otitis media and its complications deserve special attention.

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.

Acute Mastoiditis Caused by Streptococcus pneumoniae

Acute mastoiditis (AM) is a relatively rare complication of acute otitis media (AOM). The most common pathogens include Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus. Pneumococcal vaccination and changes in antibiotic prescribing recommendations for AOM may change the incidence of AM in the future. Diagnosis of AM can be made based on clinical presentation, but computed tomography of the temporal bone with contrast should be considered if there is concern for complicated AM. Both extracranial and intracranial complications of AM may occur. Previously, routine cortical mastoidectomy was recommended for AM treatment, but new data suggest that a more conservative treatment approach can be considered, including intravenous (IV) antibiotics alone or IV antibiotics with myringotomy. [Pediatr Ann. 2016;45(5):e176-e179.].

Bacteriology in relation to clinical findings and treatment of acute mastoiditis in children

OBJECTIVE

We assessed clinical, radiological, laboratory and microbiological findings in children with acute mastoiditis in order to improve the diagnostics and treatment of these patients. We also investigated whether different pathogens cause different clinical findings of mastoiditis.

METHODS

A retrospective review of the medical records of all children aged 0-16 years treated as in-ward patients for acute mastoiditis at Helsinki University Central Hospital, Department of Otorhinolaryngology, between 2003 and 2012.

RESULTS

Fifty-six patients met the inclusion criteria. The incidence of mastoiditis was 1.88/100000/year. The most common pathogens were Streptococcus pneumoniae (38%), Streptococcus pyogenes (11%) and Pseudomonas aeruginosa (11%). Of S. pneumoniae, 48% had reduced susceptibility (intermediate or resistant) for the common antimicrobials; this was clearly overrepresented relative to the background population (p<0.001). Otalgia and retroauricular symptoms were common in the patients with S. pneumoniae. Otorrhoea was less common (p=0.03) in these patients relative to the other pathogens. Patients with S. pneumoniae had more destruction of the mastoid septa (p=0.05) than patients with any of the other pathogens. Mastoidectomy was performed in 34% of all cases, it was most common (60%) in the patients with S. pneumoniae with reduced susceptibility. The patients with S. pyogenes had less otalgia and seemed to have less retroauricular symptoms relative to other pathogens. P. aeruginosa especially affected children with tympanostomy tubes, caused otorrhoea in all patients and caused a milder form of disease with less retroauricular swelling (p=0.04) than the other pathogens, and there was no need for mastoidectomies. The younger children (<2 years) had less otorrhoea and more retroauricular symptoms of infection than the older patients. No significant differences emerged in outcome of the patient groups.

CONCLUSIONS

The clinical findings of acute mastoiditis differ according to the causative pathogen. S. pneumoniae, especially strains with reduced susceptibility, causes severe symptoms and leads to mastoidectomy more often than the other pathogens. S. pyogenes causes less otalgia than the other pathogens. P. aeruginosa particularly affects children with tympanostomy tubes and causes a less aggressive form of disease.

Intratemporal and intracranial complications of acute otitis media in a pediatric population

OBJECTIVE

To review all cases intratemporal and intracranial complications of acute otitis media (AOM) in infants and children from 1998 to 2013.

METHODS

Retrospective chart review of 109 consecutive patients admitted for complications of AOM during a 15-year period at a tertiary-care children's hospital. The main outcomes are: (1) complications of AOM, (2) bacteriology, (3) management strategies.

RESULTS

In our population, complications included mastoiditis (86.1%), subperiosteal abscess (38%), facial nerve palsy (16.7%), sigmoid sinus thrombosis (8.3%) and epidural abscess (7.4%). Other complications included post-auricular cellulitis, otic hydrocephalus and elevated intracranial pressure, internal jugular thrombosis, cranial nerve VI palsy and Gradenigo's syndrome, labyrinthine fistula, sensorineural hearing loss, and cerebellar infarct. Sixty-one patients (56%) received antibiotics prior to presentation. Cultures revealed Streptococcus pneumoniae in 36 patients (33.3%), other bacteria in 30 patients (27.8%), and "no growth" in 33 patients (30.5%). Nine patients (8.3%) did not undergo culture. Of the patients with S. pneumoniae, 20 cultures (55%) were found to be multidrug-resistant. Eleven patients (10.2%) were treated non-surgically, 31 (31%) were treated with myringotomy and intravenous antibiotics. Forty patients (97.5%) presenting with subperiosteal abscess required mastoid surgery. Thirteen of 18 (72.2%) patients with facial paralysis had full recovery. Eight of 10 (80%) patients with epidural abscess empyema required mastoid surgery and incision and drainage of the abscess.

CONCLUSION

Complications of AOM are uncommon, yet continue to have potentially serious consequences. The bacteriology in this population reveals an increasing trend of multi-drug resistant S. pneumoniae as the causative organism.

Complicated necrotizing otitis externa

Necrotizing (malignant) otitis externa (NOE) is a rare and invasive infection originating in the external acoustic meatus seen most commonly in diabetes and other immunocompromised states. After a protracted course, disease can smolder and extend into the mastoid, skull base, dural sinuses, and intracranially. We present a case of NOE complicated by mastoiditis, dural sinus thrombosis, and Bezold's abscess in an uncontrolled diabetic presenting with a prolonged course of facial nerve palsy. We stress the importance of maintaining a high index of clinical suspicion for NOE in diabetic patients and offering timely, aggressive treatment to mitigate its complications.