Management of paediatric acute mastoiditis: systematic review

Tenfold Increase: Acute Pediatric Mastoiditis Before, During, and After COVID-19 Restrictions

INTRODUCTION

Acute mastoiditis (AM) is a relatively rare complication arising from acute otitis media, a common condition among children. The COVID-19 pandemic has significantly impacted AM cases. We noted a surge in pediatric AM cases in Germany after COVID-19 restrictions were lifted in 2022. This study assesses AM incidence and the clinical course in children before, during, and after the pandemic. The study also explores complication rates and microbial changes.

METHODS

Participants: We included children (0-18 yr) diagnosed with AM who underwent mastoidectomy at a tertiary-care university hospital from January 2012 to June 2023.Objectives: We aimed to evaluate AM incidence during pre-COVID, COVID, and post-COVID periods; assess complications; and analyze the microbial spectrum.Data Analysis: Incidence and complication rates were compared between periods, along with the microbial spectrum.

RESULTS

Population: 75 children were included (median age, 3.3 yr).Incidence: Significant increases in AM cases occurred in the post-COVID period compared to pre-COVID and COVID periods. No significant difference was observed between pre-COVID and COVID periods.Complications: Complication rates increased notably in the post-COVID period compared to pre-COVID and COVID periods with respect to more sensitive imaging methods being used in the post-COVID period. No significant difference was observed between pre-COVID and COVID periods.Spectrum of Pathogens: No significant differences were found in pathogen distribution between periods. Streptococcus pyogenes and Streptococcus pneumoniae were common throughout.

DISCUSSION

The study highlights a substantial rise in AM cases and complications after COVID-19 restrictions were lifted in Germany. This underscores the importance of monitoring infectious diseases and their complications during health crises. Additionally, the study highlights the importance of contrast-enhanced imaging. Further research is needed to explore the mechanisms behind this trend.

CONCLUSION

The study reveals a significant increase in pediatric AM cases and complications following the COVID-19 pandemic in Germany. Adequate computed tomographic or magnetic resonance imaging, including contrast enhancement, is shown to be a very important parameter beside clinical symptoms in deciding for the right therapy. Thus, surgical treatment became more important. Continuous monitoring and adaptive healthcare strategies during health crises are vital for optimal patient care. Further research is warranted to understand the reasons behind these trends and to inform future pandemic preparedness efforts.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clarifying the Diagnosis and Management of Acute Uncomplicated Pediatric Mastoiditis

INTRODUCTION

Acute pediatric mastoiditis is a bacterial infection of the mastoid bone most commonly associated with acute otitis media. Complicated mastoiditis is traditionally characterized by intracranial complications or subperiosteal abscess, but definitions are inconsistent in the literature. Surgical intervention is identified as the main treatment for complicated mastoiditis, but there is some evidence to support medical management of uncomplicated mastoiditis. This study sought to clarify the diagnostic criteria and management of uncomplicated acute mastoiditis.

METHODS

All cases of acute pediatric mastoiditis were identified from a single institution over a 16-year period and reviewed for demographic and clinical data. Two different definitions of uncomplicated mastoiditis were compared; the traditional one that excluded patients with intracranial complications or subperiosteal abscess (SPA) and the proposed definition that also excluded patients with any evidence of bony erosion including coalescence, not just SPA. Univariate and multivariate analysis was conducted.

RESULTS

Eighty cases were identified. Using the traditional definition of uncomplicated mastoiditis, 46.3% of cases were uncomplicated, compared to 36.2% when using the proposed definition. Truly uncomplicated patients, categorized with the proposed definition, were treated more consistently: no patients underwent mastoidectomy and they were less likely to receive a long term course of antibiotics. On multivariate regression analysis, only categorization with the proposed definition of uncomplicated mastoiditis was independently associated with less long-term antibiotic therapy and non-surgical management.

CONCLUSION

Uncomplicated acute mastoiditis should be defined using clinical criteria and exclude any cases with evidence of bony erosion, including coalescence or subperiosteal abscess. These truly uncomplicated patients often do not require mastoidectomy and can be prescribed a shorter course of antibiotics. Further research into treatment pathways is necessary to optimize the management of uncomplicated acute pediatric mastoiditis.

The Clinical Value of Cranial CT Venography for Predicting Fusobacterium necrophorum as the Causative Agent in Children with Complicated Acute Mastoiditis

BACKGROUND AND PURPOSE

Fusobacterium necrophorum (F necrophorum) is an anaerobic bacteria that causes invasive head and neck infections in children. Several studies have demonstrated an increasing prevalence of F necrophorum as the causative agent in acute mastoiditis in children, with associated high rates of intracranial complications such as epidural abscess and sinus venous thrombosis, to name a few. F necrophorum requires a treatment protocol that differs from the empiric treatment that is tailored to more common pathogens (eg, group A streptococci, Streptococcus pneumonia), and hence expediting the diagnosis is important. For evaluating complicated acute mastoiditis in children, cranial CT venography remains the imaging study of choice in most medical centers due to its availability in emergency situations. Based on our clinical experience, our hypothesis is that children with F necrophorum-associated complicated acute mastoiditis can be differentiated from those with other etiologies using CT venography.

MATERIALS AND METHODS

CT venography studies of 76 children hospitalized and treated for complicated acute mastoiditis were retrospectively reviewed. Retrieved imaging data included intracranial complications (epidural abscess, sinus venous thrombosis), cranial bone-related complications, and extracranial complications (subperiosteal abscess, temporomandibular joint abscess, and soft-tissue inflammation). The cohort was divided into children with F necrophorum-related disease (study group) and those with non-F necrophorum-related disease (control group).

RESULTS

Thirty-seven children (49%) comprised the study group, and 39 children in whom the causative agents were other bacteria comprised the control group. There were significantly higher rates of complications in the study group: sinus venous thrombosis (P < .001), perisigmoid epidural abscess (P = .036), and extramastoid osteomyelitis (P < .001). Thrombosis in venous sites beyond the sigmoid sinus and jugular foramen (a pattern consistent with an otogenic variant of Lemierre syndrome) and emphysematous osteomyelitis were found only among children in the F necrophorum-related study group (32% and 22% accordingly).

CONCLUSIONS

In children with complicated acute mastoiditis, CT venography findings of emphysematous osteomyelitis and/or thrombosis in venous sites beyond the sigmoid sinus and jugular foramen (a pattern consistent with the otogenic variant of Lemierre syndrome) should lead the radiologist to suggest F necrophorum-related mastoiditis.

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.

Rise in complications of acute otitis media during and after the COVID-19 pandemic

PURPOSE

After the lifting of nonpharmaceutical interventions (NPIs) during the COVID-19 pandemic, clinical observation showed an increase in complications of acute otitis, followed by a rise in the number of mastoidectomies performed. The aim of this study was to record the number of mastoidectomies performed before, during and after the COVID-19 pandemic as an indicator for complications of acute otitis media.

METHODS

Data were collected from a tertiary hospital in a university setting, as well as from four major public health insurance companies in Germany. The data of 24,824,763 German citizens during a period from 2014 until 2023 were analyzed.

RESULTS

According to the data, during the COVID-19 pandemic, the number of mastoidectomies performed dropped by 54% for children aged 0-6 and by 62% for children aged 7-18. For adults, there were 30% fewer mastoidectomies performed between 2020 and 2022. After the lifting of most NPI's in the season from July 2022 to June 2023, there was a sharp increase in the number of mastoidectomies performed on patients of all ages.

CONCLUSIONS

During the COVID-19 pandemic, a decrease in the number of mastoidectomies performed was seen, suggesting a lower incidence of complicated acute otitis, most likely linked to the general decrease of upper airway infections due to NPI's. In contrast, a sharp increase in the incidence of complicated otitis occurred after the hygiene measures were lifted. The current development causes a more frequent performance of mastoidectomies, thus entailing a change in the challenges for everyday clinical practice.

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.

Risk factors for recurrent acute mastoiditis in pediatric patients: a registry-based cohort study

OBJECTIVE

To describe characteristics of pediatric patients with recurrent acute mastoiditis, and to identify risk factors for this condition.

STUDY DESIGN

A retrospective cohort study.

SETTING

Data based on electronic medical records of the largest Health Maintenance Organization in Israel.

METHODS

Children hospitalized due to acute mastoiditis during the years 2008-2018 were identified, and their diagnosis was verified. Patients with recurrent acute mastoiditis were identified and grouped, and their characteristics were outlined and compared to those of the original group to identify risk factors for recurrence.

RESULTS

During the 11-year period, a total of 1115 cases of children hospitalized due to acute mastoiditis were identified with a weighted incidence rate of 7.8/100,000. Of this group, 57 patients were diagnosed with recurrence following a full clinical recovery. The incidence proportion of recurrent acute mastoiditis was 5.1% (57/1115), male-to-female ratio was 27:30, 73.4% were younger than 24 months, the median period from the first episode was 3.4 months (IQR 2.0;10.0), and 82.5% of the patients (n = 47) had a single recurrence, whereas 18.5% (n = 10) had two recurrences or more. Mastoidectomy and swelling over the mastoid area during the first episode were identified as the main risk factors for recurrent mastoiditis HR = 4.7 [(2.7-8.2), p < 0.001] and HR = 2.55 [(1.4-4.8), p = 0.003], respectively. Mastoidectomy was the only independent significant risk factor for recurrence in a multivariate analysis.

CONCLUSIONS

Mastoidectomy and swelling over the mastoid area during the first episode of acute mastoiditis were found strongly related independent risk factor for future recurrent episodes of acute mastoiditis.

Otogenic brain complications: a systematic review and meta-analysis

OBJECTIVE

This study aimed to form astute deductions regarding the presentation, treatment and mortality of otogenic brain complications.

METHODS

A systematic literature search of four medical databases (PubMed, Embase, Web of Science and Scopus) was conducted. Studies associated with otogenic brain complications were considered eligible. Fixed- and random-effects model meta-analysis was developed to assess the proportion estimate for each outcome individually.

RESULTS

Twenty-eight studies, with 1650 patients in total, were included. In 66 per cent of patients there was a known history of chronic otitis media. The most common symptoms were purulent otorrhoea (84 per cent), headache (65 per cent) and otalgia (45 per cent). A brain abscess was observed in 49 per cent of patients, followed by meningitis (34 per cent) and sinus thrombosis (22 per cent). A combination of surgical and conservative therapy was chosen in 84.3 per cent of cases and the mortality rate approached 11.1 per cent.

CONCLUSION

Otogenic brain complications are a possibly life-threatening condition. Prompt imaging examination may set the final diagnosis and lead to an effective treatment.

Complications of acute mastoiditis in a paediatric population at a UK Tertiary Centre: A retrospective review

OBJECTIVES

Acute mastoiditis (AM) and its associated intra and extracranial complications are rare complications of acute otitis media. However, they are associated with a high morbidity. The management of AM with complications carries significant variations in approach. We aimed to evaluate the presentation of children with AM with complications to a tertiary referral centre in the United Kingdom and describe evolution of the treatment approaches.

METHODS

We undertook a retrospective chart review of all children admitted with AM to the University Hospitals of Leicester between 2013 and 2022.

RESULTS

Twenty-seven children were included in this study: 7 patients had sigmoid sinus thrombosis (SST), 4 had an intracranial collection, 3 had cranial nerve palsy and 16 had a subperiosteal abscess (SPA); some patients had more than 1 complication. In this study, treatment of SPA with incision and drainage (I&D) and grommet insertion was effective, as all patients treated with grommet insertion and I&D recovered well and did not require a subsequent cortical mastoidectomy. All patients with SST received anticoagulation and intravenous (IV) antibiotics; surgical input consisted of grommet insertion alone and cortical mastoidectomy was not routinely performed in these patients.

CONCLUSION

In our series, management of SPA with grommet insertion and drainage had good outcomes. SST management mainly consisted of IV antibiotics, anticoagulation and grommet insertion with good recovery. The evidence to guide the management of complications of mastoiditis is of poor quality and further research is needed to clarify the optimal management of these complications.

A Novel Diagnostic and Treatment Algorithm for Acute Mastoiditis in Children Based on 109 Cases

BACKGROUND

Acute mastoiditis (AM) is a potentially life-threatening condition primarily affecting children. To date, there are no consistent criteria or valid guidelines for the diagnosis and treatment of pediatric AM. Therefore, this study evaluates the clinical course of AM in terms of clinical signs and treatment. In addition, a novel classification scheme for the disease and a treatment algorithm is being proposed.

METHODS

Patient records over a 12-year period from a single center were reviewed to identify confirmed cases of AM in children. Data collected included clinical signs, body temperature, and infection parameters during the disease, as well as radiological imaging, antibiotics, and surgical as well as conservative treatment. In addition, a classification of the AM stages was established in accordance with the findings described and practical experience, consisting of four stages (1, mastoidal irritation; 2, mild AM; 3, advanced AM; 4, advanced AM and additional complications) with corresponding treatment recommendations. In the retrospective cohort, those AM cases that were treated alongside the classification were compared with the rest concerning clinical course and outcome.

RESULTS

A total of 109 patients (mean age, 3.8 ± 3.8 years) were included. The main symptoms at hospital admission were auricular protrusion (n = 73; 67.0%), fever (n = 56; 51.4%) with a mean temperature of 38.3 ± 1.1°C, and otalgia (n = 28; 25.7%). The mean laboratory-tested levels of leukocytes and C-reactive protein at the time of hospital admission were 15.96 ± 8.7/nl and 59.6 ± 54.0 mg/L, respectively. During winter, there was a higher prevalence of AM, with peak hospital admissions in April (n = 22). The most common pathogen was Streptococcus pyogenes (32 cases). Treatment was purely conservative in four cases, whereas the remaining cases underwent surgery (41× grommet insertion, 64× plus mastoidectomy). The outcome was generally good, but in eight patients a second surgical procedure had to be performed as they showed signs of clinical deterioration. A total of 101 patients were treated according to the proposed algorithm, and all of which had a good outcome without the need for further interventions.

CONCLUSION

Based on clinical experience in a large cohort of pediatric AM patients, a novel diagnostic and treatment algorithm has been developed and successfully tested in a retrospective cohort for AM in children to prevent further complications and to ease its management by pediatricians and otorhinolaryngologists in the emergency setting.

[Increased rate of complications of pediatric acute otitis media and sinusitis in 2022/2023]

BACKGROUND

Acute mastoiditis and orbital complications of acute rhinosinusitis are among the most common complications of pediatric infections in otolaryngology.

OBJECTIVE

The aim of this study was to investigate the frequency of pediatric acute mastoiditis in the setting of acute otitis media as well as pediatric orbital complications in the setting of acute rhinosinusitis. Data from before the pandemic were compared to data after the end of the COVID-19 restrictions.

MATERIALS AND METHODS

Included were hospitalized children who presented with acute mastoiditis from acute otitis media or with orbital complications from acute rhinosinusitis during the period from April 2017 to March 2023. Compared were three periods using descriptive statistics: April 2017 to March 2020 (before the pandemic in Germany), April 2020 to March 2022 (during the contact restrictions of the pandemic), and April 2022 to March 2023 (after the contact restrictions were lifted).

RESULTS

A total of 102 children (43 with acute mastoiditis, 42%, and 59 with orbital complications of acute sinusitis, 58%) were included. During the 2022/2023 period, more than twice as many children with acute mastoiditis and approximately three times as many children with orbital complications of acute rhinosinusitis were hospitalized compared to the average of the periods 2017/2018, 2018/2019, and 2019/2020. In the 2021/2022 period, the number of these patients was below the average of previous years.

CONCLUSION

This year's seasonal cluster of upper respiratory tract infections is associated with a higher-than-average incidence of orbital complications and mastoiditis.

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 Bacterial Sinusitis With Epidural and Subdural Involvement

Sinusitis is a common childhood infection with potential for rare intracranial complications. These neurologic sequelae can lead to serious morbidity and mortality if not addressed promptly. We describe a case of suspected sinusitis in a 13-year-old male complicated by a superior sagittal sinus thrombosis along with subdural and epidural empyemas.

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.

Epidemiology and variability in management of acute mastoiditis in children

BACKGROUND

To evaluate the epidemiology, management and outcome of acute mastoiditis (AM) in children and to improve strategies for antimicrobial stewardship.

METHODS

We conducted a retrospective observational study of children aged >6 months to ≤18 years of age admitted to a tertiary care hospital with AM over an 8-year period (2011-2019). Electronic medical records were reviewed to collect data.

RESULTS

A total of 129 patients met inclusion criteria for AM during this time period. Eighty-one (63 %) were males with 110 (81 %) White and 67 (52 %) non-Hispanic. The median age at presentation was 6.4 years (3-10.1 years). Ear protrusion was associated with reduced odds of having AM with intracranial extension (ICE) (OR 0.307, 95 % CI = 0.107-0.883) whereas presence of headaches and/or neck pain increased the odds of having AM with ICE (OR = 3.96, 95%CI 1.29-12.1). The most common etiologies were Streptococcus pyogenes (n = 23, 19.2 %), Pseudomonas aeruginosa (n = 20, 17 %), and Streptococcus pneumoniae (n = 15, 12.5 %). Empiric antibiotic selection and duration of therapy was highly variable. The most common empiric antibiotic used was intravenous vancomycin with a third generation cephalosporin (n = 45, 34.8 %). Majority completed course (n = 92; 73 %) with an oral antibiotic. Shorter (≤10 and ≤14 days) versus longer courses (>10 and >14 days) did not affect readmission rates for AM without ICE.

CONCLUSION

There is high variability of treatment of AM in children. Broad spectrum antibiotics, especially vancomycin were used most frequently despite low rates of Methicillin Resistant Staphylococcus aureus. The use of antibiotic stewardship is essential for judicious antibiotic use.

Clinical characteristics and an evaluation of predictors for a favorable outcome of Mycobacterium abscessus otomastoiditis: a systematic review and meta-analysis of individual participant data

BACKGROUND

Otomastoiditis caused by Mycobacterium abscessus is rare, but its incidence has increased over the last decades and its optimal treatment remains unknown. This study aims to summarise clinical and therapeutic features and to find characteristics associated with favourable treatment outcomes of patients with M. abscessus otomastoiditis.

METHODS

We searched MEDLINE, EMBASE and Web of Science to identify studies including patients with M. abscessus otomastoiditis. A one-stage individual patient data (IPD) meta-analysis was conducted. A two-level mixed-effects linear regression model was provided for antimycobacterial treatment duration.

RESULTS

Twenty-three studies reported a total of 85 patients. Children presented with an unique clinical profile of a history of ear infections, tympanostomy tube placement and antibiotic treatment. Antimycobacterial treatment was administered for 26 (Inter Quartile Range (IQR): 15-35) weeks. Macrolides were prescribed in 98.8%. Surgery was performed in 80.5%, of which 47.1% required revision surgery. Otalgia was a significant predictor (β = 9.3; p = .049) of antimycobacterial treatment duration.

CONCLUSIONS

Mastoid surgery (regularly requiring revision) and a multidrug regimen for a minimum of six months including a minimum of three active agents are most often needed to attain cure. The presence of otalgia significantly extends the treatment duration of M. abscessus otomastoiditis.

Case report: Otitis media with subsequent mastoiditis and cerebral herniation in a patient with Arnold chiari malformation

We present the case of a 13-year-old boy who unexpectedly needed to be resuscitated at home after an assumed uncomplicated otitis media. Imaging at our clinic showed mastoiditis and a cystoid mass in the left cerebellopontine angle compressing the brainstem, as well as an Arnold-Chiari-Malformation. Both the laboratory examination of cerebrospinal fluid (CSF) and surgical biopsy with pathological evaluation of the mastoid supported the inflammatory etiology of the mass. Microbiologically, Streptococcus intermedius was detected in the blood culture and CSF. Due to brain death, which most likely already existed preclinically, the organs were released for donation during the course. Our case demonstrates a very rare lethal complication of acute otitis media on the basis of a cerebral malformation and emphasizes the need to stay alert when patients complain of symptoms after assumed resolution.

Post-operative clinical course in children undergoing mastoidectomy due to complicated acute mastoiditis

PURPOSE

To determine the immediate post-operative course and outcome of pediatric patients with complicated acute mastoiditis (CAM) following surgical treatment.

METHODS

A retrospective chart review of children diagnosed with CAM who underwent mastoid surgery during 2012-2019 in a tertiary care university hospital. 33 patients, divided into 2 groups: 17 patients with sub-periosteal abscess (SPA) alone-single complication group (SCG) and 16 patients with SPA and additional complications: sigmoid sinus thrombosis (SST), peri-sinus fluid/abscess, epidural/subdural abscess, and acute meningitis-multiple complications group (MCG).

RESULTS

33 patients belong to the SCG 17(51%) and 16(49%) belonged to the MCG, respectively. 6/17(35.3%) SCG patients experienced POF vs. 12/16(75%) in the MCG (P = 0.012). At post-operative day 2 (POD2), 10/13(77%) febrile patients belonged to MCG and 3/13(23%) to SCG (P = 0.013). POF was recorded until POD6 in both groups. Seven patients, all from MCG with POF, underwent second imaging with no new findings; a total of 18 positive cultures were reported. Fusobacterium necrophorum counted for 8/18(44.5%) of all positive cultures, 7/9(77.8%) in the MCG vs. 1/9(11.1%) in the SCG, P = 0.004. Streptococcus pneumoniae was reported only in SCG (5/9, 55.5%, vs. 0/9, P = 0.008).

CONCLUSION

Post-mastoidectomy fever due to CAM is not unusual and seems to be a benign condition for the first 5-6 days, following surgery. MCG patients are more prone to develop POF. F. necrophorum is more likely to be associated with MCG, and S. pneumoniae is common in SCG patients.

Acute paediatric mastoiditis in the UK before and during the COVID-19 pandemic: A national observational study

OBJECTIVES

To explore the impact of COVID-19 on the management and outcomes of acute paediatric mastoiditis across the UK.

DESIGN

National retrospective and prospective audit.

SETTING

48 UK secondary care ENT departments.

PARTICIPANTS

Consecutive children aged 18 years or under, referred to ENT with a clinical diagnosis of mastoiditis.

MAIN OUTCOME MEASURES

Cases were divided into Period 1 (01/11/19-15/03/20), before the UK population were instructed to reduce social contact, and Period 2 (16/03/20-30/04/21), following this. Periods 1 and 2 were compared for population variables, management and outcomes. Secondary analyses compared outcomes by primary treatment (medical/needle aspiration/surgical).

RESULTS

286 cases met criteria (median 4 per site, range 0-24). 9.4 cases were recorded per week in period 1 versus 2.0 in period 2, with no winter increase in cases in December 2020-Febraury 2021. Patient age differed between periods 1 and 2 (3.2 vs 4.7 years respectively, p < 0.001). 85% of children in period 2 were tested for COVID-19 with a single positive test. In period, 2 cases associated with P. aeruginosa significantly increased. 48.6% of children were scanned in period 1 vs 41.1% in period 2. Surgical management was used more frequently in period 1 (43.0% vs 24.3%, p = 0.001). Treatment success was high, with failure of initial management in 6.3%, and 30-day re-admission for recurrence in 2.1%. The adverse event rate (15.7% overall) did not vary by treatment modality or between periods 1& 2.

CONCLUSION

The COVID-19 pandemic led to a significant change in the presentation and case mix of acute paediatric mastoiditis in the UK.

Temporal Trends and Regionalization of Acute Mastoiditis Management in the United States

OBJECTIVE

To describe demographics and to analyze temporal trends in the inpatient management of acute mastoiditis admissions.

STUDY DESIGN

Cross-sectional analysis.

SETTING

National Inpatient Sample, 2002-2014.

PATIENTS

26,072 nonelective inpatient admissions with primary diagnosis of acute mastoiditis.

INTERVENTION

Myringotomy, mastoidectomy, or no procedure.

MAIN OUTCOME MEASURES

We described the patient- and hospital-level demographics of acute mastoiditis admissions and the frequency of complications. We evaluated the percentage of patients requiring surgical management. Binary logistic regression was performed to determine whether there was a significant increase in the percentage of patients treated at academic institutions.

RESULTS

The majority of patients were ≤40 years old (64.9%) and Elixhauser comorbidity index ≥4 (57.4%); 23.3% (SE 0.8%) presented with complications associated with acute mastoiditis, the most common of which was a subperiosteal abscess (11.5%, SE 0.7%). Among all admissions, 30.9% (SE 1.1%) underwent myringotomy, 13.8% (SE 0.8%) required both myringotomy and mastoidectomy. On multivariate analysis, there was a statistically significant increase in the percentage of mastoiditis admissions to teaching hospitals for all admissions (OR 1.55 [CI 1.22-1.97], p < 0.001) and even more evident for cases with associated complications (OR 1.85 [CI 1.21-2.83], p = 0.004).

CONCLUSIONS AND RELEVANCE

A sizeable percentage of patients with acute mastoiditis present with complications which may require surgical intervention. From 2002 to 2014, inpatient care of acute mastoiditis became increasingly regionalized to teaching hospitals, suggestive of increased specialization within certain facilities. This trend may have significant impacts on the cost and subsequent quality of care provided to these patients.

Reducing antibiotic prescriptions in children is not associated with higher rate of complications

Acute otitis media (AOM) and sore throat are common reasons for antibiotic prescription in children. Starting from 2007, evidence-based guidelines and other multifaceted improvement activities (ProBA project) were implemented in Emilia-Romagna, a northern Italian region. Antibiotic prescription rate in the region decreased with time (37% relative reduction from 2005 to 2019). Within the ProBA project, this retrospective observational study, including all hospitals of the region, aims to assess if lower rate of antibiotic prescription was associated with an increased rate of acute mastoiditis and acute rheumatic fever (ARF). Hospital admission rates for acute mastoiditis and ARF from 2005 to 2019 were calculated using ICD-9 codes. Hospital intervention rates for myringotomy, incision of mastoid, and mastoidectomy were also assessed. A comparison with antibiotic prescription rate in the pediatric population was performed. Data were gathered using administrative databases and trends were calculated using Poisson regression. During the study period, rate of mastoiditis and similar diagnosis declined from 54.1 to 33.6 per 100.000 (β coefficient = - 0.047, p value < 0.001) and rate of surgical treatment from 134.6 to 89.6 per 100.000 (β coefficient = - 0.036, p value < 0.001), whereas rate of ARF remained stable at around 4.4-4.8 per 100.000 (β coefficient = - 0.009, p value = 0.472).Conclusion: ProBA project implementation-recommending 5 days of amoxicillin for AOM when needed and 6 days of amoxicillin when streptococcal pharyngitis is detected-was associated with a reduced antibiotic use without an increase of complications. What is Known: • Acute otitis media (AOM) and streptococcal pharyngitis are common pediatric infections and frequent cause of antibiotics prescription. • Fear of rare complications like mastoiditis and acute rheumatic fever can hinder health professionals' compliance with evidence-based guideline. What is New: • Guidelines recommending a short course of antibiotics for AOM and streptococcal pharyngitis are associated with reduced antibiotic prescriptions and no increase of complications. • Analysis based on administrative databases is useful for monitoring projects and supporting health professionals in complying with guidelines.

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.

Management of infective complications of otitis media in resource-constrained settings

PURPOSE OF REVIEW

Complications of otitis media are a cause of significant morbidity and mortality, compounded in resource-constrained settings in which human and physical resources to manage disease are suboptimal. Here, we examine the current best evidence to devise a protocol for management, in particular exploring the opportunity for conservative or nonspecialist management.

RECENT FINDINGS

Reviews of the literature suggest that intratemporal and extracranial infections can be managed with antibiotics in the first instance, with aspiration or incision and drainage of abscess. Failure to respond necessitates mastoidectomy, which need not be extensive, and can be performed with hammer and gouge. Suspected or possible intracranial extension requires referral for computed tomography (CT) imaging. Intracranial infection can in some instances be managed with antibiotics, but large or persistent intracranial abscess, or the presence of cholesteatoma requires management in a centre for specialist surgery.

SUMMARY

Many complications of otitis media could be managed by nonspecialists in appropriately equipped local or regional health facilities, and supported by appropriate training. However, regional centres with CT imaging and specialist surgery are required for assessment and treatment of cases that are suspected of having complex or advanced disease, or that fail to respond to initial treatment. Those involved in planning healthcare provision should look to develop infrastructure to support such management.

Acute mastoiditis complicated by cerebral venous sinus thrombosis in children

AIM

Diagnosis and management of complicated mastoiditis in childhood are still controversial. We investigated the clinical manifestations, evaluation and management of children with mastoiditis complicated with cerebral venous sinus thrombosis.

METHODS

Retrospective cohort study that included all children admitted for acute mastoiditis over the last 5 years. Children were divided in two groups based on the presence or not of venous sinus thrombosis. Clinical, laboratory, imaging and management data were retrieved and compared.

RESULTS

Overall, 20 children with acute mastoiditis were included, of whom 5 had magnetic resonance imaging-confirmed cerebral venous sinus thrombosis and elevated intracranial pressure (ICP). In all complicated cases, neurological signs rather than mastoiditis signs, prevailed. The more prominent neurologic signs observed were lethargy (60%), nuchal rigidity (60%), abducens nerve palsy (60%) and ataxic gait (20%). Treatment consisted of intravenous antibiotics combined with anticoagulation. Surgery was performed in four children (4/5). Complicated cases had prolonged symptoms prior to admission (p 0.002), presented with neurologic signs and symptoms (p < 0.001), underwent more often lumbar puncture (p < 0.001) and brain imaging (p < 0.001), and were treated with prolonged courses of antibiotics and surgery (<0.001), compared to children with uncomplicated mastoiditis.

CONCLUSION

Neurological signs and symptoms and elevated ICP dominate in children with mastoiditis complicated with thrombosis. Brain imaging is essential for early diagnosis of cerebral venous sinus complications and appropriate management.

Impact of the 13-valent pneumococcal conjugate vaccine (PCV13) on acute mastoiditis in children in southern Israel: A 12-year retrospective comparative study (2005-2016)

OBJECTIVES

To define the trends in acute mastoiditis (AM) incidence, microbiology, complications and management in children, before and after the 13-valent pneumococcal conjugate vaccine (PVC13) introduction.

METHODS

Medical records of all AM patients <15 years of age diagnosed during 2005-2016 were reviewed. The study years were divided into three periods: pre-vaccination (2005-2008), interim (2009-2011) and post-PCV13 vaccination (2012-2016).

RESULTS

238 patients (53.4% males) were enrolled, 81, 56 and 101 in the 3 time periods, respectively. Overall, 177/238 (75.2%) of children were <5 years of age. Mean AM incidence in the whole population was 10.32/100,000, with no changes during the study years. Ninety-three (45.6%) of 204 evaluable patients had positive middle ear fluid/mastoid cultures; S. pneumoniae (SP) was isolated in 47/93 (50.5%) cases. Mean incidence of SP-AM during the study years was 2.49 cases/100,000. A trend for decrease in mean incidence of SP-AM was recorded between the pre and the post-vaccination periods (3.05/100,000 vs. 1.82/100,000, P = 0.069). Among patients <5 years, SP-AM rates decreased from pre to post-vaccination period (19/50, 38% vs. 15/73, 20.6%, P = 0.034). No changes were reported in percentages of culture negative-AM and of AM complications in the post-PCV13 period compared with the pre-vaccine period. A significant decrease in distribution of PCV13 serotypes was recorded (17/19, 89.5% vs. 8/12, 66.6% and vs. 7/16, 43.75% during the 3 study periods, P = 0.015) accompanied by a complementary increase in non-vaccine serotypes.

CONCLUSIONS

The introduction of PCV13 was accompanied by a significant decrease in SP-AM cases among children <5 years of age. PCV13 serotypes decreased significantly as etiologic agents of SP-AM while non-vaccine serotypes and culture negative-AM became more common in the postvaccination period.

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.

Surgical and Orthodontic Approach to Temporomandibular Joint Ankylosis After Ear Infection: A Case Series

Ankylosis of the temporomandibular joint (TMJ) is defined as the emergence of a bony or fibrous compound between the condyle and the cranial base. It can result in divergent craniofacial characteristics. The aim of this study was to present an orthodontic-surgical approach in a case series of 4 patients with a diagnosis of TMJ ankylosis as a complication of otomastoiditis. The patient characteristics of 4 patients in whom TMJ ankylosis was diagnosed as a complication of otomastoiditis were described. All patients were treated with gap arthroplasty with costochondral graft, physiotherapy, and orthodontic therapy to achieve acceptable mouth opening and function. All reacted differently to this therapy, and additional interventions were required during childhood. In early-onset ankylosis, however, guiding the mandibular growth orthodontically can prevent increasing facial asymmetry and canting of the occlusal plane. After the pubertal growth spurt is finished, orthodontic treatment combined with surgical intervention may be considered to correct facial asymmetry and provide good dental occlusion. Orthodontic and surgical treatments showed themselves to be fundamental for patients with TMJ ankylosis as a complication of otomastoiditis, although continual monitoring until the end of growth is necessary to achieve the most functional recovery possible.

Acute mastoiditis in children: contemporary opportunities and challenges

BACKGROUND

Mastoiditis is the most common intra-temporal complication of acute otitis media. Despite potentially lethal sequelae, optimal management remains poorly defined.

METHOD

A retrospective case review was conducted of children diagnosed with mastoiditis at a tertiary referral centre, in North East England, between 2010 and 2017.

RESULTS

Fifty-one cases were identified, 49 without cholesteatoma. Median patient age was 42 months (2 months to 18 years) and median hospital stay was 4 days (range, 0-27 days). There was no incidence trend over time. Imaging was conducted in 15 out of 49 cases. Surgery was performed in 29 out of 49 cases, most commonly mastoidectomy with (9 out of 29) or without (9 out of 29) grommets. Complications included sigmoid sinus thrombosis (3 out of 49) and extradural abscess (2 out of 51), amongst others; no fatalities occurred.

CONCLUSION

A detailed contemporary description of paediatric mastoiditis presentation and management is presented. The findings broadly mirror those published by other UK centres, but suggest a higher rate of identified disease complications and surgical interventions.

Risk Factors Associated With Mortality in Patients With Otogenic Brain Abscess

OBJECTIVE

Otogenic brain abscess is a well-recognized clinical condition that describes brain abscess secondary to an ear infection or mastoiditis. Current evidence remains limited on risk factors associated with mortality as most data are from case series. We aimed to 1) report the mortality rate among patients who did and did not receive mastoidectomy 2) identify factors associated with inpatient mortality.

STUDY DESIGN

Retrospective cohort study.

SETTING

Multi-institutional.

PATIENTS

We identified a cohort of patients for years 2008 to 2014 who in their inpatient hospitalization carried the diagnoses of both brain abscess and infectious ear disease.

INTERVENTIONS

Inpatient neurotology and neurosurgical procedures.

MAIN OUTCOME MEASURES

A multivariable logistics regression model was built to identify the factors associated with inpatient mortality.

RESULTS

The final analysis included 252 patients, of which 84 (33.3%) underwent mastoidectomy. The rate of inpatient morbidity and mortality were 17.5% and 4.0%, respectively. The rate of mortality in patients without mastoidectomy versus those with mastoidectomy was 4.2% versus 3.6%, respectively (p > 0.99). The odds of inpatient mortality were significantly increased for every 10-year increase in age (odds ratio [OR] 2.73, 95% confidence interval [CI]: 1.39-7.01, p = 0.011) and for Black compared to White patients (OR: 45.81, 95% CI: 4.56-890.92, p = 0.003).

CONCLUSION

Older age and Black race were associated with increased odds of inpatient mortality and there were no significant differences in mortality between mastoidectomy cohorts. This research serves to generate further hypotheses for larger observational studies to investigate the association between sociodemographic factors and surgical variables with outcomes among this surgical population.

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.

Complications of Serious Pediatric Conditions in the Emergency Department: Definitions, Prevalence, and Resource Utilization

OBJECTIVES

To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications.

STUDY DESIGN

Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges.

RESULTS

We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P < .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke).

CONCLUSIONS

Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children.

Preventative and medical treatment of ear disease in remote or resource-constrained environments

BACKGROUND

Important ear problems can affect the outer ear, the middle ear and the inner ear. Globally, the greatest burden of disease is due to ear conditions that are associated with otorrhoea and hearing loss.

METHODS

This study reviewed the literature on the prevention and treatment of common ear conditions that are most relevant to settings with high rates of ear disease and limited resources. The grading of recommendations assessment, development and evaluation ('GRADE') approach was utilised to assess interventions.

RESULTS

Accurate diagnosis of ear disease is challenging. Much of the preventable burden of ear disease is associated with otitis media. Nine otitis media interventions for which there is moderate to high certainty of effect were identified. While most interventions only provide modest benefit, the impact of treatment is more substantial in children with acute otitis media with perforation and chronic suppurative otitis media.

CONCLUSION

Disease prevention through good hygiene practices, breastfeeding, reducing smoke exposure, immunisation and limiting noise exposure is recommended. Children with acute otitis media with perforation, chronic suppurative otitis media, complications of otitis media, and significant hearing loss should be prioritised for medical treatment.