Computed tomographic versus surgical findings in complicated acute otomastoiditis

Otogenic Meningitis: A Comparison of Diagnostic Performance of Surgery and Radiology

Development of intracranial complications from middle ear infections might be difficult to diagnose. We compared radiological and surgical findings of 26 patients affected by otogenic meningitis. Results of our analysis showed that surgery is more reliable than imaging in revealing bone defects. Therefore, suggest that surgery be performed for diagnosis and eventual management of all cases of suspected otogenic meningitis.

Surgically Cured, Relapsed Pneumococcal Meningitis Due to Bone Defects, Non-invasively Identified by Three-dimensional Multi-detector Computed Tomography

A 43-year-old Japanese man presented with a history of bacterial meningitis (BM). He was admitted to our department with a one-day history of headache and was diagnosed with relapse of BM based on the cerebrospinal fluid findings. The conventional imaging studies showed serial findings suggesting left otitis media, a temporal cephalocele, and meningitis. Three-dimensional multi-detector computed tomography (3D-MDCT) showed left petrous bone defects caused by the otitis media, and curative surgical treatment was performed. Skull bone structural abnormalities should be considered a cause of relapsed BM. 3D-MDCT was useful for revealing the causal minimal bone abnormality and performing pre-surgical mapping.

Pott's puffy tumor: a rare complication of acute otitis media in child: a case report

To describe a rare case of Potts' puffy tumor (PPT) in the zygomatic area, which developed as a complication of acute otitis media in a 6-year-old child. To date, only one case of PPT has been described in the literature as a complication of latent mastoiditis in an adult, and one case of PPT as a complication of acute mastoiditis in a 10-year-old child. Urgent surgical intervention, including evacuation of the purulent lesion, removal of inflamed soft tissue and osteolysis of the involved bone, and antromastoidectomy, intravenous treatment with broad-spectrum antibiotics, including G+, G-, anaerobes and fungi, and local therapy.

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.

Magnetic resonance imaging in acute mastoiditis

Background

In cases of suspected mastoiditis, imaging is used to evaluate the extent of mastoid destruction and possible complications. The role of magnetic resonance imaging (MRI) in mastoiditis has not been systematically evaluated.

Purpose

To assess the diagnostic performance of MRI in patients with suspected acute mastoiditis.

Material and Methods

Twenty-three patients with suspected acute mastoiditis were included in this retrospective study (15 boys, 8 girls; mean age, 2 years 11 months). All patients were examined on a 1.5 T MRI system. The MRI examination included both enhanced and non-enhanced turbo spin echo (TSE), diffusion-weighted images, and venous time-of-flight magnetic resonance angiography (TOF MRA) for the evaluation of the venous sinuses. Surgical findings, as well as clinical and imaging follow-up were used as the standard of reference. The sensitivity and accuracy of MRI for mastoiditis and subperiosteal abscesses was calculated.

Results

Twenty (87%) of 23 patients had mastoiditis, and 12 (52%) of 23 patients had a subperiosteal abscess in addition to mastoiditis. Mastoiditis and subperiosteal abscesses were identified by MRI in all cases. Sensitivity for mastoiditis was 100%, specificity was 66%, and accuracy was 86%. Sensitivity for subperiosteal abscesses was 100% and accuracy was 100%.

Conclusion

Multiparametric MRI has high accuracy for mastoiditis and subperiosteal abscesses.

Timely recanalization of lateral sinus thrombosis in children: should we consider hypoplasia of contralateral sinuses in treatment planning?

The objective of this study was to evaluate long-term clinical and radiological outcomes in children treated with lateral sinus thrombosis secondary to acute mastoiditis considering also contralateral sinus hypoplasia. This study was a retrospective chart review, conducted in tertiary pediatric hospital. Medical reports of eight children with acute mastoiditis and lateral sinus thrombosis from 1998 to 2011 were examined in terms of therapy, clinical recovery and radiological proof of lateral sinus recanalization. Three children presented hypoplasia of contralateral venous drainage system. Condition of sinuses was regularly monitored with MRI. Otologically and neurologically, all children recovered fully. All received antibiotics; six received additional low molecular weight heparin therapy. Mastoidectomy was performed on six cases. Incision and thrombectomy were applied in the other two, one involving internal jugular vein ligation. This latter case presented also contralateral venous hypoplasia; visual impairment proved permanent. The other two children with contralateral sinus hypoplasia recovered fully after steroid, dehydration and low molecular weight heparin therapy. Recanalization occurred in all children except the one with internal jugular vein ligation, in whom good collateral circulation was observed. There were no bleeding complications. Anatomical variations of cerebral venous drainage system can frequently be observed and should be considered in treatment planning. Mastoidectomy with antibiotics and additional low molecular weight heparin treatment is a safe, promising alternative to thrombectomy and internal jugular vein ligation in children with lateral sinus thrombosis following acute mastoiditis, also having contralateral sinus hypoplasia. Recanalization can be expected within two to five months.

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.

Computed tomography in chronic suppurative otitis media: value in surgical planning

The present study was conducted prospectively to evaluate how accurately high resolution computed tomography scanning could define the extent and severity of the underlying disease in patients with chronic suppurative ear disease, thus, helping convert a surgical exploration into a planned procedure. Sixty adult consecutive cases of chronic suppurative otitis media underwent a detailed high resolution computed tomography by a single radiologist. The recorded radiological findings in various heads were then compared to the surgical findings during mastoid exploration of these patients by a single otologist and the two statistically compared. The presence and distribution of soft tissue in the middle ear cleft and mastoid could confidently be predicted using this modality. The malleus, body and short process of incus were well visualized, but not the long process of incus and the stapes suprastructure. Lateral semicircular canal fistulae could be demonstrated with an acceptable degree of accuracy. It was possible to detect facial nerve dehiscence and defects in tegmen tympani in significant number of cases although, statistical values were low for these structures. High resolution scanning is a modality which can accurately image the pathological anatomy in unsafe chronic suppurative otitis media. Otologists should use it more often, especially in complicated cases as an adjunct to better preoperative assessment, and thus, the surgical outcome. Its accuracy is likely to improve with larger studies and better experience, wherein its routine use may become justifiable.

Mastoiditis on MRI: Fact or Artifact?

Fluid signal in the mastoid can be an incidental finding on T2-weighted magnetic resonance imaging and often is interpreted as mastoiditis by radiologists. This study examines 28 consecutive cases of such erroneously diagnosed “mastoiditis” and documents the presence or absence of otologic symptoms and clinical signs. We found a very low prevalence of otologic symptoms or pathology and no cases of mastoiditis in these patients, and we determined that magnetic resonance imaging is not an effective screening modality for mastoiditis. We also reviewed the literature on current diagnostic criteria for mastoiditis and propose alternative terminology to replace the use of excessively alarming terms such as “mastoiditis” unless they apply to that specific clinical diagnosis.

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.

[Complications of acute mastoiditis in children]

OBJECTIVE

The incidence of complications resulting from acute otitis media has significantly decreased since the introduction of antibiotics. The use of antibiotics has lead to decrease in the complications of acute mastoiditis as well as the mortality of the disease. The purpose of the study was to review our experience in the diagnosis and treatment of complications of acute mastoiditis in children. Study design. Retrospective clinical study.

MATERIAL AND METHODS

We present a retrospective study of 70 children with extracranial and intracranial complications of acute mastoiditis who were treated in the period from 1968 to 2006 at Department of Otolaryngology, Medical University of Gdansk. Their treatment has been documented with long period of otologic follow-up.

RESULTS

Extracranial complications occurred in 41 (30.4%) of treated acute mastoiditis cases, and subperiostal abscess was the commonest one in 37 (90.2%) patients. Intracranial complications occurred in 29 (21.4%) of acute mastoiditis cases and facial paralysis was the commonest one in 14 (40.0%) cases, followed by sigmoid sinus thrombosis and perisinus abscess. Ear cultures grew in patients with otogenic complications, the most often Staphylococcus aureus, Streptococcus sp. and Pseudomonas aeruginosa were found. Mastoidectomy with myringotomy resolved the disease in 46 (65.7%) children, only myringotomy in 6 (8.6%) and canal wall down mastoidectomy in 18 (25.7%) children. Complete resolution was achieved in all cases.

CONCLUSION

The persistent othorrea, otalgia and headache, prolonged high fever, neurological signs were the most common symptoms associated with the development of intracranial complications of acute mastoiditis in children. Computed tomography and MRI are necessary tools for diagnosis and surgery planning in every case of latent mastoiditis. Antibiotic treatment of acute mastoiditis does not prevent otogenic complications. Extracranial or intracranial complications of acute mastoiditis need surgical treatment and prolonged antibiotic therapy. The present study found evidence for decreased incidence of mastoiditis and their suppurative complications during last years.

Vascular and Parameningeal Infections of the Head and Neck

Vascular and parameningeal infections of the head and neck are rare but frequently life threatening. These infections include intracranial and extracranial septic venous thrombophlebitis, arterial mycotic aneurysms and erosions, subdural empyema, and epidural abscesses. They usually arise as complications of otogenic, oropharyngeal, or paranasal sinus infections, and management involves an aggressive combined medical-surgical approach.

Indications for surgery in acute mastoiditis and their complications in children

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

Rapid evolution of acute mastoiditis: three case reports of otogenic meningitis in adults

Otogenic meningitis is the most common intracranial complication of neglected otitis media. In the western world, such complications seldom occur in children and young adults and are extremely rare in adults and elderly people. The current use of antibiotics and of more sophisticated surgery has greatly diminished the incidence of otogenic meningitis in comparison with the past. This has resulted in physicians having less experience concerning diagnosis and treatment of this complication. The authors reported 3 consecutive cases of otogenic meningitis in adults, which occurred in the space of 3 months after a 6-year absence of such pathology at their institution. In all 3 cases, conventional antibiotic therapy proved ineffective; the course of the disease worsened rapidly in contrast with the lack of symptoms during the period before treatment. Emergency surgical treatment was mandatory.