Complications of Mastoiditis in Children at the Onset of a New Millennium

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.

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.

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.

Performance of deep learning to detect mastoiditis using multiple conventional radiographs of mastoid

Objectives

This study aimed to compare the diagnostic performance of deep learning algorithm trained by single view (anterior-posterior (AP) or lateral view) with that trained by multiple views (both views together) in diagnosis of mastoiditis on mastoid series and compare the diagnostic performance between the algorithm and radiologists.

Methods

Total 9,988 mastoid series (AP and lateral views) were classified as normal or abnormal (mastoiditis) based on radiographic findings. Among them 792 image sets with temporal bone CT were classified as the gold standard test set and remaining sets were randomly divided into training (n = 8,276) and validation (n = 920) sets by 9:1 for developing a deep learning algorithm. Temporal (n = 294) and geographic (n = 308) external test sets were also collected. Diagnostic performance of deep learning algorithm trained by single view was compared with that trained by multiple views. Diagnostic performance of the algorithm and two radiologists was assessed. Inter-observer agreement between the algorithm and radiologists and between two radiologists was calculated.

Results

Area under the receiver operating characteristic curves of algorithm using multiple views (0.971, 0.978, and 0.965 for gold standard, temporal, and geographic external test sets, respectively) showed higher values than those using single view (0.964/0.953, 0.952/0.961, and 0.961/0.942 for AP view/lateral view of gold standard, temporal external, and geographic external test sets, respectively) in all test sets. The algorithm showed statistically significant higher specificity compared with radiologists (p = 0.018 and 0.012). There was substantial agreement between the algorithm and two radiologists and between two radiologists (κ = 0.79, 0.8, and 0.76).

Conclusion

The deep learning algorithm trained by multiple views showed better performance than that trained by single view. The diagnostic performance of the algorithm for detecting mastoiditis on mastoid series was similar to or higher than that of radiologists.

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

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

Acute mastoiditis in children

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

Acute Otitis Media and Acute Coalescent Mastoiditis

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

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

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

Cranial Rhabdomyosarcoma Masquerading as Infectious Mastoiditis: Case Report and Literature Review

BACKGROUND

Rhabdomyosarcoma originating in the mastoid is rare and may be misdiagnosed as an infectious mastoiditis due to overlapping clinical and imaging features. We aimed to identify distinguishing characteristics to facilitate earlier diagnosis and treatment.

METHOD

Here we describe a case report and a systematic review of 23 reports describing previous cases of mastoid rhabdomyosarcoma. We compare these patients to a systematic review of patients with infectious mastoiditis and identify distinguishing clinical features.

RESULTS

A total of 43 patients with rhabdomyosarcoma of the mastoid were identified and compared with patients with mastoiditis. Rhabdomyosarcoma patients were more likely to present with a mass (86%) or cranial nerve dysfunction (83.7%), while mastoiditis patients were more likely to have fever (72.4%), pain (48.2%), and present at a younger age (4.4 vs. 6.1 years). The average lifespan with rhabdomyosarcoma of the mastoid was 7.1 months after diagnosis, with 41.7% of patients alive at the time of report.

CONCLUSIONS

Based on abstracted and aggregated information, we identified unique features observed more frequently in each of rhabdomyosarcoma and mastoiditis. These predictive features allow for the differentiation of each diagnosis and avoid the delay of proper treatment.

Management of paediatric acute mastoiditis: systematic review

Background:

Acute mastoiditis remains the commonest intratemporal complication of otitis media in the paediatric population. There has been a lack of consensus regarding the diagnosis and management of acute mastoiditis, resulting in considerable disparity in conservative and surgical management.

Objectives:

To review the current literature, proposing recommendations for the management of paediatric acute mastoiditis and appraising the treatment outcomes.

Method:

A systematic review was conducted using PubMed, Web of Science and Cochrane Library databases.

Results:

Twenty-one studies were included, with a total of 564 patients. Cure rates of medical treatment, conservative surgery and mastoidectomy were 95.9 per cent, 96.3 per cent and 89.1 per cent, respectively.

Conclusion:

Mastoidectomy may be the most definitive treatment available; however, reviewed data suggest that conservative treatment alone has high efficacy as first-line treatment in uncomplicated cases of acute mastoiditis, and conservative therapy may be an appropriate first-line management when treating acute mastoiditis.

Acute Mastoiditis in Children: Is Computed Tomography Always Necessary?

Objectives

Acute mastoiditis (AM) is the most common intratemporal complication of acute otitis media in children. In the past decade, reports have indicated a rise in the incidence of AM in the pediatric population. A parallel rise in the use of computed tomography (CT) imaging has occurred. The rise in the use of CT scanning in the pediatric population, entraining with it a rise in pediatric brain irradiation, has led us to question the necessity of using CT for pediatric patients with AM.

Methods

We reviewed the medical files of pediatric patients who had AM in the years 2005 through 2007.

Results

Fifty patients were identified. The gender distribution was equal, and the ages ranged from 4 months to 12 years. Of the 46 patients who were admitted to our institution “de novo,” only 2 underwent CT scanning on admission, and 4 other patients had CT performed during hospitalization. The majority of patients (92%) with AM did not have a CT scan performed and were treated conservatively with no complications.

Conclusions

In most pediatric patients, CT does not seem to be indispensable in the diagnosis of AM. Conservative therapy and close follow-up seem to suffice for most.

Acute mastoiditis in children with a cochlear implant

OBJECTIVES

Cochlear implantation is performed at a young age, when children are prone to acute otitis media. Acute mastoiditis is the most common complication of otitis media, but data on its management in the presence of a cochlear implant are sparse. The objective of this study was to assess the characteristics, treatment, and outcome of acute mastoiditis in children with a cochlear implant.

METHODS

The medical files of all children who underwent cochlear implantation at a pediatric tertiary medical center in 2000-2014 were retrospectively reviewed. Those diagnosed with acute mastoiditis after implantation were identified, and data were collected on demographics, history, presentation, method of treatment, complications, association with untreated otitis media with effusion, and long-term middle-ear sequelae.

RESULTS

Of the 370 children (490 ears) who underwent cochlear implantation, 13 (3.5%) were treated for acute mastoiditis (median age at acute mastoiditis, 32 months). Nine had a pre-implantation history of chronic secretory or acute recurrent otitis media, and 5 had been previously treated with ventilation tubes. In all 9 children who had unilateral cochlear implant, the acute mastoiditis episode occurred in the implanted ear. The time from implantation to mastoiditis was 5-61 months. The same treatment protocol as for normal-hearing children was followed, with special attention to the risk of central nervous system complications. Primary treatment consisted of myringotomy with intravenous administration of wide-spectrum antibiotics. Surgical drainage was performed in 8 out of 13 patients, with (n=7) or without (n=1) ventilation-tube insertion, to treat subperiosteal abscess or because of lack of symptomatic improvement. There were no cases of intracranial complications or implant involvement or need for a wider surgical approach. No middle-ear pathology was documented during the average 3.8-year follow-up.

CONCLUSIONS

The relatively high rate of acute mastoiditis and subperiosteal abscess in children with a cochlear implant, predominantly involving the implanted ear, supports the suggestion that recent mastoidectomy may be a risk factor for these complications. Despite the frequent need for drainage, more extensive surgery is usually unnecessary, and recovery is complete and rapid. As infections can occur even years after cochlear implantation, children with otitis media should be closely followed, with possible re-introduction of ventilation tubes.

Subperiosteal abscesses in acute mastoiditis in 115 Swedish children

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diseases of the middle ear in childhood

Middle ear diseases in childhood play an important role in daily ENT practice due to their high incidence. Some of these like acute otitis media or otitis media with effusion have been studied extensively within the last decades. In this article, we present a selection of important childhood middle ear diseases and discuss the actual literature concerning their treatment, management of complications and outcome. Another main topic of this paper deals with the possibilities of surgical hearing rehabilitation in childhood. The bone-anchored hearing aid BAHA(®) and the active partially implantable device Vibrant Soundbridge(®) could successfully be applied for children. In this manuscript, we discuss the actual literature concerning clinical outcomes of these implantable hearing aids.

Genetic susceptibility to chronic otitis media with effusion: candidate gene single nucleotide polymorphisms

OBJECTIVES/HYPOTHESIS

The genetic factors leading to a predisposition to otitis media are not well understood. The objective of the current study was to develop a tag-single nucleotide polymorphism (SNP) panel to determine if there is an association between candidate gene polymorphisms and the development of chronic otitis media with effusion.

STUDY DESIGN

A 1:1 case/control design of 100 cases and 100 controls was used. The study was limited to the chronic otitis media with effusion phenotype to increase the population homogeneity.

METHODS

A panel of 192 tag-SNPs was selected. Saliva for DNA extraction was collected from 100 chronic otitis media with effusion cases and 100 controls. After quality control, 100 case and 79 control samples were available for hybridization. Genomic DNA from each subject was hybridized to the SNP probes, and genotypes were generated. Quality control across all samples and SNPs reduced the final SNPs used for analysis to 170. Each SNP was then analyzed for statistical association with chronic otitis media with effusion.

RESULTS

Eight SNPs from four genes had an unadjusted P value of <.05 for association with the chronic otitis media with effusion phenotype (TLR4, MUC5B, SMAD2, SMAD4); five of these polymorphisms were in the TLR4 gene.

CONCLUSIONS

Even though these results need to be replicated in a novel population, the presence of five SNPs in the TLR4 gene having association with chronic otitis media with effusion in our study population lends evidence for the possible role of this gene in the susceptibility to otitis media.

Fusobacterium necrophorum mastoiditis in children - emerging pathogen in an old disease

BACKGROUND

Anaerobic bacteria are uncommon etiologic agents of acute mastoiditis in children. However, recent studies suggest an increase in the incidence of Fusobacterium necrophorum mastoid infections in the last two decades.

METHODS

A surveillance study performed over 3.5 years in a tertiary pediatric medical center identified 7 children with acute F. necrophorum mastoiditis. Clinical, laboratory, and treatment data were collected by file review.

RESULTS

Five of the 7 children presented in the last year of the study. All 7 children were less than 26 months old on admission, and none had a history of otogenic infections. All cases were characterized by significantly elevated levels of inflammatory markers. All were diagnosed as complicated mastoiditis with abscess formation. Four children had an epidural abscess, three children had evidence of osteomyelitis beyond the mastoid bone, and four children had imaging evidence of sinus vein thrombosis. All seven children required cortical mastoidectomy with ventilatory tubes insertion and two children required more than one surgical intervention. During follow-up, two children had recurrent episodes of mastoiditis due to other pathogens.

CONCLUSION

Our data support the literature suggesting that the occurrence of F. necrophorum mastoiditis among children is rising. Acute coalescent mastoiditis due to F. necrophorum is associated with a complicated course and warrants particular attention by pediatricians, infectious disease experts, and ear, nose and throat specialists.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Algorithmic management of pediatric acute mastoiditis

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acute mastoiditis in children: a retrospective study of 188 patients

OBJECTIVE

The aim of this study is to define the clinical and bacteriological characteristics of acute mastoiditis (AM) in children in order to optimize diagnostic work-up and treatment.

METHODS

In this retrospective study, 188 children between 3 months and 15 years of age (15±24 months; median±SD) were referred to our pediatric ENT emergency center for AM during a 7-year period (December 2001-January 2008).

RESULTS

Fifty seven percent were male and 43% were female. Clinical follow-up duration was 3.9±0.7 months (mean±SEM). The incidence of AM remained stable during the whole study period. Microbiological samples (n=236) were negative in 33% of cases. The most frequently isolated germs were Streptococcus pneumoniae (51%), Streptococcus pyogenes (11.5%), Anaerobes (6.5%), and coagulase-negative Staphylococcus (6.5%). Paracentesis, puncture of retro auricular abscess under local anesthesia, and peroperative samples all contributed to isolate the involved germ(s). All the patients were hospitalized and received intravenous antibiotics, and 36.2% (n=68) underwent surgery. Several surgical procedures were necessary in 4 cases (2.1%). AM recurrences requiring a second hospitalization were observed in 8 patients (4.3%). The only observed complication was lateral sinus thrombosis (n=6; 3.2%). Surgical failures, requiring more than one surgical procedure, were more frequent in case of: (i) presence of Anaerobes (p≤0.001) or Gram-negative bacteria (p≤0.05) in microbiological samples; (ii) surgical drainage without mastoidectomy (p≤0.001). Recurrences were more frequent in AM due to Streptococcus pneumoniae.

CONCLUSIONS

Based on our findings and on literature data, a protocol was established in order to standardize the management of pediatric AM in our center. The mains points are: no systematic surgery; if surgery is indicated, it must encompass a mastoidectomy; broad-spectrum intravenous antibiotic treatment covering the most commonly involved germs (3rd generation cephalosporin) and secondarily adapted to the results of microbiological samples. If the infection is not controlled after 48 h of intravenous antibiotherapy, a mastoidectomy had to be performed.

[Acute mastoiditis in the pneumococcal vaccine era]

INTRODUCTION AND OBJECTIVES

Acute mastoiditis is the most common complication of acute otitis media. Recent studies have noticed an increase in cases. The goal of this study was to review acute mastoiditis cases diagnosed in children younger than 14 years old.

MATERIAL AND METHODS

A retrospective study of all patients under 14 years old admitted with a diagnosis of mastoiditis between 1996 and 2008 was performed. Epidemiological, laboratory and clinical variables were analysed.

RESULTS

Sixty-one charts were reviewed. The mean age was 28 months; 55.7% of the patients were male. Most cases were in the autumn and winter; 79% occurred from 2002 to 2008. Most cases (82%) had antecedents of an upper airway catarrhal process and 60.7% had a clinical diagnosis of acute otitis media. Prior antibacterial agent therapy had been administered in 55.7% of the cases. Culture of middle ear effusions was performed in 48 patients, revealing Streptococcus pneumonia in 39.7%, Haemophilus influenzae in 2%, Staphylococcus aureus in 12.5% and Pseudomonas aeruginosa in 8.3%. Cultures were sterile in 18 patients (37.5%). Of the pneumococcal isolates, 26.2% were resistant to penicillin or third generation cephalosporins. Most cases (93.4%) responded well to antibacterial therapy alone or with myringotomy. There were complications in 7 patients (11.5%). Mastoid surgery was performed in 4 patients.

CONCLUSIONS

Acute mastoiditis shows a rising incidence in recent years. The most commonly isolated form is the pneumococcus, the high rates of antibiotic resistance in our study being notable. Treatments with antibiotics alone or in combination with myringotomy are effective in less severe forms.

Shifting trends: mastoiditis from a surgical to a medical disease

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical, laboratory, and microbiological differences between children with simple or complicated mastoiditis

OBJECTIVE

To assess clinical, laboratory, and microbiological differences between children with simple and complicated mastoiditis.

PATIENTS AND METHODS

Data on all children who were hospitalized at a tertiary center for acute mastoiditis over a 5-year period were collected from the computerized files. Findings were compared between those with simple mastoiditis vs. cases with intra- or extra-cranial complications.

RESULTS

Of the 308 children with acute mastoiditis, 55 (17.9%) had complicated disease. This group was characterized by a significantly higher maximal fever at presentation and higher absolute neutrophil count and C-reactive protein level than the children with simple disease. There was no statistically significant between-group difference in age, history of otitis media, prior antibiotic treatment, days of illness before presentation, absolute leukocyte count, and platelet count. No difference was detected between the groups in the penicillin and ceftriaxone susceptibility of the Streptococcus pneumoniae isolates.

CONCLUSION

High-grade fever, high absolute neutrophil count, and high C-reactive protein level may serve as clinical and laboratory markers of complicated mastoiditis. Children with these findings warrant close follow-up and perhaps, earlier surgical intervention.

Conservative management of acute mastoiditis in children

OBJECTIVE

To review the current management of acute mastoiditis with critical emphasis on the role of myringotomy.

DESIGN

A retrospective chart review.

SETTING

Tertiary-care, university affiliated children's hospital.

PATIENTS

One hundred and forty-four consecutive children hospitalized for acute mastoiditis between the years 1991 and 2002.

INTERVENTIONS

All children were treated with parenteral antibiotics (conservative management). Myringotomy was performed at the discretion of the otolaryngologist on-call.

MAIN OUTCOME MEASURES

Comparing outcomes of children with or without myringotomy regarding hospital stay, complications and the need for surgical interventions.

RESULTS

Myringotomy was performed in 34.6% of episodes. The children who underwent myringotomy were found to be significantly younger (22.4 compared to 28.8 months, p=0.028) and had more complications (n=17 vs. n=8, p<0.001). Complications overall occurred in 16.3% of episodes. Performing myringotomy had no significant effect on the duration of hospital stay. Children pretreated with antibiotics underwent significantly less myringotomies p=0.027. There were no significant differences between children who underwent myringotomy and those who did not with regard to WBC count, or ESR.

CONCLUSIONS

These findings suggest that myringotomy may not be required in all cases of acute mastoiditis. Parenteral antibiotics is sufficient in most cases. Criteria for myringotomy may include a younger age. Conservative management resulted in good outcomes in this series.

Acute mastoiditis in children: the "Ferrara" experience

OBJECTIVE

This study aims to investigate the clinical features and outcomes of acute mastoiditis in children referred to the ENT/Audiology Department of the University of Ferrara from January 1994 to December 2005. It also aims to discuss risk factors and to find predictors for surgery.

METHODS

A retrospective study on case sheets of children with an acute mastoiditis diagnosis was carried out. Fifty-five cases fulfilled the inclusion criteria: they presented otoscopical evidence of acute otitis media and inflammatory findings of the mastoid area such as post-auricular swelling, redness or tenderness, protrusion of the auricle and/or radiological findings.

RESULTS

Twenty-six patients were only treated with antibiotic therapy, tympanocentesis alone was performed in 11 cases; in 5, a ventilation tube was positioned. Mastoidectomy was performed in 13 patients. The group who underwent mastoidectomy had a median hospital stay of 15 days (5-54), in this group were found the following complications: 1 meningitis, 1 meningo-encephalitis, 1 lateral and sigmoid sinus thrombosis, 1 facial palsy.

CONCLUSION

the incidence of otomastoiditis does not seem to be decreasing, on the contrary, in some countries, it seems to be on the increase. Our experience cannot confirm a real increase of the incidence but we noted periodic variations during the time of observation. It is important, that careful attention is paid to the clinical assessment of children who are 2-years old or under, as they seem to be more exposed to the risk of clinical complications; therefore, it is highly recommended that the otologist and the paediatrician collaborate closely.

Adenoidectomy and tympanostomy tubes in the management of otitis media

Otitis media is one of the most common childhood infections and the most frequent cause for antibiotic prescriptions in children. As respiratory infections are also associated with childhood asthma, children with recurrent otitis media or with persistent middle-ear effusion are also at an increased risk for developing asthma, which should be appreciated when a child with middle-ear disease is evaluated. The first choice of surgery in chronic middle-ear inflammatory disease is the insertion of tympanostomy tubes. It is warranted when the middle-ear effusion has lasted for 3 or more months. When chronic adenoid infection is suspected, adenoidectomy may be beneficial in treating otitis media in children who are older than 4 years of age and who have previously undergone tympanostomy-tube insertion.

Acute mastoiditis and osteomyelitis of the temporal bone

OBJECTIVE

Acute mastoiditis becomes clinically significant when infection spreads through the periosteum and induces periosteitis. This study describes an atypical complication of acute mastoiditis: osteomyelitis of the temporal bone.

PATIENTS AND METHODS

The study sample included all patients admitted for acute mastoiditis between September 2001 and December 2003 who had symptoms, signs and imaging findings of osteomyelitis of the temporal bone beyond the mastoid area. The files were reviewed for diagnosis, work-up, radiographic findings and treatment.

RESULTS

The study group included 6 of the 120 patients treated for acute mastoiditis. In four children (66%), the diagnoses of acute otitis media and acute mastoiditis were made simultaneously at admission. Ear cultures yielded coagulase-positive Staphylococcus in three patients, Bacteroides in two, multiple organisms in two, S. pneumoniae in one, and no growth in two. Complications were suspected if there was a lack of improvement in symptoms and signs, or in cases of skin involvement over the temporal bone beyond the area of the mastoid in accordance with imaging findings. Computerized tomography demonstrated temporal bone absorption beyond the mastoid area (squama and/or petrous bones) in all children, suspected sinus vein thrombosis in two, and suspected epidural abscess in one. All children were treated with at least cortical mastoidectomy and insertion of ventilation tubes. Revision mastoidectomy was performed in three children in whom no improvement was noted and imaging suggested other complications.

CONCLUSION

The present study describes an unusual complication of acute mastoiditis-osteomyelitis of the temporal bone beyond the mastoid framework. The disorder is characterized by a failure to respond both locally and systemically to accepted medical and surgical therapy, persistent fever and high levels of inflammatory markers, and computerized tomography findings of temporal bone destruction. Treatment includes broad-spectrum antibiotics and at least cortical mastoidectomy. Prognosis is good.