Postauricular Needle Aspiration of Subperiosteal Abscess in Acute Mastoiditis

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.

Our experience on the management of acute mastoiditis in pediatric acute otitis media patients

OBJECTIVE

The incidence of complications due to acute otitis media (AOM) in childhood has decreased significantly with the use of new antibiotics in recent years. However, acute mastoiditis (AM) is still the most common complication that can lead to further intracranial conditions with high morbidity. Our study aimed to evaluate the clinical characteristics of children with AM and identify possible indicators for further intracranial complications associated with this condition.

METHODS

Children hospitalized in our clinic with a diagnosis of AM were reviewed. Demographic data, disease-related symptoms, types of complications accompanied by AM, medical/surgical treatments modalities, and culture results were screened. The patients were divided into two groups as those with and without intracranial complications (ICCs). Routine complete blood count tests, biochemical analysis, and C-reactive protein (CRP) level measurement were evaluated and compared between the groups.

RESULTS

Of the 28 AM patients, five (17.9%) had isolated AM. Complications associated with AM included sub-periosteal abscess (28.6%), facial paralysis (25%), meningitis (17.9%), meningitis with sigmoid sinus thrombosis (7.1%), and meningitis with cerebellar abscess (3.6%). Eight patients developed ICCs (28.6%), of whom three had more than one complication. Ceftriaxone was found to be the first-line medical treatment (57.1%). Streptococcus pneumoniae was the most common pathogen isolated from the cultures (42.9%). Three patients (10.7%) were treated non-surgically, eight (28.6%) with myringotomy and ventilation tube (VT) insertion, eight patients (28.6%) with abscess drainage and VT insertion, and nine (32.1%) with cortical mastoidectomy and VT insertion. There was no significant difference between the patients with and without ICCs in terms of complete blood count parameters. The CRP level and the CRP-albumin ratio were significantly higher in patients with ICCs than those without these complications (p < 0.001).

CONCLUSION

AM remains to be the most common complication of AOM in childhood and can lead to further life-threatening conditions. Additional interventions according to the type of the complication with VT insertion is safe and effective in the management of AM. In patients with AM, it is of great importance to determine whether there is an accompanying ICC. The CRP-albumin ratio is a simple and reliable calculation to detect ICCs in patients with AM.

ACR Appropriateness Criteria® Radiologic Management of Infected Fluid Collections

Infected fluid collections are common and occur in a variety of clinical scenarios throughout the body. Minimally invasive image-guided management strategies for infected fluid collections are often preferred over more invasive options, given their low rate of complications and high rates of success. However, specific clinical scenarios, anatomic considerations, and prior or ongoing treatments must be considered when determining the optimal management strategy. As such, several common scenarios relating to infected fluid collections were developed using evidence-based guidelines for management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Therapeutic approach to pediatric acute mastoiditis – an update

Introduction

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

Objective

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

Methods

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

Results

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

Conclusions

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

Pediatric recurrent acute mastoiditis: Risk factors and insights into pathogenesis

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Safety and postoperative adverse events in management of acute mastoiditis in children - 30 Day NSQIP outcomes

OBJECTIVE

To examine preoperative risk factors, postoperative 30-day outcomes and adverse events of acute mastoiditis using a national pediatric surgical database.

METHODS

We explored our objectives using a cross-sectional analysis of a hospital-based reporting system database. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) pediatric database was used to identify surgical encounters for the treatment of acute mastoiditis from 2012 to 2015. Patient demographics, co-morbidities, laboratory values, surgical details, complications, and outcomes were tabulated. Linear regression was used to determine predictors of prolonged hospital stay based on pre-operative, surgical and outcome variables.

RESULTS

113 patients with acute mastoiditis were identified from with mean age of 7.8 years. Mastoidectomy was the most common index procedure performed (44; 34%). Average hospital stay length was 5.2 days. No patients died within 30 days. 4 (3.1%) patients required readmission, and 9 (6.9%) required unplanned subsequent operative procedures. Pre-operative presence of sepsis or systemic inflammatory response syndrome (SIRS; p = 0.03), and unplanned additional procedures were associated with a prolonged hospital stay (p = 0.03), but age, gender, race, and pre-operative morbidities were not (p > 0.05).

CONCLUSIONS

Contemporary surgical management of acute mastoiditis in children appears to be safe. Mortality is rare and has been potentially eliminated as a complication. Rates of pre-operative systemic infection were very high, despite current antibiotic utilization trends. Opportunities for quality improvement exist to investigate how to decrease rates of preoperative sepsis, limit readmissions, and unplanned re-operations. The role of mastoidectomy appears prominent, as it was used in about two-thirds of cases.

LEVEL OF EVIDENCE

4.

Acute Otitis Media and Acute Coalescent Mastoiditis

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

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

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

Management of paediatric acute mastoiditis: systematic review

Background:

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

Objectives:

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

Method:

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

Results:

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

Conclusion:

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

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.

Two cases of acute mastoiditis with subperiosteal abscess

The incidence of mastoiditis in pediatric age has consistently increased over the last two decades due to increase of antibiotic-resistant bacteria. Compared to young patients, occurrence of acute otitis media complications such as acute mastoiditis and subperiosteal abscess is relatively low in adults. Various treatments for acute mastoiditis with subperiosteal abscess such as tympanostomy tube insertion, intravenous antibiotics, and postauricular incision and drainage have avoided the morbidity and necessity of mastoid surgery. Recently, many studies have indicated mastoidectomy only in cases of severe complications or failure of disease improvement after antibiotic treatment and myringotomy. In this report, we present two cases of successful treatment of subperiosteal abscess and discuss the management of acute mastoiditis with subperiosteal abscess in both child and adult.

National assessment of validity of coding of acute mastoiditis: a standardised reassessment of 1966 records

OBJECTIVES

To investigate the internal validity of the diagnosis code used at discharge after treatment of acute mastoiditis.

DESIGN

Retrospective national re-evaluation study of patient records 1993-2007 and make comparison with the original ICD codes.

SETTING

All ENT departments at university hospitals and one large county hospital department in Sweden.

PARTICIPANTS

A total of 1966 records were reviewed for patients with ICD codes for in-patient treatment of acute (529), chronic (44) and unspecified mastoiditis (21) and acute otitis media (1372).

MAIN OUTCOME MEASURES

ICD codes were reviewed by the authors with a defined protocol for the clinical diagnosis of acute mastoiditis. Those not satisfying the diagnosis were given an alternative diagnosis.

RESULTS

Of 529 records with ICD coding for acute mastoiditis, 397 (75%) were found to meet the definition of acute mastoiditis used in this study, while 18% were not diagnosed as having any type of mastoiditis after review. Review of the in-patients treated for acute media otitis identified an additional 60 cases fulfilling the definition of acute mastoiditis. Overdiagnosis was common, and many patients with a diagnostic code indicating acute mastoiditis had been treated for external otitis or otorrhoea with transmyringeal drainage.

CONCLUSIONS

The internal validity of the diagnosis acute mastoiditis is dependent on the use of standardised, well-defined criteria. Reliability of diagnosis is fundamental for the comparison of results from different studies. Inadequate reliability in the diagnosis of acute mastoiditis also affects calculations of incidence rates and statistical power and may also affect the conclusions drawn from the results.

Acute mastoiditis in children: a 10-year retrospective and validated multicenter study

BACKGROUND

Conservative treatment of acute otitis media may lead to more complications. This study evaluates changes in incidence, the clinical and microbiological findings, the complications and the outcome of acute mastoiditis in children in a country employing conservative guidelines in treating acute otitis media.

METHODS

All admitted children (0-15 years) diagnosed with acute mastoiditis during the period from 1998 to 2007 in eastern Denmark (population 2.2 million) were identified. Patient files were retrieved and reviewed; the data were entered into a database.

RESULTS

The average incidence of admitted children with acute mastoiditis was 4.8/100,000 children per year (95% CI were ± 0.03 -0.04), and there was no change in the incidence during the 10-year period. Of the 214 children included (mean age 2.1 years, range 0.3-13.1, median 1.3 years), 100% presented with protrusion of the pinna and 95% with retroauricular swelling and redness, whereas 32% had a retroauricular abscess. Mastoidectomy had been performed in children with a retroauricular abscess. Thirty-one percent had a ventilation tube inserted. The remaining group was treated with antibiotics and analgesics, and 86% also had a myringotomy performed. Streptococcus pneumoniae and group A streptococci were the bacteria most commonly cultured, 94% being susceptible to penicillin. The complication rate was low at 1.9%. All children included were initially admitted; no patients were outpatients.

CONCLUSIONS

The incidence of acute mastoiditis is stable in eastern Denmark where conservative management guidelines for treating acute otitis media are used. Bacterial resistance toward penicillin is low (6%), complications are rare and the treatment outcome is good. Furthermore, no severe complications after treatment were observed.

Recurrent acute mastoiditis - a retrospective national study in Sweden

CONCLUSIONS

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

OBJECTIVE

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

METHODS

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

RESULTS

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

Mastoid subperiosteal abscess in children: drainage or mastoidectomy?

OBJECTIVE

To evaluate the management of mastoid subperiosteal abscess using two different surgical approaches: simple mastoidectomy and abscess drainage.

METHOD

The medical records of 34 children suffering from acute mastoiditis with subperiosteal abscess were retrospectively reviewed. In these cases, the initial surgical approach consisted of either myringotomy plus simple mastoidectomy or myringotomy plus abscess drainage.

RESULTS

Thirteen children were managed with simple mastoidectomy and 21 children were initially managed with abscess drainage. Of the second group, 12 children were cured without further treatment while 9 eventually required mastoidectomy. None of the children developed complications during hospitalisation, or long-term sequelae.

CONCLUSION

Simple mastoidectomy remains the most effective procedure for the management of mastoid subperiosteal abscess. Drainage of the abscess represents a simple and risk-free, but not always curative, option. It can be safely used as an initial, conservative approach in association with myringotomy and sufficient antibiotic coverage, with simple mastoidectomy reserved for non-responding cases.

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.

Pediatric acute mastoiditis in the post-pneumococcal conjugate vaccine era

OBJECTIVES/HYPOTHESIS

To determine whether the characteristics of acute mastoiditis in children have changed in the post-heptavalent pneumococcal conjugate vaccine (PCV7) era.

STUDY DESIGN

Case series.

METHODS

Clinical data for all patients admitted for acute mastoiditis at an urban tertiary children's hospital from July 1, 1996, to June 30, 2009, were reviewed. Patients with a known immune deficiency or cholesteatoma were excluded. Patients were divided into pre-PCV7 (July 1996 to December 2002; n = 38) and post-PCV7 (January 2003 to June 2009; n = 58) groups. Statistical analyses were used to compare the two groups.

RESULTS

Ninety-six children met the inclusion criteria. There was a 53% increase in admission for acute mastoiditis in the post-PCV7 era. The pre- and post-PCV7 groups had similar demographic features, presenting history, signs and symptoms, laboratory study results, and medical management. Computed tomography scan abnormalities seen in the two groups were similar except for subperiosteal abscess, which was seen more frequently in the post-PCV7 group. Streptococcus pneumoniae was the most common pathogen isolated in both groups. The patients in the post-PCV7 group had shorter hospital stays, despite undergoing more extensive surgery to address their disease.

CONCLUSIONS

The number of acute mastoiditis admissions did not decrease with the widespread use of PCV7. Computed tomography findings and surgical procedures required to address acute mastoiditis indicate that the post-PCV7 group had more advanced disease. S pneumoniae remains the main pathogen in acute mastoiditis, and its nonsusceptibility to penicillin and ceftriaxone may be increasing.

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.

Pediatric otogenic intracranial abscesses

Objective: To describe the presentation and management of otogenic intracranial abscesses in a tertiary care pediatric hospital.

Study Design: Case series and chart review.

Setting: Tertiary care pediatric hospital.

Subjects and Methods: An inpatient database was queried for the following diagnostic codes from 2000 to 2008: [383.2] petrositis, [383] acute mastoiditis, [386.3] labyrinthitis, [351.0] facial paralysis (Bell's palsy), [351.9] facial nerve disorder unspecified, [351.8] other facial nerve disorders, [383.01] subperiosteal abscess, [383.02] Gradenigo's syndrome, [320] meningitis, [324.9] extradural or subdural abscess, [324.0] intracranial abscess, [325] thrombosis of intracranial venous sinus, and [348.2] otic hydrocephalus. Presenting signs and symptoms, microbiology, length of stay, surgical findings, and outcomes were recorded for each patient.

Results: Forty patients were identified with an otogenic intracranial complication. Thirty patients had evidence of an intraparenchymal, epidural, subdural, or petrous apex suppurative complication of otitis media. Twenty-four of 30 (80%) patients had a canal wall up mastoidectomy, three (10%) patients had a craniotomy without a mastoidectomy, and three (10%) patients were managed with intravenous antibiotics with or without pressure equalization tubes. There were no mortalities in this series of patients.

Conclusion: Patients with intracranial abscesses, in selected cases, can be managed with intravenous antibiotics without mastoidectomy. The use of canal wall up mastoidectomy is an acceptable alternative to radical mastoidectomy when surgical intervention is necessary.

Complications of chronic otitis media and cholesteatoma

The incidence of complications of chronic otitis media and cholesteatoma has decreased since the proliferation of antibiotics early in the twentieth century. However, these complications continue to occur, and can be lethal if they are not identified and treated properly. Therapy for the complications associated with chronic otitis media, unlike that of acute otitis media, usually involves surgical intervention. As medical (antibiotic) therapy continues to improve, and new imaging techniques are introduced, less invasive treatment modalities may be shown to be as effective as the classic, time-tested, surgical options.