Acute mastoiditis in children: epidemiologic, clinical, microbiologic, and therapeutic aspects over past years

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.

Clinical Characteristics and Treatment Experiences of Pediatric Acute Mastoiditis and Its Complications at the University Tertiary Care Center in the 10-Year Prevaccinal Period

Introduction: We aim to provide an overview of the clinical characteristics and treatment of pediatric acute mastoiditis (AM) and its complications in the prevaccinal pneumococcal period. Materials and methods: Retrospective case series. An analysis of pediatric patients with AM treated at a university tertiary care center from 2008 to 2018 was performed. Results: The research included 121 children, and 27.3% of them had some form of complication. The mean age at presentation of AM was 3.7 years (range = 0-18 years). The most common extracranial complication of AM was a subperiosteal abscess (n = 25, 75.8%) and the most common intracranial complication was meningoencephalitis (n = 2, 6%). The most common pathogen isolated in the complicated AM was Streptococcus pneumoniae (n = 17, 51.5%). A total of 60% of patients reported antibiotic use before hospital admission, mostly third-generation cephalosporins (37.5%). There was a statistically significant difference between age group and occurrence of complications (P = .001). Females had complications more frequently than males (P = .035). There were no statistically significant differences in levels of inflammatory parameters (C-reactive protein and leukocyte count) between patients with or without complications (P = .373 and P = .124; respectively). All patients with complications of AM were surgically treated. Mortality was 0% and all children completely recovered. Conclusion: Extracranial and intracranial complications of AM required surgical treatment and extended antibiotic therapy. Inflammation parameters did not have a predictive role in identifying children with complications of AM. Further investigations will determine whether the introduction of the mandatory pneumococcal vaccine in our country has led to a reduction in the incidence of AM and its complications.

[Outpatient Antibiotic Prescription Rates and Mastoiditis in Children and Adolescents, Saarland, 2014-2019]

BACKGROUND

Infections of the respiratory tract are the main indication for outpatient antibiotic therapy in children and adolescents. In recent years the antibiotic prescription rate (APR) in the pediatric population has decreased significantly.

OBJECTIVES

The aim of the retrospective mastoiditis audit in the PaedineSaar network is to investigate the incidence of inpatient acute mastoiditis (AM) in Saarland (2014-2019) regarding to the decreasing APRs in children, as well as to gather data of the clinical course of AM.

METHODS

All inpatient AM cases 2014-2019 were analyzed retrospectively from 6 hospitals for pediatrics and/or otorhinolaryngology in Saarland and Trier. Children and adolescents aged 0-17 years and residing in Saarland were included in the study.

RESULTS

2014-2019 53 inpatient treated AM cases have been recorded. During the study period there was no significant increase of AM incidence (mean incidence 2014-2019: 6.1/100,000). 34% (18/53) of the patients received prehospital antibiotic treatment (main indication: acute otitis media (AOM) 15/18, 83%). At least one complication occurred in 30% of the patients (16/53). There was a slight trend to more complications in children without oral antibiotic treatment before admission (14/35 (40%) vs. 2/18 (11%) p=0.056).

CONCLUSIONS

The incidence of AM leading to inpatient treatment in children in Saarland did not increase 2014-2019 despite a significant and sustained decline in the outpatient APRs. The results of this audit should be used for the development of a more standardized approach concerning the diagnostics and treatment of children with AM.

A Review of Noninfectious Diseases Masquerading as Acute Mastoiditis

OBJECTIVE

Acute mastoiditis is commonly attributed to infection. Rarely do clinicians encounter cases that do not respond to traditional antibiotics or surgical management. The goal of this study was to systematically review the literature to characterize diseases masquerading as acute infectious mastoiditis.

DATA SOURCES

PubMed, Embase, and Scopus.

REVIEW METHODS

A systematic review was performed to identify all publications that reported on diseases with presentations mimicking acute mastoiditis, defined as postauricular redness, swelling, and tenderness. We included clinical prospective studies, retrospective studies, and case series/reports. Exclusion criteria included non-English articles, letters/commentaries, abstracts, and review articles.

RESULTS

Out of 3339 results, 35 studies met final inclusion criteria. In children, 11 diseases were reported to mimic mastoiditis, including solid tumors, hematologic diseases, and autoimmune/inflammatory diseases. The most common disease in children was Langerhans cell histiocytosis, followed by rhabdomyosarcoma and acute myelogenous leukemia. In adults, 8 additional diseases were reported. The most common disease in adults was squamous cell carcinoma, followed by nasopharyngeal carcinoma and Langerhans cell histiocytosis. Presenting symptoms are reviewed, as well as characteristic radiographic, laboratory, and intraoperative features that may assist with diagnosis. A diagnostic algorithm for atypical cases of acute mastoiditis is proposed.

CONCLUSION

A small but significant group of diseases in children and adults can mimic acute mastoiditis. In such cases, history and examination alone may be insufficient to reach a diagnosis, and further investigation may be necessary. Otolaryngologists should always be mindful of the possibility that noninfectious pathologies may present with a constellation of symptoms similar to mastoiditis.

Epidemiology of pediatric acute mastoiditis in Israel: A National Registry 10-year perspective

Background and Objectives

Previous small studies have proposed a higher incidence of acute mastoiditis in Israeli pediatric patients than in other Western countries. The aim of this study was to describe the incidence of acute mastoiditis and its epidemiological features over a decade, in order to identify variables that could possibly affect the incidence.

Methods

All admitted patients aged <18 years diagnosed with acute mastoiditis between 2008 and 2018 at Clalit Healthcare Services were identified and a database was generated.

Results

A total of 1189 and 1115 patients met the inclusion criteria, respectively. Acute mastoiditis diagnosis was confirmed in 95.2% of the patients. The incidence was 7.78 cases per 100,000 children-years but was significantly higher in children under 2 years of age (average of 38.31 per 100,000 children-years). No specific pattern was observed in the annualized incidence rate during the study period. Acute mastoiditis was significantly more common in children of Jewish descent than non-Jewish (10.4 vs. 3.03 per 100,000 children-years, P < 0.001) and of high socioeconomic status and is more common in the winter. The prevalence of household parental smoking (52%) was more than double that previously reported in the Israeli population.

Conclusions

A higher incidence of acute mastoiditis was observed in the Israeli population than in other reports. The age-dependent rate was identified along with unique epidemiological features such as seasonality, higher incidence in patients of Jewish descent, or high socioeconomic status. Related parental smoking habits lend further support against the exposure of young children to household smoking.Level of evidence: Individual retrospective cohort study.

A Systematic Review of Cases with Bezold's Abscess

OBJECTIVE

The objective for this systematic review is to characterize clinical presentations of Bezold's abscesses to improve awareness and promote earlier diagnoses and prompt intervention in this increasingly rare otologic infection.

DATA SOURCES

Pubmed/Medline, CINAHL (EBSCOhost), and Web of Science articles in all languages were searched.

STUDY SELECTION

Inclusion criteria were that the article was either a case report, case series, or retrospective review with individual case data available. Non-English articles were excluded if they lacked an English language abstract and if that abstract lacked information on baseline demographics, clinical presentation, and management.

DATA EXTRACTION

Included studies were evaluated using fulltext review and demographics, etiology, microbiology, antibiotic usage, and surgical variables were collected.

DATA SYNTHESIS

Data were qualitatively synthesized, with means and averages obtained for all continuous variables.

CONCLUSIONS

Bezold's abscess remains a rare otologic infection, but they are relatively commonly associated with serious neurologic and systemic complications. Delay in diagnosis was a frequent commonality and diagnostic vigilance is tantamount in avoiding this sequelae. Aggressive surgical extirpation and long-term antibiotic treatment is recommended.

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.

Bezold's abscess: An extremely rare complication of suppurative mastoiditis: Case report and literature review

INTRODUCTION

Bezold abscess is a suppurative complication of mastoiditis that the incidence has significantly decreased in the current era due to the introduction of antibiotics.

PRESENTATION OF CASE

We discuss the case of a 62-year-old male who developed Bezold abscess following a right mastoiditis. He presented with laterocervical swelling. His management included; incision and drainage of the abscesses; and mastoidectomy.

CONCLUSION

The incidence of Bezold abscess appears to be increasing, perhaps due to ignorance of the disease by many clinicians, and diagnosis is often delayed with potentially fatal consequences.

Acute mastoiditis in infants aged six months or younger

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Acute mastoiditis in infants younger than 6 months: is an alternative treatment protocol needed?

OBJECTIVES

Several studies have reported that younger children suffer from increased incidence and more severe episodes of acute mastoiditis (AM) than older children, whereas other researchers have found the opposite. The aim of our study was to describe the occurrence, clinical, and microbiological aspects of AM in children 6 months or younger, and compare them with the results in an older reference age band.

METHODS

The medical files of children hospitalized with a diagnosis of AM during 2001-2016 were retrospectively reviewed. Diagnosis of AM was based on the presence of clinical signs of acute otitis media (AOM) accompanied by two or more of the following: auricle protrusion, retro-auricular erythema, swelling, and local tenderness. Children were divided into two age bands, 6 months or younger, and older than 6 months.

RESULTS

Fifty patients in the young age band and 335 in the older reference age band were included. Bilateral AOM was identified in 14 (28%) children under 6 months, and 50 (14.9%) in the reference age band (p < 0.001). Fever, mean WBC, and CRP values were similar in both age bands; 4 (8%) children under 6 months had pre-auricular/zygomatic area swelling, as compared to 1(0.02%) in the reference age band (p < 0.001). Complication rates (subperiosteal abscess, sinus vein thrombosis, and epidural abscess) were similar in both age bands. All children were treated with myringotomy and IV antibiotics. Cortical mastoidectomy with the insertion of ventilation tube was performed in 10 (20%) children in the younger age band and 58(17.3%) in the reference age band. Streptococcus pneumoniae was the most common (38%) isolated bacteria in the younger age band, and Group A streptococcous (GAS) (20.6%) in the reference age band.

CONCLUSIONS

AM in children 6 months or younger has similar presentation and characteristics as in older children. Pre-auricular swelling and bilateral AOM are more typical in the younger age band; Streptococcus pneumoniae is the most common pathogen in the younger children. We suggest that the treatment approach should be the same for both groups.

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Bezold's abscess: A rare complication of suppurative mastoiditis

Bezold’s abscess is a suppurative complication of mastoiditis rarely seen in the current era of antimicrobials. It can lead to seriously sequelae if not diagnosed and treated early. We describe a patient with recurrent bilateral otalgia who had received multiple courses of antimicrobials who presented with severe headache, neck pain and right sided hearing loss. Imaging studies showed chronic mastoiditis and formation of a Bezold’s abscess. Drainage was performed but symptoms persisted. Our report highlights the need for further evaluation of patients presenting with complicated mastoiditis and the need for prolonged antimicrobial therapy.

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.

Acute mastoiditis in an Italian pediatric tertiary medical center: a 15 - year retrospective study

BACKGROUND

Acute mastoiditis is the main suppurative complication of acute otitis media. Its incidence ranges from 1.2 to 4.2/100.000 children/year and a rise has been reported in the last years. There are controversial data regarding risk factors for mastoiditis and its complications.

AIM OF THE STUDY

to evaluate demographics and clinical characteristics of children with acute mastoiditis and to identify possible risk factors for complications.

METHODS

We retrospectively reviewed medical charts of all the children aged 1 month-14 years admitted to our Paediatric Emergency Department from January 2002 to December 2016.

RESULTS

One hundred forty-seven cases (97 males and 50 females) were included in the analysis, mean age was 4.8 ± 3.6 years and 28.2% of the patients were younger than 2 years. We found an increasing number of mastoiditis per year during the last 3 years of the study. Children younger than 2 years were less treated with antibiotics for acute otitis media or treated for a shorter period (p < 0.05), while they were treated at higher antibiotic's dosage for mastoiditis (p < 0.01). Older children presented more frequently with symptoms such as earache or retroauricular pain (p < 0.0001, p < 0.001). We didn't identify any risk factor for mastoiditis complications in our study.

CONCLUSIONS

Despite the introduction of pneumococcal vaccines, the incidence of acute mastoiditis in our population has not been reduced during the last years. We have to face all the reasons why this condition is still relevant, such as antibiotic resistance, new pathogens involved and a possible role played by the implementations of therapeutic acute otitis media guidelines restricting the use of antibiotics in this disease. A particular attention should be given to younger children where signs and symptoms may be less pronounced, therefore acute otitis media or mastoiditis may be misunderstood and appropriate treatment delayed.

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.

Outpatient management of pediatric acute mastoiditis

OBJECTIVE

Evaluate the Montreal Children's Hospital experience with outpatient management of uncomplicated acute mastoiditis with parenteral antibiotic therapy alone and determine if it is a safe alternative to inpatient management.

SUBJECTS AND METHOD

A retrospective review of pediatric patients diagnosed with acute mastoiditis at a tertiary care pediatric hospital between 2013 and 2015 was performed. Patients with syndromes, immunodeficiency, cholesteatoma, chronic otitis media, cochlear implant in the affected ear, or incidental mastoid opacity were excluded.

RESULTS

56 children age 6 months to 15 years old were treated for acute mastoiditis, including 29 hospitalizations and 27 outpatients. Patients managed as outpatient with daily intravenous ceftriaxone had a 93% cure rate. Eighteen hospitalized and one outpatient had complications of acute mastoiditis. Children with complications were more likely to be febrile (p = 0.045). Two patients failed outpatient therapy and were admitted; one for myringotomy and piperacillin-tazobactam treatment and one required a mastoidectomy. 4/27 children treated as outpatient underwent myringotomy and tube insertion, 2 underwent myringotomy and tube along with admission and 21 did not require tube insertion. The average total duration of intravenous antibiotic therapy was respectively 4.9 and 18.9 days in the outpatient and hospitalized group. The average duration of admission was 5.9 days.

CONCLUSION

Outpatient medical therapy of uncomplicated pediatric mastoiditis is safe, successful, and efficient. Benefits include efficient use of surgical beds, cost savings and patient and family convenience. Careful patient selection and close monitoring are keys for successful outcome.

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.

A New Classification System is Helpful in Diagnosing Intracranial Complications of Acute Mastoiditis in CT

PURPOSE

To assess the usefulness of the new computed tomography (CT) classification criteria proposed by Horowitz et al. and their effect on inter-observer agreement when estimating intracranial complications of acute mastoiditis.

METHODS

In this study 53 contrast-enhanced CT scans of patients with acute mastoiditis were each retrospectively reviewed by two radiologists, using two different assessment criteria for intracranial complications. According to the new criteria, intracranial CT findings in the perisinuous area were graded into four classes (I normal, II linear halo, III nodular halo ≤4 mm thick and IV nodular halo >4 mm thick), where classes III and IV indicate a high risk for epidural abscesses. Inter-reader agreement was estimated by weighted kappa analysis for both methods.

RESULTS

With the old method, epidural abscesses were suspected in six and venous sinus thrombosis in five patients. With the new method, high-risk perisinuous lesions (classes III or IV) were detected in 11 patients, and sinus thrombosis outside the perisinuous area in 3 patients. All epidural abscesses were in the perisinuous area. Of the patients four, in whom intracranial pathology was not suspected with the old method, fell into the high-risk group (class III) according to the new method. All class IV lesions were also determined to be pathological with the old method. The inter-observer agreement (weighted kappa) rose from 0.21 (old method) to 0.80 (new method) when assessing epidural abscesses and from 0.44 (old method) to 0.85 (new method) when assessing sinus thrombosis.

CONCLUSION

The new assessment method raised the inter-observer agreement for detection of intracranial acute mastoiditis complications, namely epidural abscesses and venous sinus thrombosis.

Management of acute complicated mastoiditis at an urban, tertiary care pediatric hospital

OBJECTIVES/HYPOTHESIS

To describe the presentation and management of acute complicated mastoiditis in children.

STUDY DESIGN

Retrospective case series.

METHODS

An analysis of pediatric patients with acute complicated mastoiditis treated at an urban, tertiary care children's hospital from 2007 to 2014 was performed.

RESULTS

Forty-eight patients presented with a total of 67 complications of acute mastoiditis. Mean age at presentation was 4.8 years (range = 0.1-15.3 years). The most common complications were subperiosteal abscess (n = 22, 45.8%), epidural abscess (n = 16, 33.3%), and sigmoid sinus thrombosis (n = 14, 29.2%). The most common pathogens isolated included Streptococcus pneumoniae (n = 14, 29.2%) and group A streptococcus (n = 10, 20.8%). Multidrug resistance was not associated with complication type. Surgical management included myringotomy ± tympanostomy tube placement in 46 (95.8%) patients (the only surgery in 10), drainage of subperiosteal abscess without mastoidectomy in 18 (37.5%) patients, and mastoidectomy in 21 (43.8%) total patients. Patients presenting with intracranial complications were the most likely to undergo a mastoidectomy. Anticoagulation was used in the management of nine of 14 (64.3%) patients presenting with sigmoid sinus thrombosis. Neurosurgical interventions (n = 7, 14.6% patients) were primarily performed to manage increased intracranial pressure.

CONCLUSIONS

Subperiosteal abscess was the most common complication of acute mastoiditis, and when occurring as the sole complication was successfully managed with antibiotics and surgical intervention that did not include mastoidectomy. Epidural abscess and sigmoid sinus thrombosis were more prevalent than reported in prior series and were managed more aggressively. These patients were more likely to need neurosurgical interventions.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2321-2327, 2017.

Severe Acute Mastoiditis Admission is Not Related to Delayed Antibiotic Treatment for Antecedent Acute Otitis Media

BACKGROUND

Delayed antibiotic treatment for acute otitis media (AOM) is recommended for children >6 months with nonsevere illness, no risk factors for complications or history of recurrent AOM. This study evaluates relationship between delayed antibiotic treatment for antecedent AOM and severity of subsequent acute mastoiditis admission.

METHODS

A prospective observational study of children aged 0-14 years admitted with acute mastoiditis to 8 hospitals between 2007 and 2012 calculates rates of severe acute mastoiditis admission [defined by ≥1 of the following: complication (mastoid subperiosteal abscess, brain abscess and sagittal vein thrombosis), need for surgical procedure and duration of admission >6 days].Severe acute mastoiditis admissions in children with antecedent AOM treated with immediate antibiotics were compared with those with delayed antibiotic treatment.

RESULTS

Antecedent AOM was diagnosed in 216 of 512 acute mastoiditis admissions (42.1%), of whom 159 (73%) immediately received antibiotics, and 57 (27%) had delayed antibiotic treatment. Higher rate of recurrent AOM was noted in the immediate compared with delayed antibiotic treatment group (29% vs. 8.7%, P = 0.0021). Complication rates were 19.5% versus 10.5% (P = 0.12), rates of surgical procedures required, 30% versus 10% (P = 0.0033); admission rates >6 days, 37% versus 29% (P = 0.28) for immediate antibiotic therapy and delayed antibiotic treatment. On logistic regression analysis, immediately treated AOM patients had increased need for surgery for acute mastoiditis with adjustment for history of recurrent AOM (relative risk: 3.2, 95% confidence interval: 1.4-7.0).

CONCLUSIONS

Delayed antibiotic treatment for antecedent AOM is not associated with an increase in severity parameters in subsequent acute mastoiditis admission.

Respiratory Tract Infections

Respiratory tract infections are among the most common and important problems in clinical medicine. The approach to these infections begins with a basic understanding of the pathophysiology of the respiratory tract and how immune defences interact with pathogens. A number of distinct clinical syndromes can be defined which help physicians and clinical microbiologists develop a differential diagnosis of potential infecting pathogens. The type and severity of infection is often modulated by the medical characteristics of the patient, circumstances surrounding infection, geography and environmental exposures. Multiple laboratory test methodologies are available to aid clinical diagnosis and close communication between clinicians and laboratory personnel can optimise the efficiency and cost-effectiveness of diagnosis. Molecular testing for respiratory viruses has become widely used in the clinical setting and will expand to include other pathogens of the respiratory tract.

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.

Infants under the age of six months with acute mastoiditis. A descriptive study of 15 years in Sweden

OBJECTIVE

To investigate the occurrence, clinical signs and outcome of acute mastoiditis in infants under the age of 6 months in Sweden between the years 1993-2007.

METHODS

All ENT departments in Sweden reported children 0-5 months treated for acute mastoiditis 1993-2007 and all records were reviewed. The clinical course and various characteristics were recorded.

RESULTS

Seventeen young infants with acute mastoiditis were identified. Three patients had suffered acute otitis media earlier, otherwise the children were previously healthy. Preceding the episode of acute mastoiditis, the children had an upper respiratory tract infection or fever for seven days in mean (median three days) and the mean number of days with ear-symptoms was three days (median two days). Three patients were treated with antibiotics prior to admittance. Almost all children presented with clear retroauricular signs with protruding ear and redness behind the ear. The children were hospitalised for six days (mean and median). Eight patients (47%) suffered from a subperiosteal abscess. All but one patient underwent surgery: myringotomy (13); incision or punction of the mastoid (5); mastoidectomy (3). Streptococcus pneumoniae was the most frequent bacterium identified in cultures. No intracranial complications or other severe complications were found.

CONCLUSION

Acute mastoiditis is extremely rare in infants under the age of 6 months. The patients in this study did not have any predisposing diseases. An upper respiratory tract infection had preceded the episode of acute mastoiditis for some time in the majority of cases, but the time from first ear symptoms to hospitalization was very short. Acute mastoiditis is a potentially life-threatening disease, but the timely administration of intravenous antibiotics and surgical intervention prevented the occurrence of severe complications in these young infants.

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.

The diagnosis and management of acute otitis media

This evidence-based clinical practice guideline is a revision of the 2004 acute otitis media (AOM) guideline from the American Academy of Pediatrics (AAP) and American Academy of Family Physicians. It provides recommendations to primary care clinicians for the management of children from 6 months through 12 years of age with uncomplicated AOM. In 2009, the AAP convened a committee composed of primary care physicians and experts in the fields of pediatrics, family practice, otolaryngology, epidemiology, infectious disease, emergency medicine, and guideline methodology. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the new literature related to AOM since the initial evidence report of 2000. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific, stringent definition of AOM. It addresses pain management, initial observation versus antibiotic treatment, appropriate choices of antibiotic agents, and preventive measures. It also addresses recurrent AOM, which was not included in the 2004 guideline. Decisions were made on the basis of a systematic grading of the quality of evidence and benefit-harm relationships. The practice guideline underwent comprehensive peer review before formal approval by the AAP. This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

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.

What effect has pneumococcal vaccination had on acute mastoiditis?

BACKGROUND

Streptococcus pneumoniae is a frequent cause of acute mastoiditis. Despite the recent (2005) introduction of pneumococcal vaccination, mastoiditis incidence and severity may be increasing. This study aimed to assess the incidence, severity and microbiology of acute mastoiditis over an 11-year period.

METHODS

Retrospective review of paediatric acute mastoiditis cases seen at our institution (2000-2010), comparing patients seen prior to vaccination introduction (period one, 2000-2004), around the time of vaccine introduction (period two, 2005-2007) and post-vaccination (period three, 2008-2010).

RESULTS

We reviewed 84 children. In periods one, two and three, respectively: mean annual case load was 8.4, 5 and 9 children; pneumococcal isolates were seen in 40.5, 6.7 and 29.6 per cent of cases; highest recorded fever was 38.6, 38.9 and 38.2°C and highest leukocyte count 18.9, 15.0 and 15.6 × 109/l; incidence of intracranial complications was 11.9, 0 and 7.4 per cent; mean duration of intravenous antibiotics was 6.0, 4.1 and 4.2 days; proportion treated surgically was 71.4, 60.0 and 48.1 per cent; and mean length of in-patient stay shortened.

CONCLUSION

Pneumococcal mastoiditis admission rates appeared to fall when vaccination was introduced, with concomitant reduction in overall mastoiditis incidence and intracranial complications; subsequently, however, admission rates rapidly returned to pre-vaccination levels.

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.

Acute mastoiditis--the role of radiology

Acute mastoiditis is a commonly occurring condition in children and adults, and one that most radiologists will come across at some point during their on-call duties. Acute mastoiditis is usually clinically apparent. However, the complications, especially the intracranial ones, can be more insidious and may have fatal consequences. Therefore, it is imperative that the radiologist is well versed in identifying these. Local spread of infection from the mastoids and middle ear cleft may occur via four routes: bone erosion, thrombophlebitis, periphlebitis, and via the anatomical pathways. The role of radiology is largely to demonstrate the complications of mastoiditis, which can be clinically occult and are often serious; this article will highlight these complications.

Acute mastoiditis in children in Sweden 1993-2007--no increase after new guidelines

OBJECTIVE

To study whether the incidence and characteristics of acute mastoiditis in children changed in Sweden following the introduction of new guidelines for diagnosis and treatment of acute otitis media advocating "watchful waiting" as an option in children 2-16 years of age with uncomplicated acute otitis media.

METHODS

The records for all patients treated for mastoiditis during 1993-2007 at all Ear, Nose and Throat departments in Sweden were reviewed retrospectively according to defined criteria for acute mastoiditis. In this study the data from children aged 0-16 years were analyzed and compared 71/2 years before and 71/2 years after the introduction of the new guidelines in 2000.

RESULTS

A total of 577 cases aged 0-16 years fulfilled the inclusion criteria during the whole study period. Cases involving cholesteatoma were excluded. The number of children affected by acute mastoiditis did not increase after the introduction of new guidelines. Acute mastoiditis was most common in children younger than two years of age. The proportion of acute mastoiditis increased after 2000 in the group aged 2-23 months although they were not affected concerning treatment by the new guidelines. No decrease was found in the frequency of prehospital antibiotic treatment among the children admitted with acute mastoiditis, and no increase was seen in the duration of ear symptoms before hospital admission, duration of hospital stay, or in the frequency of complications or mastoidectomies, after the introduction of the new guidelines in either group of children.

CONCLUSIONS

The incidence of acute mastoiditis in children in Sweden did not increase following the introduction of new guidelines in 2000 for the diagnosis and treatment of acute otitis media. This is despite the fact that a significant decrease in antibiotic prescriptions for otitis media has been reported during the same time period. The characteristics of acute mastoiditis reflecting severity of illness did not change over time. Acute mastoiditis was most common and increased after 2000 only in children younger than two years of age in which antibiotics were still recommended in all cases of acute otitis media.

Intratemporal complications from acute otitis media in children: 17 cases in two years

BACKGROUND

To describe the clinical features of intratemporal complications of acute otitis media (AOM) in children, a retrospective study was carried out for two years.

METHODS

We considered acute mastoiditis, presence of postauricular swelling, erythema and tenderness and anteroinferior displacement of the auricle; labyrinthitis, presence of vestibular symptoms (spontaneous nystagmus and ataxia with or without vomiting; and facial nerve palsy, absence or decreased motility in hemiface. All children underwent otomicroscopy for evidence of coexistent or recent AOM. Cultures were obtained by tympanocentesis and myringotomy, drainage of subperiosteal abscess or from granulation tissue during tympanomastoidectomy.

RESULTS

From January 2008 to December 2009, 17 patients fulfilled the entry criteria. Median age: 54.2 months. Of the 17 cases, 30% were infants younger than twelve months and most were boys (70.6%). 8/17 were receiving antimicrobial treatment. Diagnoses included 9/17 (52.9%) acute mastoiditis, 7/17 (41.2%) labyrinthitis and 1/17 (5.9%) facial nerve palsy. Intracranial complications were present in 17.6%. All required intravenous antimicrobial treatment. Myringotomy was performed in 16/17, drainage of subperiosteal abscess in 3/17 and tympanomastoidectomy in 2/17. Bacteriology was positive in 9/17 cases, isolating Streptococcus pyogenes (S. pyogenes) in 44% of patients. Secuelaes: One unilateral sensorineural hearing loss.

CONCLUSIONS

Acute mastoiditis is the most common complication. Labyrinthitis was diagnosed in 41.2% of cases. S. pyogenes was prevalent in these serious invasive infections in our area. Associated intracranial complications were present in 17.6% cases. Resolution of AOM complications required surgical procedures in all cases (myringotomy, drainage of subperiosteal abscess or tympanomastoidectomy).

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.

Ophthalmic complications of otitis media in children

PURPOSE

To evaluate the outcome of ophthalmic complications in children with otitis media.

METHODS

The records of children with ophthalmic complications arising from otitis media who presented to the British Columbia Children's Hospital between August 2006 and March 2008 were reviewed retrospectively.

RESULTS

Of 1,400 patients presenting to the emergency department for otitis media during the study period, 7 with ophthalmic complications were identified (age range, 1-11 years). All patients had abducens nerve palsy on presentation. Other notable ophthalmic complications included papilledema, Horner syndrome, and proptosis. Extracranial and intracranial complications included mastoiditis, petrositis, parapharyngeal abscess, hydrocephalus, epidural abscess, and cerebral venous thrombosis, including cavernous sinus thrombosis in 2. Of the 7 patients, 6 were treated with surgery, including myringotomy and tube placement (6 patients) and mastoidectomy (3 patients). All patients were initially anticoagulated and received intravenous antibiotics. Satisfactory final visual outcomes and stereopsis ranging from 40 to 100 seconds were achieved in all patients.

CONCLUSIONS

Ophthalmic complications of otitis media in children are likely to include abducens palsy. All patients in our series required anticoagulation and intravenous antibiotics. Most required otolaryngologic surgery, but none required strabismus surgery, and all patients had satisfactory visual and ocular motility outcomes.

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.

Risk-benefit analysis of restricting antimicrobial prescribing in children: what do we really know?

PURPOSE OF REVIEW

Most childhood respiratory infections including acute otitis media (AOM), sore throat, upper respiratory tract infections (URTIs) and sinusitis are self-limiting illnesses. Yet, despite extensive guidance discouraging routine use of antibiotics to limit side-effects and combat antimicrobial resistance, antibiotic prescribing for these conditions remains high in many developed countries, fuelled by the fear of rare but serious bacterial complications including mastoiditis, quinsy, pneumonia and brain abscess. This review summarizes evidence for the role of antibiotics in preventing serious complications of URTIs in children.

RECENT FINDINGS

From a key observational study reporting antibiotic use in children, the calculated excess risk of suppurative complications of respiratory tract infections in children who did not receive an antibiotic was 3.8 per 10 000. Despite extensive searches of the literature, no data were found to assess the affect of antibiotics upon the risk of brain abscess after sinusitis in children.

SUMMARY

New information from observational studies suggests antibiotics show little benefit in preventing complications of mastoiditis following AOM, quinsy following sore throat and pneumonia following URTI/bronchitis. Further research should focus on stratifying the key risk factors for such complications and optimizing long-term monitoring strategies to detect any future changes in the risk-benefit analysis for antibiotic prescription.

Acute mastoiditis in southern Sweden: a study of occurrence and clinical course of acute mastoiditis before and after introduction of new treatment recommendations for AOM

Watchful waiting was recommended as an option for uncomplicated episodes of acute otitis media in Sweden in the year 2000. Concern was raised that these recommendations would lead to a higher incidence of acute mastoiditis. The aim of this study was to map the occurrence, treatment policy and the clinical course of mastoiditis before and after the new treatment recommendations were introduced. Included in the study were all patients (adults and children) who were admitted to two ENT departments in southern Sweden for acute mastoiditis from 1996 to 2005. A total of 42 cases of mastoiditis were identified: 23 during the first period of 1996-2000 and 19 during 2001-2005. Mastoidectomy was performed in 14 patients during the first period and in 8 during the second period. As much as 39% of mastoiditis patients received antibiotics before hospital care, but had no improvement. There was no indication that the number of patients with acute mastoiditis was increasing after new treatment recommendation of AOM. There was no increase in the occurrence of mastoidectomy. Severe complications of mastoiditis were rare. Although there were potentially threatening complications of mastoiditis in the study, these did not lead to sequelae. It is important to follow up the consequences when treatment recommendations of AOM are changed.

Bezold's abscess: a serious complication of otitis media

This report describes a case of Bezold's abscess, a rare complication of mastoiditis, following otitis media. Included is a discussion of mastoiditis and its management.

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.