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International Journal of Pediatric Otorhinolaryngology 73 (2009) 15201524

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Contents lists available at ScienceDirect

International Journal of Ped

journa l homepage: www.e l1. Introduction

Acute mastoiditis remains a relatively common clinicalproblem. This condition may develop within days and thecomplications may also develop quickly and be life threatening.Alternately patients may have an atypical presentationwhich doesnot immediately suggest acute mastoiditis. Patients may presentwith alternative symptoms and signs which do not immediatelysuggest acute mastoiditis. Appropriate treatment is widelyavailable and very effective. Early diagnosis and Otolaryngologicalreferral should lead to satisfactory outcomes in most cases.

Acute otitis media (AOM) remains to be the one of the mostfrequent diseases in early infancy and childhood. Research fromFinland indicates an overall annual incidence of 16.6%. The highestincidence was among infants 611 months old at 75.5%. Fiftypercent of Finnish children had experienced at least one ear

infection before their third birthday and 75% before the age of 10[1]. Further work from Norway reported the incidence of acutemastoiditis in children below 2 years of age. This ranged from 13.5to 16.8 per 100,000 and for those aged 216 years the ratewas 4.37.1 per 100,000 [2]. The incidence of acutemastoiditis has declinedsince the introduction of antibiotics. In 1959, Palva and Pulkkinen[3] reported that 0.4% of AOM developed into acute mastoiditis. In1985, Palva reported annual incidence of mastoiditis of 0.004%among cases of AOM [4]. While most episodes of AOM resolvewithout antibiotics, a comparative study across several Europeancountries, Canada, Australia and the United States indicated thatthe incidence of AOM in the Netherlands, with a low antibioticprescription rate was 3.8/100,000. In Norway and Denmark, withhigh prescription rates, the incidence rate was comparable at 3.5/100,000 and 4.2/100,000, respectively. In all other countries withvery high prescription rates the incidence was considerably lower,ranging from 1.2 to 2.0/100,000 [5]. This work indicates that theroutine treatment of AOMwith antibiotics decreases the incidenceof acute mastoiditis. The Cochrane review found that antibiotictreatment may play an important role in reducing the risk ofmastoiditis in populations where it is more common. Overallantibiotics provide a small benet for acute otitismedia in children

Available online 15 September 2009

Keywords:

Paediatric

Mastoiditis

Microbiology

Complications

Treatment

from 1 January 1996 through 31 December 2006 inclusive. Criteria assessed included demographic

characteristics, clinical features, symptom duration and treatment initiated by the general practitioner.

The results of investigations at SCH were reviewed including white blood cell count, microbiology and

imaging. The presence of complications was determined and the results of medical and surgical

treatment were assessed.

Results: Seventy-nine episodes of acute mastoiditis were managed in 76 patients. Treatment prior to

SCH was commenced by the family practitioner or district hospital doctor in 53/79 patients. The mean

duration of community initiated treatment before presentation to SCH was 3.7 days. In 33 episodes a

previous history of acute otitis media was noted (42%). In the remaining 46 episodes (58%) mastoiditis

was the initial diagnosis. Complications were found in 30 episodes (38%) and 36 episodes (46%) required

surgical treatment.

Conclusions: Mastoiditis often develops rapidly but may be treated very effectively. The potential for

signicant morbidity remains high but excellent outcomes can be expected for those who are managed

without delay. Childrenwith acutemastoiditis should bemanaged in centreswhere timely and complete

medical and surgical treatment is available.

2009 Elsevier Ireland Ltd. All rights reserved.

This paper was presented by Dr Pang at Australasian Society of Paediatric Oto-

Rhino-Laryngology Conference, Queenstown, New Zealand, July 810, 2007.

* Corresponding author.

E-mail address: thavas@ozemail.com.au (T.E. Havas).

0165-5876/$ see front matter 2009 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.ijporl.2009.07.003Mastoiditis in a paediatric population: Amanagement

Leo H.Y. Pang, Michael S. Barakate, Thomas E. Hava

The University of New South Wales, Department of Otolaryngology, Head and Neck Surg

A R T I C L E I N F O

Article history:

Received 17 December 2008

Received in revised form 7 July 2009

Accepted 7 July 2009

A B S T R A C T

Objective: This study explor

with acute mastoiditis and

Methods: Retrospective revreview of 11 years experience in

*

y, The Prince of Wales and Sydney Childrens Hospitals, Sydney, Australia

the experience at Sydney Childrens Hospital (SCH) managing children

tablishes a robust treatment algorithm.

w of all patients admitted to SCH with an ICD-10 coding of Mastoiditis

iatric Otorhinolaryngology

sev ier .com/ locate / i jpor l

complications, temporal bone infections, temporal bone infectionsand complications. The discussion is based on the authorsexperience and review of the international literature.

3. Results

Seventy-nine episodes of acutemastoiditis weremanaged in 76patients. There were 44males and 32 females. Themean age was 3years, 9 months with a range of 1 month to 17 years. The meanmale age was 4 years, 1 months and the mean female age was 3years, 5 months. Prior to presentation the mean duration ofsymptoms was 16 days (range 150 days). Overall, 79 episodes ofacute mastoiditis from 76 patients were included. One patientdeveloped acute mastoiditis in the contralateral ear during thestudy period, and two patients presented with bilateral disease.Thirty-ve episodes involved the right ear, and 44 the left ear.Twenty-two patients were transferred from district hospitals to

L.H.Y. Pang et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 15201524 1521as most cases will resolve spontaneously. This benet must beweighed against the possible adverse reactions [6].

Mastoiditis is an inammatory process of the mastoid air cells.The mastoid cells are contiguous with the middle ear cleft andmastoiditis is itself a complication of AOM. Acute mastoiditisoccurs when the infection spreads beyond the middle ear, usuallyby direct bony erosion or through the mastoid emissary veins. Forthis study children with acute mastoiditis were identied by ourhospitals medical records database and were dened as per ICD-10 (H70). The complications of mastoiditis may be intratemporaland extratemporal. Intratemporal complications include tympanicmembrane perforation, conductive hearing loss, ossicular lesions,facial palsy and petrositis. The development of acute labyrinthitismay lead to sensorineural hearing loss. Extratemporal complica-tions are subdivided into intracranial (abscess of the centralnervous system, meningitis, lateral sinus thrombophlebitis andotic hydrocephalus) and extracranial complications (retroauricu-lar, zygomatic and Bezold abscess).

The treatment at SCH was reviewed including medical andsurgical options. All patients received initial medical treatmentwhich included intravenous and ototopical antimicrobial therapyalong with supportive therapy. The decision to choose surgicaltreatment was indicated by clinical presentation with a complica-tion of mastoiditis or for those without complication, progressiondespite medical treatment. Surgical treatment options for theacute presentation included the insertion of a middle earventilation tube (MEVT), cortical mastoidectomy and wherepresent abscess drainage. This study explores the experience atSydney Childrens Hospital and establishes a robust managementalgorithm for children with acute mastoiditis.

2. Methods

The diagnosis of acute mastoiditis was made based on clinicalfeatures suggesting extension of the inammatory process beyondsimple AOM. These include localisedmastoid tenderness, swelling,erythema, and features suggestive of intra- or extra-temporalcomplication. Imaging was performed for those with failure ofmedical management or the presence of a complication. Patientspresenting with acute mastoiditis secondary to cholesteatomawere excluded from the study. Those patients with purulentotorrhoea who had no prior otological history and no prior tubeinsertion were interpreted to have a tympanic membraneperforation as a complication of mastoiditis.

Institutional board approval was gained from the South EasternSydney Illawarra Area Health Service Human Research EthicsCommittee (Ref: 07/115, approved 30 May 2007) to review allpatients admitted to SCH with an ICD-10 coding of Mastoiditisfrom 1 January 1996 through 31 December 2006 inclusive. Thepatient records were reviewed to determine demographiccharacteristics, clinical features before presentation to SCH,symptom duration and treatment initiated by the generalpractitioner, and past history of acute otitis media or mastoiditis.On presentation to SCH the following clinical and laboratorycriteria were analysed; the presenting symptoms and signs,features indicating the presence of complications, white cellcount, imaging performed (computed tomography of the petroustemporal bones), and bacteriology. Coalescent mastoiditis wasdened as acute mastoiditis with evidence of destruction of bonyseptae on CT scan.

Published literature on mastoiditis was obtained throughundertaking a comprehensive search in MEDLINE (from 1950 topresent). The reviewwas then based upon the authors conclusionsfrom the articles selected for inclusion. Searches were performedusing the following keywords; paediatric or paediatric, otitismedia, otitismedia and complications,mastoiditis, mastoiditis andSCH after initial medical management. Treatment prior to SCHwascommenced by the family practitioner or district hospital doctor in53/79 patients (see Table 1). The mean duration of communityinitiated treatment before presentation to SCH was 3.7 days.Thirty-three patients had a previous history of acute otitis media(AOM, 42%) and the remaining 46 patients (58%) presented withmastoiditis as their initial diagnosis. Thirty patients had otorrhoeaor a tympanic membrane perforation on presentation, and twopatients had a pre-existingMEVT in situ. The presenting symptomsand signs are shown in Fig. 1.

On admission at SCH a white cell count was performed in 67patients and 45 had leukocytosis >11 109, while 2/67 hadleukophilia

Table 2Microbiology.

Organism Number positive

(out of 56 specimens obtained)

Streptococcus pneumonia 16

Pseudomonas aeruginosa 11

Staphylococcus aureus 4

Streptococcus pyogenes 3

Haemophilus inuenza 3

Aspergillus spp. 2

Polymicrobial 3

No growth 22

Specimens were obtained from ear swabs where purulent otorrhoea was present or

from operative specimens taken at tube insertion, cortical mastoidectomy and/or

abscess drainage.

Table 3Patient details based on the absence or presence of complications.

L.H.Y. Pang et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 152015241522mastoiditis. Patient details based on the absence or presence ofcomplications is shown in Table 3. Treatment at SCH is summarised inTable 4. The mean duration of in hospital stay for those who requiredsurgical treatment was 7.8 days (range 336). The suggested protocolfor the treatment of children with mastoiditis is shown in Fig. 4.

4. Discussion

This series reports the management of 76 children with 79episodes of mastoiditis. Thirty-three patients had a past history ofAOM (42%). In the remaining patients (58%) mastoiditis was theinitial diagnosis and the rst presentation of otologic disease.Mastoiditis remains a diagnosis based on clinical and radiologicalcriteria. Complications were found in 30 episodes (38%). At SCH CTPTB was 100% sensitive in conrming the diagnosis of mastoiditisand was highly accurate in detecting associated complications.Forty-three patient episodes were treated successfully with IV

Fig. 2. Complications of mastoiditis summary. Y-axis: number of patients.

Fig. 1. Presenting symptoms and signs. Y-axis: number of patients. Mastoid P/T/E:pain (P), tenderness (T) and erythema (E).

Acute mastoiditis

(49 episodes)

Complicated

mastoiditisTable 4

(30 episodes)

Mean age 4.3 years 3.1 years

Mean hospital stay 4.4 days 8.6 days

Symptom duration before

presentation to SCH

8.2 days 11.5 days

Prior antibiotics 60.4% 80%

Preceding diagnosis of AOM

or past history of mastoiditis

46.8% 36.6%antibiotics alone. Thirty-six episodes required IV antibiotics plusthe following procedures; 13/79 (16.4%) insertion of aMEVT alone;22/79 (27.8%) insertion of MEVT + cortical mastoidectomy; 1/79(1.2%) modied radical mastoidectomy. AOM and mastoiditisremain conditions with the potential for signicant morbidity.With inadequate treatment mastoiditis may be masked leading toa higher rate of intracranial complications [7]. Without timely andoptimal management mastoiditis may progress rapidly and haveserious consequences.

Surgical treatment at SCH based on the absence or presence of complications.

Acute mastoiditis

(49 episodes)

Complicated acute

mastoiditis (30 episodes)

Middle ear ventilation tube 18% 83%

Cortical mastoidectomy 4% 67%

Fig. 3. The complications of mastoiditis.

L.H.Y. Pang et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 15201524 1523A systematic review of diagnostic criteria for acute mastoiditisin children found a lack of consensus regarding the criteria andstrategies for making the diagnosis. Only 26 of 65 articles reportedthe criteria upon which the diagnosis of acute mastoiditis inchildren was based. The criteria most frequently used were theclinical signs of post-auricular swelling, erythema, tenderness, andprotrusion of the auricle. The most frequently used imagingmodality was CT scanning (68% of patients in 39 of 65 studies). Themost frequently used laboratory test was white blood count (100%of patients in 45 of 65 studies). In 63 studies, the result of culturingfrom the otomastoid was reported with Streptococcus pneumoniaethe most frequently isolated bacterium [8]. The microbiology ofAOM has changed in the heptavalent pneumococcal conjugatevaccine (PCV) era. Roddy et al. [9] investigated if a similar changehas occurred with paediatric mastoiditis. The aetiology ofmastoiditis pre-PCV (January 1995-December 2000) was com-pared with that post-PCV (January 2001April 2005) to guideempiric antimicrobial therapy. The most common bacterialisolates in order were S. pneumoniae, Pseudomonas aeruginosa,Staphylococcus aureus, Streptococcus pyogenes, and Haemophilusinuenzae. There was no reduction in mastoiditis due to S.pneumoniae from the pre-PCV to the post-PCV eras. Ceftriaxonenon-susceptibility was seen in 30% of post-PCV S. pneumoniaeisolates compared with 7% of pre-PCV isolates. Spratley et al. [10]

Fig. 4. Suggestedmanagement protocol. Based on our experiencewe recommend allchildren with mastoiditis be admitted for inpatient IV ceftriaxone and

metronidazole empirically with ototopical antibiotics as appropriate. In the

presence of purulent otorrhoea, swabs should be taken for microbiology testing.

Culture directed antibiotics should then be prescribed. A CT scan of the petrous

temporal bones should be performed in all cases. In this series CT scan was 100%

sensitive for the diagnosis of associated complications. A suggested management

protocol is outlined below.reported the most common organisms recovered from cultureswere S. pneumoniae and S. pyogenes. Zapalac et al. [11] reviewedsuppurative complications of AOM in the era of antibioticresistance. A trend toward an increasing number of cases requiringsurgical intervention was noted during the study period, corre-sponding to an increasing number of resistant S. pneumoniaeisolates. This work suggests that resistant S. pneumoniamay causeamore aggressive infective process whichmay necessitate surgicalintervention. In this study, 22 out of 56 microbiological studiesfailed to identify a causative organism. This however, may be areection of sampling times, as many microbacterial swabs weretaken intraoperatively after the patients had been treated withintravenous antibiotics.

The decision to operate on a child with mastoiditis remainsthe key to effective management. Zanetti and Nassif [12]assessed the indications for surgery in acute mastoiditis andthe outcomes of treatment. This study found that children canfully recover with conservative treatment or with insertion of aMEVT. A simple mastoidectomy tympanoplasty is warrantedfor exteriorization, if the child is older than 30 months or >15 kg ofweight or for infected cholesteatoma or granulation tissue.Immediate surgical treatment is indicated for intracranial com-plications combined with a neurosurgical procedure as needed.Gliklich et al. [13] investigated the indications for surgicaltreatment and found an elevated white blood cell count, proptosisof the auricle, and fever on admission were indicators for surgicalintervention. All those with complications (27%) proceeded tosurgical intervention. The average length of hospital stay was 7.9days. The strongest predictor for an increased length of hospitalstay was whether the patient required surgery. We found thepresence of a complication was predictive of the need for surgicaltreatment and that appropriate imaging was helpful for the earlydiagnosis of complications. All patients in this study who under-went surgical intervention had a pre-operative CT scan. Imagingpreoperatively may be helpful for the surgeon. Imaging mayidentify complications that are not clinically apparent and assistwith surgical planning. Young children will require generalanaesthesia for CT scanning. Where possible, imaging anddenitive surgery were performed under the one anaesthetic.

Intracranial complications remain the most feared complica-tions of mastoiditis. Ozdemir et al. [14] reported their experiencemanaging a child with sigmoid sinus thrombosis followingmastoiditis. The presentation was non-specic and the diagnosiswas made on MR imaging. The patient responded very well tointravenous antibiotics with a rapid clinical improvement andcomplete recanalization of the thrombosed sigmoid sinus. Thisreport concluded that with early diagnosis a favourable prognosiscan be achieved with conservative management without per-forming any surgical intervention. Kuczkowski et al. [15] reportedtheir experience managing two children with otogenic otitichydrocephalus and lateral sinus thrombosis. The clinical pre-sentation of otogenic lateral sinus thrombosis may be masked byantibiotic treatment. In this report otitic hydrocephalus wassuggested clinically by vomiting, headache, visual impairmentand a history of AOM. MRI scans facilitated the early diagnosis ofdural sinus thrombosis with increased intracranial pressure.Contrast-enhanced computed tomography scan and magneticresonance imaging play amajor role in determining diagnosis andtreatment plans in these intracranial complications.Managementincluded systemic antibiotics, short-term heparin anticoagula-tion and surgical decompression. This paper reported thatintensive IV antibiotic treatment, steroids, anticoagulants andmastoidectomy with delamination of the sigmoid sinus andpuncture led to a signicant improvement in the clinicalcondition.

Acute mastoiditis usually develops secondary to AOM. How-ever, the medical management of AOM does not seem to preventthe progression to acute mastoiditis. Acute mastoiditis maydevelop no matter which type of antibiotic is given initiallyduring the preceding course of AOM. The key to the pathophysiol-ogy is impaired mastoid air cell drainage. In patients who developmastoiditis impaired air cell drainage leads to the formation of anenvironment which is favourable for the rapid progression of theinfective process. Prompt treatment is required to interrupt this.Surgical treatment is indicated by the failure of medical manage-ment or the presence of complications. With the knowledge thatmastoiditis often develops rapidly but may be treated veryeffectively, good outcomes should be expected for children whoare managed without delay.

References

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L.H.Y. Pang et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 152015241524

Mastoiditis in a paediatric population: A review of 11 years experience in managementIntroductionMethodsResultsDiscussionReferences