Abstract
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 perfomed 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.
1
Introduction
Acute mastoiditis (AM) is an infectious disease of the mastoid bone. It is known to be the most common intratemporal complication of acute otitis media (AOM) . Over the past decade, there have been reports indicating a rise in the incidence of AM in the pediatric population . Consequently, with the rise in the incidence of AM, the question has risen concerning the most effective treatment of this disease and its complications. There has been a shift of trends in the treatment of AM; aural surgeons that once operated every case of AM today consider other treatments more appropriate. There seems to be a consensus that in most cases of AM, medical treatment consists of the mainstay therapy .
The aim of this study is to review the outcome of pediatric patients with AM 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. We examined the specific combination of intravenous (IV) antibiotic therapy, myringotomy, and subperiosteal abscess incision and drainage (if needed) on the outcome of patients with AM. For this purpose, a retrospective case series of 51 patient files hospitalized in our tertiary care center was performed.
2
Patients and methods
We reviewed the medical records of all children admitted to Shaare Zedek Medical Center, Jerusalem, with the diagnosis of AM during the period of 2005 to 2008. Fifty-one patients were diagnosed with AM during this period and their medical files were studied. We excluded 4 partially treated patients transferred from another institution.
The diagnosis of AM was made using the following clinical criteria: signs of AOM on otoscopy, inflammatory findings over the mastoid area (tenderness, hyperhemia, edema, and/or abscess), and a protruded auricle.
The following data were collected: demographic, medical history notably history of prior ear disease, previous antibiotic use, laboratory data, computed tomographic imaging (if performed), complications, surgical or conservative treatment, and outcome.
Conservative treatment included IV treatment with antibiotics, laser myringotomy with a handheld otoscope combined with a flash scanner carbon dioxide laser, OtoLAM (ESC/Sharplan, Yokneam, Israel). If needed, a surgical incision and drainage of subperiosteal abscess were performed.
Computed tomographic images were required using a high-resolution spiral computed tomography (CT) of the temporal bone followed by a CT with contrast media to exclude intracranial complications.
Children who were diagnosed with subperiosteal abscess clinically, but in whom the clinician did not suspect intracerebral complications, did not undergo CT imagery.
2
Patients and methods
We reviewed the medical records of all children admitted to Shaare Zedek Medical Center, Jerusalem, with the diagnosis of AM during the period of 2005 to 2008. Fifty-one patients were diagnosed with AM during this period and their medical files were studied. We excluded 4 partially treated patients transferred from another institution.
The diagnosis of AM was made using the following clinical criteria: signs of AOM on otoscopy, inflammatory findings over the mastoid area (tenderness, hyperhemia, edema, and/or abscess), and a protruded auricle.
The following data were collected: demographic, medical history notably history of prior ear disease, previous antibiotic use, laboratory data, computed tomographic imaging (if performed), complications, surgical or conservative treatment, and outcome.
Conservative treatment included IV treatment with antibiotics, laser myringotomy with a handheld otoscope combined with a flash scanner carbon dioxide laser, OtoLAM (ESC/Sharplan, Yokneam, Israel). If needed, a surgical incision and drainage of subperiosteal abscess were performed.
Computed tomographic images were required using a high-resolution spiral computed tomography (CT) of the temporal bone followed by a CT with contrast media to exclude intracranial complications.
Children who were diagnosed with subperiosteal abscess clinically, but in whom the clinician did not suspect intracerebral complications, did not undergo CT imagery.
3
Results
Between the years 2005 to 2008, fifty-one consecutive pediatric patients with AM were hospitalized in our institution with the diagnosis of AM (27 male and 24 female). The patients’ age ranged from 4 months to 12 years (mean, 32.5 months). Thirty patients (58%) were younger than 2 years and 41 patients (80%) were younger than 4 years ( Table 1 ).
| Age in years | No. of patients | Percentage |
|---|---|---|
| 0–1 | 17 | 33 |
| 1–2 | 13 | 25 |
| 2–4 | 11 | 22 |
| 4–6 | 4 | 8 |
| >6 | 6 | 12 |
| Total | 51 | 100 |
Forty patients (78%) reported no prior otologic history, whereas 9 patients (18%) reported previous episodes of AOM. One patient (2%) reported a history of serous otitis media and another patient (2%) reported previous surgery consisting of a cortical mastoidectomy.
The mean duration of general symptoms before admission was 5 days (range, 0–14 days). In 12 patients (24%), the mean duration of symptoms was less than 24 hours and in 27 patients (53%) it was less than 72 hours.
Sixteen patients (31%) received antibiotic treatment before their hospitalization ( Table 2 ). The treatment was given an average of 2 days (ranging from 0 to 14 days). The antibiotics were amoxicillin (7 patients), amoxicillin with clavulanic acid (5 patients), cefuroxime (1 patient), ceftriaxone (1 patient), azithromycin (1 patient); and 1 patient was treated with multiple antibiotic therapies.
| Duration in days | No. of patients | Percentage |
|---|---|---|
| 0 | 35 | 68 |
| 1–2 | 9 | 18 |
| 3–4 | 2 | 4 |
| 7–8 | 3 | 6 |
| >9 | 2 | 4 |
| Total | 51 | 100 |
Before admission, 28 patients (55%) were irritable, 19 patients (37%) exhibited feeding problems, and 6 patients (12%) presented with vomiting episodes.
Physical examination on admission showed a mean buccal or rectal temperature of 37.8°C ranging from 36°C to 40.1°C.
The right ear was infected in 24 patients (47%) and the left ear infected in 27 patients (53%). Otoscopy performed showed bulging of the tympanic membrane in 51 patients (the ventilation tube present in 1 patient was blocked by secretions) (100%). Postauricular edema was reported in 49 patients (96%), postauricular erythema and hyperhemia in 47 patients (92%), and postauricular pain upon palpation was noted in 45 patients (88%). Purulent otorrhea was seen in 9 patients (17%). Contralateral AOM was seen in 15 patients (29%). Twelve patients presented initially with a subperiosteal abscess (24%).
White blood cell count ranged from 5900 to 30800/mm 3 (mean, 16720/mm 3 ).
On admission, 2 patients presented with alteration of conscience (4%) and no patient exhibited facial nerve palsy.
Overall, fifty-one “de novo” patients were admitted with the diagnosis of AM in our institution.
Initially, 49 patients admitted to our hospital were treated conservatively. This treatment included IV antibiotics, myringtomy, and, if needed, subperiosteal abscess incision and drainage. Only 2 patients underwent CT scanning on admission. The first, a stuporotic patient had a CT scan that demonstrated a sigmoid sinus thrombosis. This patient underwent a mastoidectomy with sigmoid sinus decompression. The second, a patient with a history of cholesteatoma had a CT performed, which demonstrated bony destruction over the sigmoid sinus. He underwent a mastoidectomy with clearing of his initial disease from the mastoid cavity and over the sigmoid sinus.
Further on, during hospitalization, 4 additional patients underwent CT scanning because of continued fever or progression of local disease. All 4 CT scans showed no intracerebral complications, and so all continued with conservative treatment.
Twelve patients with subperiosteal abscess were treated by incision and drainage in the clinic. Under local anesthesia, a postauricular incision of the abscess was performed and cultures were taken.
A myringotomy was performed in 50 patients (98%). One patient had a ventilation tube in the tympanic membrane. Of the 50 patients who had a myringotomy performed, 35 (68%) had a single laser myringtomy performed and 3 patients (6%) had a single knife myringotmy (because of inability to insert a laser speculum into the ear canal) ( Table 3 ).
