Algorithmic management of pediatric acute mastoiditis

doi:10.1016/j.ijporl.2012.02.042

International Journal of Pediatric Otorhinolaryngology

Volume 76, Issue 6, June 2012, Pages 791-796

https://doi.org/10.1016/j.ijporl.2012.02.042 Get rights and content

Abstract

Objective

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

Methods

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

Results

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

Conclusions

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

Introduction

Acute mastoiditis (AM) is the most common complication of acute otitis media which mainly affects pediatric age with an estimated incidence between 1.2 and 4.2/100,000 children/year [1]. AM should be treated effectively and without delay because severe intratemporal and potentially lethal intracranial complications can arise from further spreading of the disease.

Despite the extended bibliography relating to pediatric AM, there are still many areas of controversy. Up to this point no uniformly accepted diagnostic and therapeutic criteria have been established. Concerning its management, simple mastoidectomy has historically represented the standard surgical treatment of acute mastoiditis [2]. However, currently the rates of use of simple mastoidectomy in treating pediatric AM show considerable variations among reported series [3], [4]. Besides, during the last years, several centers have adopted a rather conservative management for AM and its accompanying complications [5], [6], [7], [8]. Even minor surgical interventions, like myringotomy, have been questioned, since parenteral antibiotics are considered sufficient for the treatment of AM [9], [10], [11]. Such a conservative approach may be successful for a considerable proportion of the cases but may not be adequately safe for all patients. Development of intratemporal and life-threatening intracranial complications or deterioration of pre-existing ones has been reported in children under treatment that were suffering from AM [12], [13], [14], [15].

Although every case of AM may have its specific needs, it becomes obvious that some basic directions must be set so as to maximize treatment safety. In our institution – a tertiary care pediatric center – a considerable experience on the management of AM has been gathered during the last decades. The aim of this study is to evaluate the effectiveness and safety of the management of pediatric AM we employ in our department for more than 15 years. An attempt is also made to develop an algorithmic approach in order to formalize the treatment of this disorder.

Section snippets

Patients and methods

The medical records of all children (n = 167) admitted to our department with the diagnosis of AM between January 1st 2002 and December 31st 2010 were retrospectively reviewed. An Institutional Scientific Board approved the review of the medical charts of children admitted to our center with the diagnosis of acute mastoiditis for the period of the study.

Data concerning children's age, gender, history of pre-admission middle ear infections, clinical signs, treatment before and after admission,

Epidemiology – clinical presentation

From the total of 167 children, 5 children (3%) with cholesteatoma and 4 children (2.5%) suffering from non-infectious pathology (two cases of hystiocytosis X and two with acute leukemia) were excluded from the review. Two children with otitis externa, who initially were misdiagnosed as suffering from AM and one cochlear implant recipient, were also excluded from the study. The remaining 155 children consisted of 106 male and 49 female (ratio 2.2:1, p = 0.001) with a mean age of 36.7 months

Discussion

Depending on the presentation, extent of the disease, presence of further complications and surgeons’ personal experience and attitude, the management of pediatric AM may greatly vary among different pediatric centers. One of the most characteristic differences represents the contradictory rates of the use of mastoidectomy for the treatment of AM, which fluctuate between 9% and 88% [3], [4], [16]. Currently, many researchers seem to adopt a conservative approach to pediatric mastoiditis which

Conclusions

The question of “how much conservative is safe?” in the treatment of pediatric AM must be answered with randomized prospective clinical studies. Till then, the less risky management must be applied because the development of its life-threatening complications should not be an option.

In our population we found that simple mastoidectomy is the most reliable and effective surgical option for AM with/without associated complications. However, a more conservative approach consisting of adequate

Conflict of interest

The authors declare that they have no conflict of interest.

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Pediatric intracranial empyema complicating otogenic and sinogenic infection
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To describe and compare clinical and microbiological features, surgical and medical management, and outcomes of children with otogenic and sinogenic intracranial empyema (IE) in an institution with an established multidisciplinary protocol. To use the study findings to inform and update the institutional algorithm.
Retrospective analysis was carried out on the electronic healthcare records of all children with oto-sinogenic IE admitted in a 5-year period.
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Surgical management of mastoiditis with intratemporal and intracranial complications in children. Outcome, complications, and predictive factors
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Intratemporal or intracranial complications of acute mastoiditis are often of significant severity, can be life-threatening, and require prompt and usually aggressive treatment. This study focused on analyzing the outcomes and complications of different surgical techniques used in intracranial and intratemporal complications of acute mastoiditis, the most common complication of acute otitis media.
A retrospective study of pediatric patients with mastoiditis with intratemporal and intracranial complications was designed at the Niño Jesús University Children's Hospital in Madrid, Spain, from 2005 to 2021.
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There was a favorable evolution with a low incidence of reoperation and sequelae within our series. The surgical technique of choice correlated with the severity of the complication. If the mean size of the abscess exceeds 20 mm, incision and drainage, along with myringotomy and tube placement, should be considered as the initial treatment. Closed mastoidectomy should be reserved for deteriorating of clinical evolution or acute mastoiditis with intracranial complications. Intracranial and multiple concomitant complications were associated with a more extended hospital stay, ICU occupancy, neurosurgical intervention, and risk of neurological sequelae and neutropenia. Conversely, intratemporal complications may result in permanent hearing loss.
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This study reveals that otomastoiditis caused by F. necrophorum potentially induces neurological sequelae. Thereby, 80% of all included patients (n = 16) needed readmission within six months due to recurrence or complications of otomastoiditis caused by F. necrophorum. Mean (range) of age, CRP and temperature were 4.5 years (0.9–29.3), 243 mg/L (113–423) and 40 °C (37–41). All patients were hospitalized and treated with antibiotics, mostly metronidazole (n = 13/16) and a β -lactam (n = 15/16). Additional treatment contained low molecular weight heparin (83%, n = 10/12), dexamethasone (78%, n = 7/9) and/or surgery (80%, n = 12/16, whereof 9/12 mastoidectomy).
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Citation Excerpt :
Optimal surgical management of complicated mastoiditis, from myringotomy (with or without insertion of ventilation tubes) to mastoidectomy and to the need to apply thrombectomy or internal jugular vein ligation, also remains controversial. Since 2010 [26], there has been a shift towards a more conservative approach in mastoiditis, even in patients with severe complications [5,8,26,27]. A relatively conservative surgical intervention appears to yield good results in children with sigmoid sinus thrombosis due to acute otitis media and mastoiditis [15,28].
Diagnosis and management of complicated mastoiditis in childhood are still controversial. We investigated the clinical manifestations, evaluation and management of children with mastoiditis complicated with cerebral venous sinus thrombosis.
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Overall, 20 children with acute mastoiditis were included, of whom 5 had magnetic resonance imaging-confirmed cerebral venous sinus thrombosis and elevated intracranial pressure (ICP). In all complicated cases, neurological signs rather than mastoiditis signs, prevailed. The more prominent neurologic signs observed were lethargy (60%), nuchal rigidity (60%), abducens nerve palsy (60%) and ataxic gait (20%). Treatment consisted of intravenous antibiotics combined with anticoagulation. Surgery was performed in four children (4/5). Complicated cases had prolonged symptoms prior to admission (p 0.002), presented with neurologic signs and symptoms (p < 0.001), underwent more often lumbar puncture (p < 0.001) and brain imaging (p < 0.001), and were treated with prolonged courses of antibiotics and surgery (<0.001), compared to children with uncomplicated mastoiditis.
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^☆: Part of this work (years 2002–2009) was presented at 10th International Congress of the E.S.P.O., 5–8 June 2010, Pamplona, Spain.

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Algorithmic management of pediatric acute mastoiditis☆

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Patients and methods

Epidemiology – clinical presentation

Discussion

Conclusions

Conflict of interest

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.