International Journal of Pediatric Otorhinolaryngology

56 (2000) 33 40
www.elsevier.com/locate/ijporl

Acute mastoiditis in children: review of the current status

Jorge Spratley *, Helena Silveira, Isabel Alvarez, Manuel Pais-Clemente
Di6ision of Pediatric Otorhinolaryngology, Department of Otorhinolaryngology, Hospital de S. Joao,
Uni6ersity of Porto Medical School, 4202 -451 Porto, Portugal
Received 27 May 2000; received in revised form 16 August 2000; accepted 16 August 2000

Abstract
Background: acute mastoiditis is the most common intratemporal complication of otitis media. Its management is
still a challenge due to potentially serious consequences. This study was designed to evaluate the recent experience
with pediatric acute mastoiditis at our institution and to determine if the incidence of this entity is changing over time.
Material and methods: retrospective review of records of children with acute mastoiditis treated at the hospital of the
Medical School at the University of Porto, Portugal, between July 1993 and June 1998. Criteria for the diagnosis of
acute mastoiditis were postauricular swelling and erythema, protrusion of the auricle, and evidence of co-existent or
recent otitis media. Results: 43 patients fulfilled the entry criteria. Most were boys (69%). Ages ranged from 8 months
to 14 years and 4 months; infants represented 40% of the total. Acute mastoiditis was the first recognized sign of otitis
media in 48% of patients. More recent years of the study saw an increase in the number of children referred with
acute mastoiditis. Upon admission, 56% were under antibiotic treatment, with an average intake of 5.8 days. All
patients were hospitalized; 26 cases recovered after intravenous antibiotics plus myringotomy, and the rest required
an additional surgical procedure. The most common organisms recovered from cultures were Streptococcus pneumoniae and Streptococcus pyogenes. In our series, associated complications occurred in 13.9%; facial paralysis in one, and
involvement of the central nervous system in five. Conclusions: pediatric acute mastoiditis continues to be a potentially
dangerous infection in the antibiotic era. The incidence of this complication may be increasing recently in the
community studied. Great care is required of clinicians to reach an early diagnosis in order to promote adequate
management and prevent inherently severe complications. 2000 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Acute mastoiditis; Otitis media; Children; Complications

1. Introduction
In the pre-antibiotic era, acute mastoiditis was a
common and feared complication of otitis media,
with high rates of morbidity and mortality [1]. Up
* Corresponding author. Tel.: +351-22-5029661; fax: +
351-22-2080161.
E-mail address: j.spratley@mail.telepac.pt (J. Spratley).

to 20% of cases of acute otitis media evolved into

acute mastoiditis [2], and it was frequently associated with more severe intracranial complications.
In those times, treatment of this affliction was
mainly surgical. As a consequence of the introduction of antimicrobials to treat acute otitis media,
there was a dramatic decline in the incidence of
acute mastoiditis, and the classic study by House

0165-5876/00/$ - see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 1 6 5 - 5 8 7 6 ( 0 0 ) 0 0 4 0 6 - 7

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J. Spratley et al. / Int. J. Pediatr. Otorhinolaryngol. 56 (2000) 3340

refers to a consequent 80% reduction in the number of mastoidectomies performed [3]. Subsequent
reports reinforced evidence of this tendency, noting that acute mastoiditis had been reduced to an
almost nonexistent event with an incidence between 0.2 and 2% [4 6]. Regardless of this optimistic trend, in recent years sporadic reports have
described possible resurgences of acute mastoiditis
[7 11]. Suggested reasons included the emergence
of antibiotic-resistant organisms associated with
incorrect and sometimes abusive use of antibiotics
[12,13]. Our study aimed to evaluate recent experience with pediatric acute mastoiditis at our institution, and to determine whether the incidence of
this complication is changing over time.

was considered when the following criteria were

met: postauricular inflammatory signs, protrusion
of the auricle, and evidence of an acute or recent
episode of otitis media. Charts with incomplete
data or in which the diagnosis was not conclusive
were excluded. Analysis was performed according
to the following parameters: age, gender, date of
admission, clinical history including previous
episodes of otitis media, onset of symptoms and
antibiotic treatment, presence of co-existing complications, imaging studies, laboratory studies,
type of treatment, and length of hospitalization.
Results are presented as means and standard deviations together with maximum, minimum, and
median.

2. Selection of patients and methods

3. Results

We reviewed the charts of all children under 15

years of age who had a diagnosis of acute mastoiditis upon admission at the Division of Pediatric Otorhinolaryngology, Department of
Otorhinolaryngology, Hospital S. Joao, University of Porto Medical School, between July 1993
and June 1998. This clinic is a tertiary academic
referral center located in Porto in northern Portugal, with an average of 75.991 pediatric emergency admissions per year. The hospital serves a
community where most episodes of acute otitis
media are treated with antibiotics by the primary
care physician. The diagnosis of acute mastoiditis

Charts of 49 children were reviewed, of which

43 cases fulfilled criteria for inclusion. Their ages
ranged from 4 months to 14 years and 4 months
(mean age 4 years and 7 months). Children
younger than 2 years old represented more than
one-third of cases (n= 17). Two patients were less
than 8 months old. Boys (n = 30) were much more
frequently affected than girls, but distributions by
age were similar. No cases of immuno-suppression were reported. A remarkable increase in the
absolute number of referrals for acute mastoiditis
was observed in the more recent years of our
series (Table 1). Peak incidence (41%) occurred

Table 1
Distribution of mastoiditis cases by years of the study

J. Spratley et al. / Int. J. Pediatr. Otorhinolaryngol. 56 (2000) 3340

35

Table 2
Clinical facts on admission in children with acute mastoiditis
(n= 43)
Facts

Symptoms and signs

Pain/irritability
Fever (38C)
Abnormal tympanic
membrane
Otorrhea
Retroauricular edema
or erythema
Retroauricular
abscess
History
Absence of previous
otitis media
Pre-admission
antibiotic treatment
(512 days)

Number of
patients

Frequency (%)

39
16
43

(91)
(37)
(100)

7
43

(16)
(100)

10

(23)

21

(48)

24

(56)

during autumn, and the remaining cases were

equally divided in other seasons.
In almost half (48%), the episode of acute mastoiditis was the first recognized evidence of pathologic conditions in the ear. Fifty-six percent of
patients were taking oral antibiotics prescribed by
their primary care physician within the 12 days
leading up to admission. Most commonly prescribed drugs were amoxicillin-clavulanic acid and
first- or second-generation cephalosporins. The
average duration of pre-admission treatment was
5.8 days (minimum 1 day; maximum 11 days).
An overview of the clinical facts regarding the
patients in this study is seen in Table 2. Pain,
often displayed as irritability, was the most common complaint (91%). Significant fever (\ 38C)
afflicted fewer than half the children, and five
cases had normal temperature throughout the
hospital stay. Upon admission, all the patients
had post-auricular inflammatory signs, and ten
cases showed fluctuation on palpation indicative
of superiosteal abscess. Left ears were slightly
more affected (53%) than right ears. Pathological
tympanic membranes were evident under the otomicroscope on the afflicted side in every patient.

Fig. 1. Axial T2 weighted magnetic resonance image of a 10

year-old girl with mastoiditis on the left side. Absence of blood
flow within the homolateral lateral sinus indicating thrombosis
(arrow). Compare with normal right side where active flow is
represented by signal void.

In 33 children, we detected signs of acute otitis

media with inflamed and bulging but intact
eardrums. Three patients had dull and thickened
membranes on the afflicted side corresponding to
ongoing effusion in the middle ear space, and the
remaining seven cases presented perforation of the
tympanic membrane and otorrhea. Sagging of the
posterosuperior aspect of the ear canal was documented in various reports. Four patients were
diagnosed with chronic otitis media, and in two of

Fig. 2. Axial computed tomographic scan of a 14-year-old boy

with mastoiditis on the right side. Note voluminous abscess
beneath temporalis muscle. Area of bone erosion along the
sinusal plate. Evidence of lateral sinus thrombophlebitis with
surrounding halo of contrast enhanced dura.

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J. Spratley et al. / Int. J. Pediatr. Otorhinolaryngol. 56 (2000) 3340

these the condition was surgically observed to be

a cholesteatoma; these four were older children
ranging in age from 4 to 14 years old. In our series,
associated complications occurred in 13.9% of
cases (n= 6), one presenting facial paralysis and
five with involvement of the central nervous system
(CNS). Two of those five patients had meningitis,
two suffered lateral sinus thrombosis (LST), and
one had meningitis and LST simultaneously. One
10-year-old girl with LST had extension of the
thrombophlebitic process to the homolateral internal jugular vein with associated signs of pulmonary
embolism and severe sepsis (Fig. 1).
Results from the white blood cell count (WBC)
were available in 35 cases; these ranged between
6.520 and 29.300 per mm3. Values for leukocytes
were high ( \15.000 per mm3) in 17 patients,
moderately elevated (10.000 15.000 per mm3) in
11, and normal (5 10.000 per mm3) in six patients.
In 23 cases where pus was harvested either by
tympanocentesis or in open surgical exploration,
this was cultured in the laboratory. Microorganisms were identified in ten patients: S. pneumoniae
(n= 3), Streptococcus pyogenes group A (n = 3),
Proteus mirabilis (n =2), Streptococcus hominis
(n= 1), and non-typeable Haemophilus influenzae
(n=1). A mixed culture of P. mirabilis and Candida albicans was obtained in one instance. One of
the S. pneumoniae isolated showed high penicillinresistance (MIC\1 mg/ml) and the H. influenzae
was a b-lactamase producer. Most of the positive
cultures (n=8) were obtained from patients free of
antibiotics prior to hospitalization. Thirteen specimens were sterile, ten of which were from patients
who were already taking antimicrobials on admission.
Plain mastoid radiographs (Schuller view) were
taken in 17 patients. Images were reported as
normal in six instances. The remaining 11 revealed
variable grades of clouding of the mastoid air-cell
system, sometimes coinciding with evidence of
erosion of bony trabeculae, consonant with a
radiological diagnosis of mastoiditis. Computerized tomographic (CT) scans were obtained in 13
children. These were mainly performed when the
clinical condition of the child raised suspicion of an
associated complication. Images obtained with CT
allowed a detailed assessment of the extent of the

inflammatory process within the middle ear and

mastoid. Moreover, the bony contours of these
compartments as well as of the adjacent intracranial structures could be thoroughly screened with
these studies (Fig. 2). Magnetic resonance imaging
(MRI) was complementarily taken in four patients
and proved to be a most valuable tool in the
diagnosis of LST in three situations.
Upon admission, all the patients were immediately put on broad-spectrum intravenous thirdgeneration cephalosporins with good meningeal
penetration (cefotaxime or ceftazidime 100 mg/kg
per day t.i.d.). The initial antibiotic regimen was
adjusted in ten children, following tests of the
microbiological antibiotic sensitivity or according
to the clinical situation. This was the case in
children with LST for whom metronidazole was
added to the initial regimen.
Management included surgical drainage in every
patient, ranging from immediate myringotomy in
those patients with an intact tympanic membrane
to more extended tympanomastoidectomy. Of the
surgical interventions, 26 represented minimal
treatment (antibiotics and myringotomy only), five
a moderate approach (antibiotics, myringotomy,
and drainage of the subperiosteal abscess), and 12
an aggressi6e approach (antibiotics and mastoidectomy). Transtympanic ventilation tubes were inserted in seven ears in which a previous history of
recurrent acute otitis media was elicited. Surgeries
performed in the 12 cases representing a more
aggressive approach included cortical mastoidectomy (n= 8), canal-up tympanomastoidectomy
with tympanoplasty (n= 3), canal-down tympanomastoidectomy with tympanoplasty and ligation
of the internal jugular vein (n= 1). Varying
amounts of edematous and polypoid mucosa along
with purulent secretions were found intraoperatively.
In children with LST, the sigmoid sinus was
uncovered and punctured as appropriate; in two
cases a perisinus abscess was drained; intravascular
thrombi were removed. The girl with LST complicated by thrombophlebitis of the internal jugular
vein and pulmonary embolism required further
cervicotomy with ligation of the internal jugular
vein. No post-operative complications were registered.

J. Spratley et al. / Int. J. Pediatr. Otorhinolaryngol. 56 (2000) 3340

37

Table 3
Correlation between groups of surgical procedures with mean values for fever and white blood cell count (WBC) upon admission,
and length of hospital stay
Surgical group

Temperature (C)

WBC (103 per mm3)

Hospitalization (days)

(A) Myringotomy only (n= 26)

(B) Abscess drainage (n = 5)
(C) Mastoidectomy (n = 12)

37.59 5.58
38.0 9 1.11
37.79 0.69

15.4 9 7.49
19.29 7.68
16.3 94.02

6.0 93.60
8.3 92.92
16.9 9 6.80

Length of the hospital stay ranged from 2 to 24

days (mean 8.9 days) and varied according to the
type of surgical intervention (Table 3). Following
discharge from the hospital, the children were
routinely prescribed oral amoxicillin-clavulanic
acid (50 mg/kg per day t.i.d.) for an additional
period of 10 days. All patients recovered uneventfully. Those cases treated for complications involving the central nervous system or facial
paralysis had normal neurological examinations
at discharge from the infirmary. Recurrences of
mastoiditis were not detected in our series within
a period of at least 1 year of clinical follow-up.

4. Discussion
In recent years, acute mastoiditis in children
has attracted renewed interest, and it has appeared more often in published reports. Although
most studies still note this complication of otitis
media to be rare [4 6], controversy is increasing
regarding a hypothetical resurgence of this affliction [711]. Data from two different hospitals in
the south of Portugal [10,14] have recently been
reported that indicate contradictory results concerning variation in the incidence of acute mastoiditis over a period of years. In our study, the
results are consistent with a trend towards an
increasing number of patients with acute mastoiditis in the most recent years of the study. This
is surely a basis for reflection on possible causes
for the increase.
In a retrospective review like ours, we can only
speculate on explanations for this recent tendency.
The use of broad-spectrum antibiotics as initial
treatment for acute otitis media, a rather common
practice in our country, might play a role in
selecting resistant microorganisms. Our series, in

which 56% of patients received antibiotics for

otitis media before admission, provides evidence
for the assumption that widespread use of antimicrobials in treatment of acute otitis media does
not provide complete protection against acute
mastoiditis. Furthermore, the symptoms of acute
mastoiditis may be abated, in consequence of the
treatment, requiring a high degree of awareness
by contemporary clinicians to watch for manifestations. Therefore, antimicrobials should be used
judiciously in treatment of acute otitis media,
avoiding the employment of broad-spectrum
drugs as an initial regimen. Yet, complete abstention from use of antibiotics in treatment of suppurative otitis media is not advisable, as this seems
to increase the risk of complications in general
and of acute mastoiditis in particular [15,16].
In our study, acute mastoiditis affected all pediatric age-groups. Contemporary reports [10,17
19] describe an increasing predisposition for
younger children to become afflicted by acute
mastoiditis. This is probably the population in
which immature immunological defenses predispose to greater sensitivity to risk-factors for otitis
media. Our data agree with this tendency; 40% of
the children we studied were younger than 24
months. Almost 50% of our patients had no previously recognized episodes of otitis media, which
is consistent with data previously published by
Hawkins and colleagues (64%) [17], Nadal and
co-workers (74%) [18], and Harley and colleagues
(55%) [19]. According to Dhooges team [15], this
could be related to the sometimes atypical symptoms of otitis media in young children that can
obscure the diagnosis. Likewise, the immature
immunological system of infants, in particular as
it affects the defenses of the middle ear, might
predispose an initial case of acute otitis media to
evolve more aggressively into acute mastoiditis.

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J. Spratley et al. / Int. J. Pediatr. Otorhinolaryngol. 56 (2000) 3340

Despite most cases of suppurative otitis media

being concurrent with inflammatory changes of
the mucosal lining in the mastoid cells, the progression of infection to the periosteum of the
mastoid process is a much more infrequent event.
When mucosal swelling and blockage of the aditus
ad antrum happens, however, an increase in pressure within the mastoid system develops, and this
promotes progression to periostitis. This leads to
manifest retroauricular inflammation and protrusion of the pinna, which are clinical hallmarks of
acute mastoiditis. The diagnosis is completed
when a scenario for middle ear infection is met.
Periosteitis should, however, not be confused with
a more advanced subperiosteal abscess, which
commonly requires extended, aggressive management [1].
Seemingly as the result of use of antimicrobials,
the course of both acute otitis media and acute
mastoiditis now evolves in milder forms that demand a higher degree of clinical suspicion. This
has appeared to be the case in some reported
series where confirmed acute mastoiditis was accompanied by normal otoscopic findings [19,20],
arguably as result of clearance of infection from
the middle ear with persistent blockade of the
mastoid compartment. This did not pertain to the
present study, in which every patient had documented, abnormal otomicroscopic findings on the
afflicted side. Therefore, no cases of masked mastoiditis [21] were registered in our records.
We felt that the importance of radioimaging
could be divided into two different levels. On the
one hand, plain Schuller X-rays were only marginally helpful in confirming the clinical diagnosis
in most cases. Six cases we reviewed had confirmed acute otitis media and postauricular
swelling, while reported as normal on plain radiographs. We agree with Ogle and Lauer [8] that
this examination, particularly in infants, is easily
subject to contradictory interpretations. On the
other hand, CT-scans played a determinant role in
confirming the diagnosis and in orienting plans
for management. This was particularly true when
the spread of infection to neighboring structures
was suspected, rendering CT-studies essential in
this context. Symptoms or signs that urge CT-examination should include persistent otalgia or

fever despite adequate antibiotic coverage,

lethargy, headache, and vomiting. We find it
highly recommendable to include CT-scans in the
work-up of every patient with suspected acute
mastoiditis, whenever facilities are available to
perform this study.
The risk of acute mastoiditis evolving into other
complications, either intratemporal or intracranial, is potentially high due to spread of infection
through bony routes or vascular dissemination.
Our rate of complications was 13.9%. This figure
is considerable, if we take into account that in our
study subperiosteal abscess was not considered a
complication of acute mastoiditis but rather an
advanced stage of the affliction. This percentage is
however comparable to the 15.3% recently reported by Gliklish and co-workers [22].
Treatment of acute mastoiditis is reportedly
feasible on an out-patient basis when tight daily
monitoring can be guaranteed [23]. Still, we preferred hospitalization. We took into account the
potential risks of severe complications inherent in
pediatric acute mastoiditis. Besides, many patients
appertaining to this study lived in areas distant
from our hospital, reducing the probability of
adequate compliance with ambulatory management. An increase in the average hospital stay
might have been the price to pay for this geographic diversity, but our average of 8.9 days for
in-patient treatment compares favourably to that
of Neto and colleagues [10], who reported an
average of 10.5 days.
Antibiotic treatment was complemented by
myringotomy in all patients where acute mastoiditis was associated with an intact eardrum. Over
60% of our patients were thus treated successfully.
This figure is comparable to the 57 and 63% rates
of cure noted by Hawkins and colleagues [17] and
by Ogle and Lauer [8], and again provides evidence that mastoidectomy is not mandatory in
non-complicated acute mastoiditis.
Our policy in respect to placement of ventilation tubes was conservative. We agree with Rosen
and co-workers [20] that ventilation tubes should
only be used when there is a previous history of
middle ear disease. Although examples of exclusive medical treatment for acute mastoiditis have
been reported in the past [8,10,18,19], we continue

J. Spratley et al. / Int. J. Pediatr. Otorhinolaryngol. 56 (2000) 3340

to believe that the old aphorism urbi pus e6acua

(where there is pus, drain it) still holds today
despite the vast antibiotic armamentarium at our
disposal. This is further substantiated by the
pathophysiological concept in which the occurrence of osteitis results from extension of infection
beyond the mucoperiosteum in direct correlation
to increased levels of pressure within the middle
ear and mastoid compartments [2]. Therefore, the
alleviation of pressure should be strongly
advisable.
Besides its therapeutic benefits, the role of
myringotomy in facilitating microbiological diagnosis merits emphasis. In our series, positive microbiological specimens were documented in 43%
of the cultures. Previous reports have cited identification of cultured organisms in 75% [24], 62%
[25], 50% [20], and 33% [17]. In our study, the
relatively low rate of positive cultures recovered
for each pathogen precluded evaluation of the real
incidence of each pathogen as well as resistances
to antibiotics. Possible reasons for these low numbers could have included the great proportion of
patients taking antibiotics before admission, together with less than appropriate harvesting and
transportation of specimens. Nevertheless, the detection of a variety of penicillin-resistant S. pneumoniae in this series, an infrequent finding in
Portugal in contrast to other Western European
Countries [26], should by itself justify further
investigations in regard to the prevalence of this
type of bacteria in our population together with
possible relationships between antibiotics misuse
and microbiological selection in otitis media.
Patients with LST had very favourable response
to both extended mastoidectomy and simultaneous introduction of intravenous metronidazole,
which at least suggests that in these cases the
suspicion of co-existing anaerobes might be confirmable. This assumption might be grounded in
the known prevalence of anaerobes in the pathogenesis of acute mastoiditis, which can reach values as high as 80% [27] and can rise to 96% in
chronic mastoiditis [28]. Gram-negative bacteria
have been implicated in severe forms of acute
mastoiditis [2]. This was the situation in our study
in respect to those cases with confirmed infection
by Proteus species.

39

Five patients in this study who underwent moderate surgical treatment were managed with antibiotics, myringotomy, and drainage of the
subperiosteal abscess without mastoidectomy.
These children were all younger than 2 years old,
and their mean values for fever and WBC were
proportionally higher than to those for patients
treated differently. This favoured the decision towards immediate drainage of the abscess along
with myringotomy upon admission, which proved
to be successful in these cases.
Mastoidectomy is always a delicate procedure
in infants. Whenever possible our decision to perform it in a small or absent retroauricular abscess
was deferred for 2448 h after adequate antibiotherapy, during which we implemented watchful
clinical monitoring including further imaging.
Hawkins and co-workers [17] based their decision
to operate on clinical grounds alone. Although
clinical indicators still hold as basic indications
for surgery, CT-images now play a relevant role
in assisting that decision.
Our overall impression is not absolutely pessimistic considering results obtained currently
with state-of-the-art management of acute mastoiditis, when adequate treatment is instituted.
But our data should raise concern about future
attitudes toward prevention of resurgence of this
potentially serious otologic infection.

5. Conclusions
We conclude from this study that acute mastoiditis affects young children especially, and in a
considerable number of cases without a previous
history of otitis media. With appropriate followup, acute mastoiditis without subperiosteal abscess or co-existing complications may be curable
with use of intravenous antibiotics and myringotomy. In older children presenting with acute
mastoiditis, it is important to exclude
cholesteatoma. Finally, we should stress that pediatric acute mastoiditis continues to be a problem
today, possibly regaining an importance it has
had in the past. It presents significant morbidity
and potential mortality. Great care is required of
pediatricians and otorhinolaryngologists to reach

40

J. Spratley et al. / Int. J. Pediatr. Otorhinolaryngol. 56 (2000) 3340

an early diagnosis in order to promote adequate

management and consequently prevent inherently
serious complications.

Acknowledgements
This study was supported in part by grant No.
109/99 from the Comissao de Fomento da Investigacao em Cuidados de Saude, Ministerio da
Saude de Portugal. The work of Ginny Hansen in
editing the manuscript is highly appreciated.

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