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Acute mastoiditis: A 10 year retrospective

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 International Journal of Pediatric Otorhinolaryngology
66 (2002) 143
/148
www.elsevier.com/locate/ijporl

Acute mastoiditis: a 10 year retrospective study

V. Tarantino *, R. DAgostino, G. Taborelli, A. Melagrana, A. Porcu,
M. Stura
ENT Department, Divisione di Otorinolaringoiatria, Istituto G. Gaslini, Largo G. Gaslini 5, Genova 16148, Italy

Received 18 December 2001; received in revised form 8 July 2002; accepted 9 July 2002

Abstract

This retrospective study reviews our experience in the management of acute otomastoiditis over 10 years. During the
study period we identified 40 cases in children aged 3 months
/15 years with a peak incidence in the second year of life.
Sixty per cent of them had a history of acute otitis media (AOM). All the children were already receiving oral antibiotic
therapy. Otalgia, fever, poor feeding and vomiting were the most common symptoms, all the children had evidence of
retroauricolar inflammation. Computerized tomography (CT) and magnetic resonance imaging (MRI) were used to
support the diagnosis and to evaluate possible complications. Streptococcus pneumoniae was the most common isolated
bacterium. All the patients received intravenous antibiotics, 65% of children received only medical treatment, 35% also
underwent surgical intervention. Mean length of hospital stay was 12.3 days. Cholesteathoma was diagnosed in one
child. We conclude from our study that acute otomastoiditis is a disease mainly affecting young children, that develops
from AOM resistant to oral antibiotics. Adequate initial management always requires intravenous antibiotics,
conservative surgical treatment with miryngotomy is appropriate in children not responding within 48 h from beginning
of therapy. Mastoidectomy should be performed in all the patients with acute coalescent mastoiditis or in case of
evidence of intracranial complications.
# 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Acute mastoiditis; Acute suppurative otitis media; Children

1. Introduction of AOM was adopted [1
/4]. From 1946 to date,

Acute otomastoiditis is an infrequent complica-
tion of acute otitis media (AOM), it has become
less common in children since antibiotic treatment
* Corresponding author. Tel.: /39-10-563-6598; fax: /39-
10-307-1046
E-mail address: vincenzotarantino@ospedale-gaslini.ge.it (V.
Tarantino).
0165-5876/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 1 6 5 - 5 8 7 6 ( 0 2 ) 0 0 2 3 7 - 9
house reported a 50% reduction in admissions for
AOM and an 80% reduction in the number of
mastoidectomies performed after the introduction
of sulfonamides [5].
It is widely accepted that the incidence of acute
mastoiditis is decreasing as a result of the avail-
ability of antibiotics and proper medical care [4
/
7]. Today, the estimated incidence is 2
/4 out of
100 000 AOM cases in industrialized countries [6
/
8].
144 V. Tarantino et al. / Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 143
/148
However, complications have not changed in
number or severity and they mainly include:
subperiosteal abscess, labyrintitis, facial paralysis,
meningitis, cerebral abscess, lateral sinus trombo-
flebitis, and death [8
/12].
Otomastoiditis is more frequent in males aged
between 1 and 3 years [6,9].
Streptococcus pneumoniae , Haemophilus influen-
zae and Branhamella catarralis followed by beta
Haemolityc streptococcus are the most common
infectious pathogens [4,8,13,14]. These agents
usually cause monobacterial otitis media with
inflammation of the mucoperiosteum in the middle
ear, swelling and mucosal hyperplasia.
The following pathological stages are succes-
sively encountered in the development of acute
mastoiditis:

/ blocking of the aditus ad antrum;

/ trapping of exudate in mastoid cells;

/ spreading of pus to the periosteum through the
mastoid emissary veins and formation of mas-
toid subperiosteal abscess (acute mastoiditis
with periosteitis);

/ demineralization of bone septa and osteonecro-
sis of thinner mastoid walls;

/ creation of large purulent cavities (acute coa-
lescent mastoiditis).
Children with acute mastoiditis present otalgia,
fever, proptosis of the auricle, erythema, and
disappearance of the retroauricular sulcus
[6,13,14]. The tympanic membrane is usually
inflamed and thickened and may also be perfo-
rated with mucopurulent otorrhea. The poster-
osuperior wall may protrude in the external
auditory channel [1,3,6].
Children affected by acute mastoiditis with
periosteitis are usually hospitalized for parenteral
antibiotic and/or surgical treatment [1,4], it is
important to distinguish this condition from acute
coalescent mastoiditis which requires immediate
surgery [4,8,15].
The diagnostic role of X-ray examination is
limited, while computerized tomography (CT) is
useful to study the morphology of mastoid cells
and magnetic resonance imaging is optimal in case
of suspected intracranial complications [16,17].
There is universal agreement on the need for
surgical drainage of the subperiosteal abscess in
order to prevent the spread of suppuration to vital
areas. However, new antibiotics therapies and
adequate treatment protocols seem to have ar-
rested developing otomastoiditis at the stages,
described above, thus, avoiding mastoidectomy
in a large number of cases [4,6,10].
This study reports the authors experience in the
treatment of children admitted for acute mastoi-
ditis to the ENT department of G. Gaslini
Institute over the last 10 years.
2. Materials and methods
We reviewed the clinical records of all the
patients admitted for acute mastoiditis to the
ENT department of G. Gaslini Institute between
January 1991 and December 2000.
Criteria for diagnosis of otomastoiditis were:

/ otomicroscopic evidence of purulent AOM;

/ postauricular swelling, erythema and tender-
ness;

/ anteroinferior displacement of the auricle.
Exclusion criteria were:

/ AOM without evidence of otomastoiditis;

/ AOM with retroauricular adenitis;

/ external otitis with retroauricular involvement;

/ presence of cholesteatoma.
Criteria for including children in the medical
therapy program were:

/ absence of toxic appearance or signs of intra-
cranial involvement;

/ absence of postauricular fluctuation;

/ absence of CT signs of mastoid bone cell
destruction.
Criteria for selection of surgery were:

/ intracranial complications;

/ evidence of postauricular fluctuation;

/ diagnosis of acute coalescent mastoiditis;

/ failure of medical therapy program.
 V. Tarantino et al. / Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 143
/148 145

During the study period we identified 40 cases of disappearance of the retroauricular sulcus and
acute mastoiditis. proptosis of the auricle), the remaining 25% also
All the patients were hospitalized and treated at had postauricular fluctuation. The tympanic mem-
Gaslini Institute by a team including an otolar- brane was described as abnormal in all the
yngologist, a pediatrician and a infections disease children: dull in 60%, perforated with otorrhea in
specialist. 15% (Table 1).
All the patients received intravenous antibiotic Cultures were obtained in 28 cases, 12 (42.8%)
therapy associating ceftazidime (50
/100 mg per kg of which were negative. In 8 (28.6%) of the 16
per die) and netilmicine (6
/7.5 mg kg per die). (57.2%) positive cultures, S. pneumoniae was the
Surgery was performed in cases not responding most common isolated bacterium. We also isolated
to therapy within 48 h, or in case of complications. three cases of Staphylococcus aureus (10.7%), two
cases of Pseudomonas aeruginosa (7.1%), one case
of Haemophilus, one of Proteus mirabilis , and one
3. Results of Escherichia coli (3.6%).
In the 16 positive cases, the previously adminis-
This study included 40 children (22 males and 18
tered antibiotic was:
females) aged from 6 months to 12 years with a
mean age of 4.5 years (Fig. 1). Sixty percent of
patients had a history of AOM, with a peak Table 1
Symptoms and signs of otomastoiditis in children
incidence in the second year of life.
All the children presenting acute otomastoiditis N %
were already receiving oral antibiotics such as
Symptoms
amoxicillin, cephalosporin or macrolides. Otalgia 32 80
Otalgia, often manifested as irritability, was the Fever 20 50
most frequent symptom (80%), followed by fever Vomiting 6 15
Poor feeding 16 40
(50%), poor feeding (40%) and vomiting (15%). Upper airways infection 24 60
Upper respiratory tract infection was present in Signs
60% of cases. Dull tympanic membrane 24 60
All the children studied had evidence of retro- Otorrhea 6 15
Postauricolar swelling 30 75
auricular inflammation. In 75% of them we Postauricolar fluctuation 10 25
observed postauricular swelling (with erytema,

Fig. 1. Age distribution of otomastoiditis.

146 V. Tarantino et al. / Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 143
/148
. not adequate in four cases (25%): P. aeruginosa
[2], P. mirabilis [1], E. coli [1];
. adequate but administered at inadequate do-
sage in two cases (12.5%): S. pneumoniae [1], S.
aureus [1];
. adequate, but ineffective due to resistant micro-
organism in ten cases (62.5%): S. pneumoniae
[7], S. aureus [2], H. influenzae [1].
Plain mastoid radiography was perform-
ed in 38 children, while 30 cases underwent
computed tomography, and five with suspected
intracranial complications also underwent mag-
netic resonance. All the cases were reported as
abnormal.
All the patients received intravenous antibiotics
for mean 10 days. Additional oral antibiotic
therapy (cefamandole 50
/70 mg per kg per die)
was administered after discharge in 80% of our
patients (mean duration 9.7 days).
About 26 (65%) children received only medical
treatment. In these cases, no further treatment was
required and no relapse was observed. About 14
(35%) patients also underwent surgery, namely
myringotomy eight cases (20%), and mastoidect-
omy six (15%), five of these latter patients (12.5%)
Fig. 2. Management of otomastoiditis.
underwent antroatticotomy and one (2.5%) had a
radical modified mastoidectomy [18] (Fig. 2).
The mean length of hospital stay was 12.3 days
(range 7
/22 days).
4. Discussion
Although several literature reports show that
the incidence of acute mastoiditis wasdecreased
over the last few years, there is evidence that it has
recently been rising again [6,19,20].
This phenomenon could be due to the increasing
antibiotic resistance (62.5% of our positive cul-
tures) of microorganisms like Streptococcus to
Penicillin , in particular the penicillinase-producing
S. pneumoniae and the b-lactamase producing
strains of Moraxella and Haemophilus [6,10,20].
In addition, the initial treatment can be insuffi-
cient (duration, dose) or not proper, leading to an
increase in complications such as acute mastoiditis
in the majority of cases [6]. In fact, 60% of our
patients, in the 30 days before admission to our
department, showed evidence of acute or recurrent
suppurative otitis media, which can be interpreted
as a risk factor of mastoiditis.
 V. Tarantino et al. / Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 143
/148
Before antibiotics were introduced, acute mas-
toiditis was a disorder of older children.
Recent papers have documented an increased
incidence in infants aged under 2 years [21,22]. Our
study reports the same trend and suggests that
today this disease mainly affects young children.
We could explain this phenomenon by the fact
that young children are sent early to day care
centers, where they are exposed to the risk of
developing recurrent AOM [23,24].
Acute mastoiditis arises when the most resistant
strains are involved and develops through block-
ing of the aditus ad antrum with trapping of
secretions in mastoid cells. Of infectioning spread
to the periosteum can cause periosteitis, while
acute coalescent mastoiditis occurs when the
infection extends beyond the mucoperiosteum
and destroys bone walls. This series of events
may be arrested at any stages if early recognized
and adequately treated [4].
Acute mastoiditis is essentially a clinical mani-
festation and should be suspected on the basis of
anamnesis and clinical examination, showing re-
cent evidence of AOM [4,6]. The tympanic mem-
brane is usually thickened and inflamed but may
also be perforated with Mucopurulent otorrhea.
Other signs include retroauricolar swelling, er-
ythema, tenderness, and displacement of the pinna
[1,3,6,13,14].
Moreover, mastoiditis can remain undetected as
the pathologic secretions may drain through the
tube and middle ear findings may result normal:
this condition is known as masked mastoiditis.
Diagnosis is radiological, showing suppuration in
mastoid cells in the absence of the classic signs of
otitis media [7,15,21]. MR imaging is used to
support the diagnosis and to evaluate complica-
tions.
Plain radiographs are not helpful in the diag-
nosis of acute mastoiditis and they proved to be
misleading in 16 of our cases (40%). Actually, the
specificity of plain films is too low to justify their
use in the diagnosis of acute mastoiditis in
children.
CT scans of both temporal bone and central
nervous system should be performed to identify
not only acute mastoiditis but also intratemporal
or intracranial complications such as sigmoid sinus
147
thrombosis or cerebral abscess [12,22
/24]. In these
cases, MR is also required to better evaluate the
stage of intracranial complications.
CT scans have contributed to a better definition
of the pathogenesis of this disease [4,6,16,17]. The
swollen mucosal lining favors filling of the mastoid
cells with mucopurulent secretions. In acute mas-
toiditis, inflammation of the periosteum causes
abnormal new bone formation: the trabeculae
appear intact and no postauricular abscess can
be demonstrated. In cases of acute coalescent
mastoiditis, CT confirms coalescence of the mas-
toid cells and subperiosteal abscess [4,16,17].
All our patients received intravenous antibiotics
with rapid regression of symptoms and full recov-
ery in 65% of them.
A conservative surgical approach such as a
myringotomy was adopted in 20% of patients not
responding within 48 h from beginning of anti-
biotic therapy (no regression of fever, pain,
vomiting, and poor feeding). After myringotomy,
middle ear secretion was aspirated and sent for
microbiological studies.
Surgical intervention ( antroatticotomy) was
performed in all the cases (five patients, 12.5%)
with evidence of acute coalescent mastoiditis in
order to drain the abscess and prevent further
intratemporal and intracranial complications.
One patient (2.5%), aged 10 years, presented a
cholesteatoma and, therefore, underwent radical
modified mastoidectomy. Cholesteatoma should
be suspected when mastoiditis occurs in children,
above 8 years of age.
Similary to other reported series, surgical treat-
ment was necessary in 15% of our patients (Vera-
Cruz (17.7%), Rosen (32%) or Papournas (23.2%)
[3,6,19].
5. Conclusions
On the basis of our retrospective study, we can
draw the following conclusions:

/ Acute mastoiditis is a disease mainly affecting
children [6,9].

/ AOM resistant to oral antibiotics is the first risk
factor [6,10,20].
148 V. Tarantino et al. / Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 143
/148

/ The most common symptoms are: persistent ear
pain, fever and poor feeding [1,3,6,20].

/ Retroauricolar erythema, proptosis of the auri-
cle and inflammation of the tympanic mem-
brane are the main clinical signs of acute
mastoiditis [1,3,6].

/ Radiological imaging can only support the
clinical diagnosis, however, CT scan should be
performed to identify intratemporal or intra-
cranial complications, while magnetic reso-
nance imaging (MRI) is useful to better
evaluate intracranial complications. Conver-
sely, plain radiographs are not helpful
[12,16,17,22
/24].

/ Adequate initial management always requires
intravenous antibiotics [5
/7], in our series, we
obtained good results with ceftazidime in asso-
ciation with netilmicine.

/ Conservative surgical treatment with myringot-
omy is appropriate in children not responding
within 48 h from beginning of therapy [4,6,10].

/ Mastoidectomy should be performed in all
cases of acute coalescent mastoiditis, when
there is evidence of intracranial complications
and when conservative treatment is unsuccess-
ful [4,6,18].

/ Close follow-up after discharge is mandatory,
even when the patient responds readily to
therapy [3,6,19].
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