International Journal of Pediatric Otorhinolaryngology 138 (2020) 110372

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

2016 ESPO Congress

Our experience on the management of acute mastoiditis in pediatric acute

otitis media patients
Erdem Duygu *, Sultan Şevik Eliçora
Department of Otorhinolaryngology, Faculty of Medicine, Zonguldak Bülent Ecevit University, Zonguldak, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: The incidence of complications due to acute otitis media (AOM) in childhood has decreased signifi­
Acute mastoiditis cantly with the use of new antibiotics in recent years. However, acute mastoiditis (AM) is still the most common
Pediatric complication that can lead to further intracranial conditions with high morbidity. Our study aimed to evaluate
Intracranial complications
the clinical characteristics of children with AM and identify possible indicators for further intracranial compli­
Surgical management
cations associated with this condition.
Methods: Children hospitalized in our clinic with a diagnosis of AM were reviewed. Demographic data, disease-
related symptoms, types of complications accompanied by AM, medical/surgical treatments modalities, and
culture results were screened. The patients were divided into two groups as those with and without intracranial
complications (ICCs). Routine complete blood count tests, biochemical analysis, and C-reactive protein (CRP)
level measurement were evaluated and compared between the groups.
Results: Of the 28 AM patients, five (17.9%) had isolated AM. Complications associated with AM included sub-
periosteal abscess (28.6%), facial paralysis (25%), meningitis (17.9%), meningitis with sigmoid sinus thrombosis
(7.1%), and meningitis with cerebellar abscess (3.6%). Eight patients developed ICCs (28.6%), of whom three
had more than one complication. Ceftriaxone was found to be the first-line medical treatment (57.1%). Strep­
tococcus pneumoniae was the most common pathogen isolated from the cultures (42.9%). Three patients (10.7%)
were treated non-surgically, eight (28.6%) with myringotomy and ventilation tube (VT) insertion, eight patients
(28.6%) with abscess drainage and VT insertion, and nine (32.1%) with cortical mastoidectomy and VT insertion.
There was no significant difference between the patients with and without ICCs in terms of complete blood count
parameters. The CRP level and the CRP-albumin ratio were significantly higher in patients with ICCs than those
without these complications (p < 0.001).
Conclusion: AM remains to be the most common complication of AOM in childhood and can lead to further life-
threatening conditions. Additional interventions according to the type of the complication with VT insertion is
safe and effective in the management of AM. In patients with AM, it is of great importance to determine whether
there is an accompanying ICC. The CRP-albumin ratio is a simple and reliable calculation to detect ICCs in
patients with AM.

1. Introduction intracranial. Acute mastoiditis (AM) is still the most common compli­
cation of AOM, developing in 0.4% of all AOM cases when the infection
Acute otitis media (AOM) is an acute onset inflammation of the spreads beyond the middle ear usually by direct bony erosion or through
middle ear and mastoid air cells. It is one of the most common infections the mastoid emissary veins [2,6]. In complicated AOM, the purulent
in infancy and childhood [1–4]. AOM complications occur when the infection first causes AM, which leads to further conditions, such as
infection spreads outside the airy cavities of the middle ear and temporal facial paralysis (FP), labyrinthitis, osteitis/bone erosion, sub-periosteal
bone. The incidence of complications in AOM has significantly declined abscess (SPA), meningitis, sigmoid sinus thrombosis (SST), and intra­
with the use of new antibiotics in recent years [2,5]. cranial abscess. Since most intracranial complications (ICCs) occur after
The complications of AOM can be classified as intratemporal and AM, it plays a key role in the development of further problems. ICCs,

* Corresponding author.
E-mail addresses: [email protected] (E. Duygu), [email protected] (S. Şevik Eliçora).

https://doi.org/10.1016/j.ijporl.2020.110372
Received 16 July 2020; Received in revised form 3 September 2020; Accepted 3 September 2020
Available online 7 September 2020
0165-5876/© 2020 Elsevier B.V. All rights reserved.
E. Duygu and S. Şevik Eliçora International Journal of Pediatric Otorhinolaryngology 138 (2020) 110372

while rare, can still lead to substantial morbidity and significant eco­ Table 1.
nomic cost [3,7,8]. However, there is still no standard guideline for the When the medical histories of the patients were evaluated, the most
management of pediatric AM [4,6]. The treatment of AM varies, with the common complaints were found to be otalgia, retro-auricular swelling-
currently used regimens including intravenous antibiotics alone or in hyperemia, and protruding of the auricle. The retro-auricular signs of
combination with myringotomy and/or ventilation tube (VT) insertion, AM were present in all patients. Fever was detected in only six patients,
SPA incision and drainage, and mastoidectomy [2,4,6]. irritability in three, neck stiffness in two, and limited eye abduction due
It is of great importance to detect AM in the early period since there to abducens nerve palsy in three. The three patients with abducens nerve
are still a considerable number of accompanying intracranial conditions palsy were also evaluated by a neuro-ophthalmologist, and papilledema
and the classical symptoms and signs of complications are suppressed was observed in the ophthalmic examination. No focal neurological
due to commonly used antibiotics. This study aimed to evaluate the complications were reported in our series.
clinical characteristics of children with AM and identify possible in­ In our patient population, isolated AM was seen in five patients
dicators for further intracranial complications associated with this (17.9%). Complications associated with AM included SPA (28.6%),
condition. acute FP (25%), meningitis (17.9%), meningitis with SST (7.1%), and
meningitis with cerebellar abscess (3.6%). Eight patients had ICCs
2. Material and methods (28.6%), of whom three had more than one complication. Of the patients
with FP, three were House-Brackmann grade 4, one was grade 3, and
Prior to the study, ethical approval was obtained from the Ethics two were grade 2.
Committee of Zonguldak Bülent Ecevit University (Ref: 2019/11, Date: All of our patients underwent a CT scan of the temporal bone with
July 10, 2019), and informed consent was taken from the parents of the fine cuts routinely. An MRI scan was also performed in eight patients
children. The medical charts of children hospitalized in our otolaryn­ with suspected intracranial complications. Two patients required MR-
gology clinic due to AM were retrospectively reviewed between January venography with the suspicion of SST.
2014 and July 2019. The demographic data of the patients, disease- Medical treatment was applied routinely and surgical procedures
related symptoms, types of complications accompanied by AM, and were performed if necessary. All patients received empiric oral antibi­
medical or surgical treatments were screened. Patients with chronic otics before the presentation of complications at an outpatient clinic.
otitis media, cholesteatoma, immune-deficiencies, or craniofacial mal­ Parenteral antibiotics, first line with ceftriaxone (50–100 mg/kg, ac­
formations were excluded from the study. cording to the clinical condition of the patient), was routinely started,
In our routine practice, the diagnosis of AOM is based on medical and it was mainly used as monotherapy in 16 patients (57.1%). Van­
history and physical examination findings. AM was suspected in the comycin (60/mg/kg) was preferred in certain patients depending on
presence of clinical symptoms and signs, including post-auricular clinical symptoms or culture results. Intravenous corticosteroids (1 mg/
swelling, erythema, tenderness, and protrusion of the auricle. The kg Prednisolone) were administered in patients with accompanying FP.
diagnosis of AM was confirmed by imaging methods in all patients. All patients that initially presented with FP had full recovery. In addition
Then, the AM cases were classified according to the type of accompa­ to systemic treatment, oto-topical agents were also applied routinely to
nying complications (SPA, FP, meningitis, SST, and intracranial ab­ all patients.
scess). The diagnosis of FP was based on clinical examination findings, Samples were taken for a microbiological analysis in all patients
and all patients with FP were staged according to the House-Brackmann routinely. The cultures from myringotomy or mastoidectomy specimens
grading system. revealed Streptococcus pneumoniae in 12 patients (42.9%), other bacteria
Intratemporal complications were diagnosed during the follow-up at in six patients (21.4%), fungi in one patient (3.6%), and no growth in
our otolaryngology clinic but medical treatment was carried out nine patients (32.1%).
together with the pediatrics department. In cases where ICCs were Three patients (10.7%) were treated non-surgically, eight (28.6%)
suspected, a multidisciplinary approach was used for diagnosis and with myringotomy and VT insertion, eight (28.6%) with SPA incision-
management by consulting a pediatrician, neurologist, and drainage and VT insertion, and nine patients (32.1%) with cortical
neurosurgeon. mastoidectomy and VT insertion. When choosing the appropriate sur­
At admission, routine laboratory tests, such as white blood cell count gical method, a conservative approach was adopted in patients without
(WBC), neutrophil count (NEU), lymphocyte count (LYM), and C-reac­ ICCs; thus, mastoidectomy was performed in all patients who developed
tive protein (CRP) level and classical biochemical analyses were per­ ICCs. The type and management of complications and microbiological
formed for all patients. Cultures were obtained routinely from the ear profile of the ears operated are shown in Table 2.
discharge, middle ear fluid after myringotomies, or mastoid cavity in The patients were divided into two groups as those with and without
cases where mastoidectomy was performed. All AM patients also ICCs. Then, routine blood parameters were compared between the two
routinely underwent a CT scan of the temporal bone with fine cuts. MRI groups. There was no significant difference between the patients with
testing was undertaken for patients with suspected ICCs. and without ICCs in terms of complete blood count parameters (WBC,
All patients received initial medical treatment before surgery or NEU, LYM, and NLR). The CRP level and the CRP-albumin ratio were
simultaneously with surgery, which included intravenous and oto- found to be significantly higher in patients with ICCs than those without
topical antimicrobial therapy along with supportive therapy if needed. these complications (p < 0.001). The comparison of blood parameters in
Statistical evaluations were performed using PASW software, version patients with and without ICCs is shown in Table 3.
19.0. Descriptive statistics were shown as mean ± standard deviation
(SD). To reveal the relationship between the variables, the Mann-
Whitney U test was conducted. P values of less than 0.05 were consid­
ered statistically significant for all tests.

3. Results Table 1
Demographic data of the patients.

AM was detected in 28 patients hospitalized in our clinic due to AOM Age (years) 1-15 (mean:6.7)
over five years. Of these 28 patients, 12 were female (42.9%) and 16 Gender (n, %) Male 12 (42.9%)
were male (57.1%). The mean age was 6.7 (1–15) years. Complications Female 16 (57.1%)
affected the right ear in 16 patients (57.1%) and the left ear in 12 pa­ Side Operated (n, %) Left 12 (42.9%)
Right 16 (57.1%)
tients (42.9%). The demographic data of the patients are shown in

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E. Duygu and S. Şevik Eliçora International Journal of Pediatric Otorhinolaryngology 138 (2020) 110372

Table 2 an ICC is usually determined by imaging methods [5,8,10]. In cases

Type and management of complications and microbiological profile of ears where an ICC is suspected, MRI should be performed in addition to
operated. routine imaging tests. Given the life-threatening nature of otogenic ICCs,
n % their early diagnosis is critical, since any delay can lead to increased
Complications AM 5 17.9
morbidity and mortality. MRI is an expensive imaging modality that
AM + SPA 8 28.6 normally takes longer to perform than CT, and most protocols specify
AM + FP 7 25 that especially in younger children, MRI may sometimes require general
AM + M 5 17.9 anesthesia [3]. Therefore, we wanted to investigate whether there was
AM + M + SST 2 7.1
an easier and cheaper method to determine ICCs. CRP is an acute-phase
AM + M + CA 1 3.6
Treatment Protocol Medical 3 10.7 protein that has been evaluated extensively in critical settings. It has no
VT 8 28.6 additional cost and is routinely measured in patients with AM. Previous
VT + Drainage 8 28.6 researchers have suggested that CRP can be used both as a diagnostic
VT + Mastoidectomy 9 32.1 tool for sepsis and as a guide when evaluating treatment efficacy in
Microbiology None 9 32.1
Streptococcus pneumoniae 12 42.9
infected patients [12]. Therefore, we decided to compare the CRP
Streptococcus pyogenes 2 7.1 values, and the CRP-albumin ratio between the AM patients with and
Stenotrophomonas maltophilia 1 3.6 without ICCs. We found that both values were significantly higher in
Pseudomonas aeruginosa 1 3.6 patients with accompanying ICCs (p < 0.001). Mansour et al. similarly
Proteus mirabilis + Escherichia coli 1 3.6
found higher CRP in patients with ICCs than without these complica­
Enterococcus species 1 3.6
Aspergillus spp. 1 3.6 tions but at a lower significance level. However, since our study only
covered a five-year period, the low number of patients poses a disad­
AM: Acute mastoiditis, SPA: Sub-periosteal abscess, FP: Facial paralysis, M:
vantage. Further studies with a greater number of patients are needed to
Meningitis, SST: Sigmoid sinus thrombosis, CA: Cerebellar abscess, VT: Venti­
determine the clinical value of the CRP-albumin ratio in detecting ICCs.
lation tube.
To the best of our knowledge, there are only a limited number of studies
in the literature that have focused on the differences between AM cases
Table 3 with and without accompanying ICCs.
Comparison of blood parameters in patients with and without intracranial Currently, there is not yet a complete consensus on the management
complications. of pediatric AM or associated complications in the literature [4]. Typi­
ICC (n = 8) No ICC (n = 20) P Value
cally, management is determined by the experience of the surgeon;
(mean ± SD) (mean ± SD) while some decide to directly proceed to surgery, others routinely
attempt medical therapy before a surgical intervention. Individualized
WBC (103/IU) 14.55 ± 9.52 14.16 ± 4.70 0.461
NEU (103/IU) 10.41 ± 9.03 8.37 ± 4.06 0.919 care must be provided after multidisciplinary consultation [11]. In our
LYM (103/IU) 2.83 ± 1.67 4.25 ± 2.48 0.154 management strategy, we also evaluated the cases using a multidisci­
NLR 4.45 ± 2.96 2.98 ± 2.62 0.186 plinary approach, including consultations with an otolaryngologist first,
CRP (mg/L) 131.82 ± 26.75 55.67 ± 37.70 < 0.001a
followed by a pediatrician, radiologist, microbiologist, neurologist, and
ALB (mg/L) 4.07 ± 0.39 4.19 ± 0.39 0.574
CRP/ALB 32.85 ± 8.33 13.44 ± 9.11 < 0.001a neurosurgeon. Within the framework of this approach, if an emergent
a
neurosurgical intervention was required for a patient, that intervention
Statistically significant; p < 0.05, SD: Standard deviation, ICC: Intracranial
was planned first; then, once the patient was neurologically stabilized,
complication, WBC: White blood cell count, NEU: Neutrophil count, LYM:
an otological intervention was also undertaken if necessary.
Lymphocyte count, NLR: Neutrophil to lymphocyte ratio, CRP: C-reactive pro­
In a systematic review by Anne et al. it is stated that surgical pro­
tein, ALB: Albumin.
cedures for AM and related complications include myringotomy, VT
insertion, SPA incision and drainage, and mastoidectomy. These surgical
4. Discussion
interventions can be performed alone or in combination [6]. Some au­
thors state that a mastoidectomy should be performed in all patients,
Although the complication rates of AOM declined in recent years due
while others discourage this intervention due to the associated risks [9,
to the widespread use of antibiotics, AM remains the most common
13, 14, 15]. In our practice, we experience that myringotomy and/or VT
complication that can lead to further life-threatening conditions when
insertion is sufficient for most patients with AM. We consider that the
left untreated. There is no consensus in the literature regarding the
duration of any intervention should be kept as short as possible to
management of AM and the detection of related ICCs. This study aimed
minimize the possibility of surgical complications since this patient
to evaluate the clinical characteristics and management of AM in a pe­
group is usually at a very young age. We performed a mastoidectomy
diatric population and to identify possible indicators for ICCs associated
only in patients with a severe clinical presentation and multiple com­
with AM.
plications together with ICCs, or in cases that progressed despite a
Complications related to AM can be divided into two categories as
perforated eardrum. If the patient had SPA, we routinely performed an
intratemporal (SPA, hearing loss, FP, and labyrinthitis) and intracranial
incision and drainage. However, even simple VT insertion almost always
(meningitis, SST, and intracranial abscess) [6,9]. Since the introduction
requires sedation, and a mastoidectomy is even more invasive and
of new antibiotics, the incidence of AM has declined, but the reported
riskier due to the requirement of general anesthesia [6]. The greatest
incidence of AM-related ICCs remains surprisingly high, ranging be­
problem encountered in patients treated with more conservative
tween 5% and 29% [3]. In our study of 28 cases, isolated AM was re­
methods is recurrence. In a study by Mierzwinskia et al. recurrent AM
ported in only five patients (17.9%). Complications associated with AM
was reported in 8% of the patients [9]. In our case series, no recurrent
included SPA in eight patients (28.6%), FP in seven (25%), meningitis in
AM attack was detected in any patient.
five (17.9%), meningitis with SST in two (7.1%), and meningitis with a
cerebellar abscess in one patient (3.6%). In their study, Mattos et al.
5. Conclusion
reviewed 109 complications over 15 years and reported the rate of SPA
as 38%, FP as 16.7%, and SST as 8.3% [8].
Complications should be suspected when alerting symptoms and
The detection of ICCs accompanying AM is of great importance since
signs appear in the course of AOM. AM seems to be the most common
they remain troublesome and life-threatening conditions with a mor­
complication of AOM in childhood and can lead to further life-
tality rate of 5–10% [10,11]. According to the literature, the presence of
threatening conditions. A multidisciplinary approach is required in the

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E. Duygu and S. Şevik Eliçora International Journal of Pediatric Otorhinolaryngology 138 (2020) 110372

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