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Acute mastoiditis in pediatric age
InternationalJournal of PediatricOtorhinolaryngology ELSEVIER
31 (1995) 147-151
Acute mastoiditis in pediatric age G. Magliulo*,
G.M. Vingolo, R. Petti, R. Ronzoni, P. Cristofari Via Ormisda. IO, 00165 Roma, Italy
Received13September1993;revisionreceived8 July 1994;acceptedIO July 1994
AbStrtlCt
The object of the present paper is to review 39 casesof acute mastoiditis treated surgically at the 2nd and 4th ENT Clinics of the University of Rome ‘La Sapienza’. The aetiological factors were investigated observing an association of the acute mastoid abscess with cholesteatoma. Moreover 5 patients developed mastoiditis after previous mastoid surgery. The rationale of surgical management is discussed. Keywork Acute mastoiditis; Cholesteatoma; Acute suppurative otitis media
1. Introductioll The widespread use of antibiotics has dramatically reduced the incidence of acute mastoiditis with subperiosteal abscess. However, this complication of acute otitis media continues to occur sporadically showing clinical associations previously not described. This aspect has received little attention in the recent literature [1,5,7,10]. This report reviews the authors’ experience in this particular field. The aetiological factors of acute subperiosteal mastoid abscess are investigated emphasizing our rationale of surgical management. 2. Mater&
and methods
The charts of all patients who had undergone
surgical management of a
subperiostealmastoid abscess at the 2nd and 4th ENT Clinic of University ‘La. * Correspondingauthor. 01655876/95/SO9.50 0 1995ElsevierScienceIreland Ltd. All rights reserved SSDI 0165-5876(94)01079-D
148
G. Uagliulo et al. /Int. J. Pediatr. Otorhinolaryngol. 31 (1995) 147-151
Table 1 Age and sex distribution
Age(yea&
Female
l-2 3-4 5-6 7-8 9-10 II-12 13-14 15-16
Male
n
Total (%)
-
1
2 4 4 5 2 2
I 4 2 7 3 1 1
1 3 8 6 12 5 3 I
2.6 7.1 20.5 15.4 30.8 12.8 1.7 2.6
Sapien’ in Rome from 1 November 1975to 1 December 1990.There were 39 patients. Of the study group 20 were males and 19 were females(Table 1). They ranged in age from 4 to 15 years with a mean age of 9.8 years. Abscess formation was unilateral in all cases. After surgery, all patients were recalled to follow the evolution. However, only 30 patients had regular check-ups for at least a 2 year period. The remaining were lost to the follow-up. Ten patients had a follow-up of 5 years or more. The mean follow-up period was 3.6 years. Routine audiometric tests were performed using a clinical audiometer calibrated according to IS0 standards. The audiologic findings were tabulated in the preoperative and postoperative periods to determine the air-bone gap. The comparison was analyzed calculating the mean thresholds at 0.5, 1,2 and 4 kHz. Those data were available only for 25 patients. 3. Results
The majority of the patients, 23 out of 39, suffered from acute suppurative otitis media. The major aetiological factor of the other cases was represented by a cholesteatoma.Thirty-three patients had episodesof otitis media with intermittent periods of secretory otitis media 1 year before operation. Only 6 patients had no signs of an ear infection 1 year before admission. Five patients had been treated in the sameear previously with mastoid surgery (4 of the cholesteatomagroup and 1 of the acute suppurative otitis media group). Five other caseshad been operated on, inserting ventilation tubes before the development of the acute mastoid abscess.The size of cholesteatoma was categorized according to the classification proposed by Austin [l]. The cholesteatoma involved the attic in 2 casesand the attic and the tympanum in 6 patients. Five casespresenteda cholesteatomaconfined to the attic and antrum while in the remaining casesthe diseasefilled up the whole mastoid air cell system. It is interesting to note that in 2 patients a Iistula of the lateral semicircular canal was detected.
G. Magliulo et al. /Int. J. Pediatr. Otorhinolaryngol. 31 (1995) 147-151
149
Table 2 Surgical techniques
No. of patients
Cortical mastoidectomy or extended cortical mastoidectomy
Intact canal wall tympanoplasty
Canal down procedure
23
5
II
Surgical treatment was performed through the cortical or extended cortical mastoidectomy in 23 patients, through the intact canal wall tympanoplasty in 5 patients and through the canal down procedures in the remaining 11 patients (Table 2). The cortical mastoidectomy was used for the management of the acute sup purative otitis group, while the other approaches were performed in the cholesteatoma group. The intact canal wall approaches were always staged in the two procedures.In the first operation the surgical removal of the cholesteatomaand tympanoplasty were planned, while the second operation was devoted to checking for recurrent cholesteatoma and to the reconstruction of the conductive sound system. The data of bacteria isolated in culture from these acute mastoids were available only in 21 patients. Culture results were positive in 17 patients (Table 3). Mixed infections were identified in 47% of our patients, while in 12% (2 patients) anaerobic bacteria were isolated. Staphylococcus aureus and Staphylococcus coagulase negative were the most commonly identified organisms. Antibiotic therapy varied over the years of this review. Since 1988cephalosporine (2nd or 3rd generation) was routinely used. The antibiotics were administered according to the results of the culture. No patients suffered from immune deficiencies. A 2 year follow-up showed successfulresults (dry ear and intact mobile tympanic membrane) in 66.6% of the cases.Recurrent infection occurred in 3 patients. Three Table 3 Bacteria isolated in order of frequency Aerobic
Anaerobic
Staphyiococclcsaureus Staphylococcuscoagulase negative Coryttebacterium Citrobacter Staphylococcuscoagube positive pY0w-m Pseu&monas
Fusobacterium Bacteroidesfragiis
150
G. Magh’ulo et al. /Int. J. Pediatr. Otorhinolaryngol.
31 (1995) 147-151
Table 4 Pre- and postoperative hearing results Air-bone gap
Cortical or extended cortical mastoidectomy
Open technique
Pre-operative O-20 21-30 31-40 41-50
(14) I 4 7 2
(8) -
Post operative O-20 21-30 31-40 41-50
(14) 10 2 2 -
(8)
2 4 2
15
1 1 1
Closed technique
(3)
-
2 1 (3) I 1 1
patients showed recurrent cholesteatoma (1 was operated on with the open technique; 2 with the closed technique), while the remaining patients had dry perforation. Sixty-four percent of the patients had postoperative air-bone gap within 20 dB (Table 4). It is interesting to note that no postoperative facial palsy occurred in the entire group analyzed. Failures required revision surgery with successfuloutcomes in all but 2 patients (1 recurrent cholesteatoma, 1 dry reperforation). 4. Discussion Acute mastoiditis is a relatively rare condition. Unlike the many reports of otitis media, there are few papers in the recent literature on acute mastoiditis. The introduction of antibiotics has remarkably influenced the incidence of this pathology, which in the pre-antibiotic era was a common and often fatal disease. With the routine use of antibiotics for otitis media, the incidence of subperiostial mastoid abscessdecreasedmarkedly. However, it should be rememberedthat only the western world presents this tendency. In the developing countries the acute mastoiditis is still a usual and frequent complication of otitis media [6]. In our series,41% of the casesshowed an association between acute mastoid abscessand cholesteatoma. This data confirmed previous findings [4,6,9,10]. Kacker and Sinha [5] first described this clinical stigmata. In another report [9] an underlying cholesteatoma was found in 50% of the cases suffering from coalescentmastoiditis. Five of our patients had a history of previous mastoid surgery. Among these caseswe observed 4 recurrent cholesteatomas.This condition was noted by Sade et al. [lo]. They pointed out the development of a mastoiditis following an intact canal wall tympanoplasty. This association was also
G. Magliulo et al. / Int. J. Pediatr. Otorhinolaryngol. 31 (1995) 147-151
151
observed in this report, confirming that the well pneumatized mastoid is one of the major aetiological factors in the formation of acute mastoid abscess. Findings at surgery showed that almost all our patients had granulation tissue and/or cholesteatoma in the antrum and mastoid air cell system. These irreversible pathological conditions obliged us not to postpone surgery. Controversial opinions concerning staging of surgery for acute mastoid abscesswhen a cholesteatomais present are reported in the literature [2,3,5,8]. Primrose and Cinnamond propose to initially perform cortical mastoidectomy and 4-6 weeks later to plan an open cavity procedure [9]. This policy is favoured in the view of minimizing possible surgical complications (facial paralysis, sensorineural or profound hearing loss). The outcomes of the current study demonstrated that the complications related to surgery are rare and their incidence acceptable. Thus our rationale of management is to prefer one-stage procedures combining the drainage of the abscessand the removal of cholesteatoma. In our experience no facial paralysis or deaf ear were observed. Both intact canal wall and open cavity procedures were employed. However, the high incidence of recurrence of cholesteatoma supports the view of those who favour an elective open cavity procedure in these patients. Finally the hearing results merit some discussion. Comparison between the different approaches gives better outcomes in the cortical mastoidectomy group. The main reason for this was evidently the fact that the ossicular chain was intact in the majority of the cases. No significant statistical differences were noted between the closed and open approaches. References [l] Austin, D.F. (1989) Staging in cholesteatoma surgery. J. Laryngol. Otol. 103, 143-148. [2] Bordley, J.E., Brookhouser, P.E. and Tucker, G.F. (1986) Ear, Nose and Throat Disorders in Children. Raven Press, New York. [3] Jansen, C.W. (1985) Intact canal wall for cholesteatoma. Am. J. Otol. 6, 3-4. [4] Kacker, S.K. and Sinha, A. (1986) The role of cholesteatoma is the etiology of acute mastoiditis. J. Otolaryngol. Sot. Aust. 2, 45-48. [5] Lau, T. and Tos, M. (1986) Long term results of surgery for chronic granulating otitis. Am. J. Otolaryngol. 7, 341-345. [6] Odetoyinbo, 0. (1985)The changing pattern of mastoid abscess.J. Laryngol. Otol. 99, 1081-1084. [7] Palva, T. and Pulkkinnen, K. (1959) Mastoiditis. J. Laryngol. Otol. 73, 573-588. [8] Palva, T. and Holopainen, E. (1978)Management of noncholesteatomatoussuppurative middle ear diseasein children. Adv. Otorhinolaryngol. 23, 45-57. [9] Primrose, W.J. and Cinnamond, M.J. (1987) Acute mastoid abscessand cholesteatoma. Int. J. Pediatr. Otorhinolaryngol. 12, 229-235. [IO] Sade, J., Halevy, A. and Berco, E. (1980) Acute mastoiditis after a combined approach tympanoplasty operation. Arch. Otolaryngol. 106, 727-728.
31 (1995) 147-151
Acute mastoiditis in pediatric age G. Magliulo*,
G.M. Vingolo, R. Petti, R. Ronzoni, P. Cristofari Via Ormisda. IO, 00165 Roma, Italy
Received13September1993;revisionreceived8 July 1994;acceptedIO July 1994
AbStrtlCt
The object of the present paper is to review 39 casesof acute mastoiditis treated surgically at the 2nd and 4th ENT Clinics of the University of Rome ‘La Sapienza’. The aetiological factors were investigated observing an association of the acute mastoid abscess with cholesteatoma. Moreover 5 patients developed mastoiditis after previous mastoid surgery. The rationale of surgical management is discussed. Keywork Acute mastoiditis; Cholesteatoma; Acute suppurative otitis media
1. Introductioll The widespread use of antibiotics has dramatically reduced the incidence of acute mastoiditis with subperiosteal abscess. However, this complication of acute otitis media continues to occur sporadically showing clinical associations previously not described. This aspect has received little attention in the recent literature [1,5,7,10]. This report reviews the authors’ experience in this particular field. The aetiological factors of acute subperiosteal mastoid abscess are investigated emphasizing our rationale of surgical management. 2. Mater&
and methods
The charts of all patients who had undergone
surgical management of a
subperiostealmastoid abscess at the 2nd and 4th ENT Clinic of University ‘La. * Correspondingauthor. 01655876/95/SO9.50 0 1995ElsevierScienceIreland Ltd. All rights reserved SSDI 0165-5876(94)01079-D
148
G. Uagliulo et al. /Int. J. Pediatr. Otorhinolaryngol. 31 (1995) 147-151
Table 1 Age and sex distribution
Age(yea&
Female
l-2 3-4 5-6 7-8 9-10 II-12 13-14 15-16
Male
n
Total (%)
-
1
2 4 4 5 2 2
I 4 2 7 3 1 1
1 3 8 6 12 5 3 I
2.6 7.1 20.5 15.4 30.8 12.8 1.7 2.6
Sapien’ in Rome from 1 November 1975to 1 December 1990.There were 39 patients. Of the study group 20 were males and 19 were females(Table 1). They ranged in age from 4 to 15 years with a mean age of 9.8 years. Abscess formation was unilateral in all cases. After surgery, all patients were recalled to follow the evolution. However, only 30 patients had regular check-ups for at least a 2 year period. The remaining were lost to the follow-up. Ten patients had a follow-up of 5 years or more. The mean follow-up period was 3.6 years. Routine audiometric tests were performed using a clinical audiometer calibrated according to IS0 standards. The audiologic findings were tabulated in the preoperative and postoperative periods to determine the air-bone gap. The comparison was analyzed calculating the mean thresholds at 0.5, 1,2 and 4 kHz. Those data were available only for 25 patients. 3. Results
The majority of the patients, 23 out of 39, suffered from acute suppurative otitis media. The major aetiological factor of the other cases was represented by a cholesteatoma.Thirty-three patients had episodesof otitis media with intermittent periods of secretory otitis media 1 year before operation. Only 6 patients had no signs of an ear infection 1 year before admission. Five patients had been treated in the sameear previously with mastoid surgery (4 of the cholesteatomagroup and 1 of the acute suppurative otitis media group). Five other caseshad been operated on, inserting ventilation tubes before the development of the acute mastoid abscess.The size of cholesteatoma was categorized according to the classification proposed by Austin [l]. The cholesteatoma involved the attic in 2 casesand the attic and the tympanum in 6 patients. Five casespresenteda cholesteatomaconfined to the attic and antrum while in the remaining casesthe diseasefilled up the whole mastoid air cell system. It is interesting to note that in 2 patients a Iistula of the lateral semicircular canal was detected.
G. Magliulo et al. /Int. J. Pediatr. Otorhinolaryngol. 31 (1995) 147-151
149
Table 2 Surgical techniques
No. of patients
Cortical mastoidectomy or extended cortical mastoidectomy
Intact canal wall tympanoplasty
Canal down procedure
23
5
II
Surgical treatment was performed through the cortical or extended cortical mastoidectomy in 23 patients, through the intact canal wall tympanoplasty in 5 patients and through the canal down procedures in the remaining 11 patients (Table 2). The cortical mastoidectomy was used for the management of the acute sup purative otitis group, while the other approaches were performed in the cholesteatoma group. The intact canal wall approaches were always staged in the two procedures.In the first operation the surgical removal of the cholesteatomaand tympanoplasty were planned, while the second operation was devoted to checking for recurrent cholesteatoma and to the reconstruction of the conductive sound system. The data of bacteria isolated in culture from these acute mastoids were available only in 21 patients. Culture results were positive in 17 patients (Table 3). Mixed infections were identified in 47% of our patients, while in 12% (2 patients) anaerobic bacteria were isolated. Staphylococcus aureus and Staphylococcus coagulase negative were the most commonly identified organisms. Antibiotic therapy varied over the years of this review. Since 1988cephalosporine (2nd or 3rd generation) was routinely used. The antibiotics were administered according to the results of the culture. No patients suffered from immune deficiencies. A 2 year follow-up showed successfulresults (dry ear and intact mobile tympanic membrane) in 66.6% of the cases.Recurrent infection occurred in 3 patients. Three Table 3 Bacteria isolated in order of frequency Aerobic
Anaerobic
Staphyiococclcsaureus Staphylococcuscoagulase negative Coryttebacterium Citrobacter Staphylococcuscoagube positive pY0w-m Pseu&monas
Fusobacterium Bacteroidesfragiis
150
G. Magh’ulo et al. /Int. J. Pediatr. Otorhinolaryngol.
31 (1995) 147-151
Table 4 Pre- and postoperative hearing results Air-bone gap
Cortical or extended cortical mastoidectomy
Open technique
Pre-operative O-20 21-30 31-40 41-50
(14) I 4 7 2
(8) -
Post operative O-20 21-30 31-40 41-50
(14) 10 2 2 -
(8)
2 4 2
15
1 1 1
Closed technique
(3)
-
2 1 (3) I 1 1
patients showed recurrent cholesteatoma (1 was operated on with the open technique; 2 with the closed technique), while the remaining patients had dry perforation. Sixty-four percent of the patients had postoperative air-bone gap within 20 dB (Table 4). It is interesting to note that no postoperative facial palsy occurred in the entire group analyzed. Failures required revision surgery with successfuloutcomes in all but 2 patients (1 recurrent cholesteatoma, 1 dry reperforation). 4. Discussion Acute mastoiditis is a relatively rare condition. Unlike the many reports of otitis media, there are few papers in the recent literature on acute mastoiditis. The introduction of antibiotics has remarkably influenced the incidence of this pathology, which in the pre-antibiotic era was a common and often fatal disease. With the routine use of antibiotics for otitis media, the incidence of subperiostial mastoid abscessdecreasedmarkedly. However, it should be rememberedthat only the western world presents this tendency. In the developing countries the acute mastoiditis is still a usual and frequent complication of otitis media [6]. In our series,41% of the casesshowed an association between acute mastoid abscessand cholesteatoma. This data confirmed previous findings [4,6,9,10]. Kacker and Sinha [5] first described this clinical stigmata. In another report [9] an underlying cholesteatoma was found in 50% of the cases suffering from coalescentmastoiditis. Five of our patients had a history of previous mastoid surgery. Among these caseswe observed 4 recurrent cholesteatomas.This condition was noted by Sade et al. [lo]. They pointed out the development of a mastoiditis following an intact canal wall tympanoplasty. This association was also
G. Magliulo et al. / Int. J. Pediatr. Otorhinolaryngol. 31 (1995) 147-151
151
observed in this report, confirming that the well pneumatized mastoid is one of the major aetiological factors in the formation of acute mastoid abscess. Findings at surgery showed that almost all our patients had granulation tissue and/or cholesteatoma in the antrum and mastoid air cell system. These irreversible pathological conditions obliged us not to postpone surgery. Controversial opinions concerning staging of surgery for acute mastoid abscesswhen a cholesteatomais present are reported in the literature [2,3,5,8]. Primrose and Cinnamond propose to initially perform cortical mastoidectomy and 4-6 weeks later to plan an open cavity procedure [9]. This policy is favoured in the view of minimizing possible surgical complications (facial paralysis, sensorineural or profound hearing loss). The outcomes of the current study demonstrated that the complications related to surgery are rare and their incidence acceptable. Thus our rationale of management is to prefer one-stage procedures combining the drainage of the abscessand the removal of cholesteatoma. In our experience no facial paralysis or deaf ear were observed. Both intact canal wall and open cavity procedures were employed. However, the high incidence of recurrence of cholesteatoma supports the view of those who favour an elective open cavity procedure in these patients. Finally the hearing results merit some discussion. Comparison between the different approaches gives better outcomes in the cortical mastoidectomy group. The main reason for this was evidently the fact that the ossicular chain was intact in the majority of the cases. No significant statistical differences were noted between the closed and open approaches. References [l] Austin, D.F. (1989) Staging in cholesteatoma surgery. J. Laryngol. Otol. 103, 143-148. [2] Bordley, J.E., Brookhouser, P.E. and Tucker, G.F. (1986) Ear, Nose and Throat Disorders in Children. Raven Press, New York. [3] Jansen, C.W. (1985) Intact canal wall for cholesteatoma. Am. J. Otol. 6, 3-4. [4] Kacker, S.K. and Sinha, A. (1986) The role of cholesteatoma is the etiology of acute mastoiditis. J. Otolaryngol. Sot. Aust. 2, 45-48. [5] Lau, T. and Tos, M. (1986) Long term results of surgery for chronic granulating otitis. Am. J. Otolaryngol. 7, 341-345. [6] Odetoyinbo, 0. (1985)The changing pattern of mastoid abscess.J. Laryngol. Otol. 99, 1081-1084. [7] Palva, T. and Pulkkinnen, K. (1959) Mastoiditis. J. Laryngol. Otol. 73, 573-588. [8] Palva, T. and Holopainen, E. (1978)Management of noncholesteatomatoussuppurative middle ear diseasein children. Adv. Otorhinolaryngol. 23, 45-57. [9] Primrose, W.J. and Cinnamond, M.J. (1987) Acute mastoid abscessand cholesteatoma. Int. J. Pediatr. Otorhinolaryngol. 12, 229-235. [IO] Sade, J., Halevy, A. and Berco, E. (1980) Acute mastoiditis after a combined approach tympanoplasty operation. Arch. Otolaryngol. 106, 727-728.