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Intratemporal complications of acute otitis media in infants and children
Intratemporal complications of acute otitis media in infants and children NIRA A. GOLDSTEIN, MD, MARGARETHA L. CASSELBRANT, MD, PhD, CHARLES D. BLUESTONE, MD, and MARCIA KURS-LASKY, MS, Pittsburgh, Pennsylvania
We reviewed our experience with 100 children admitted to Children’s Hospital of Pittsburgh between 1980 and 1995 with an intratemporal complication of acute otitis media. Seventy-two patients were treated for acute mastoiditis. Of these 72 children, 54 (75.0%) were treated conservatively with broad-spectrum intravenous antibiotics and myringotomy. Eighteen (25.0%) required mastoidectomy for treatment of a subperiosteal or Bezold’s abscess or cholesteatoma, or because of poor response to conservative therapy. Twenty-two children presented with facial paralysis, complete in 5 (22.7%) and incomplete in 17 (77.3%). Eighteen (81.8%) were treated conservatively, but four required mastoid surgery. Nineteen patients had adequate follow-up; of these, 15 recovered normal facial function but 4 were left with partial paralysis. Three patients presented with serous labyrinthitis and recovered completely with conservative therapy. Of the two patients who presented with suppurative labyrinthitis, one was treated conservatively, but the other required tympanomastoidectomy with cochleotomy; both patients had permanent, profound sensorineural hearing loss in the affected ear. Four patients presented with acute petrositis, and in all four it resolved with mastoidectomy. In the antibiotic era, intratemporal complications of acute otitis media still occur in otherwise healthy children, often after inadequate treatment of acute otitis media. (Otolaryngol Head Neck Surg 1998; 119:444-54.)
From the Department of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh (Drs. Goldstein, Casselbrant, Bluestone); the Department of Otolaryngology, University of Pittsburgh School of Medicine (Drs. Goldstein, Casselbrant, Bluestone); and the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (Ms. Kurs-Lasky). Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Washington, D.C., Sept. 29–Oct. 2, 1996. Reprint requests: Nira A. Goldstein, MD, Department of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh, 3705 Fifth Ave., Pittsburgh, PA 15213-2583. Copyright © 1998 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/98/$5.00 + 0 23/1/87028 444
With the introduction of modern antibiotic therapy in the 1940s, the incidence of intratemporal (i.e., extracranial) complications of acute otitis media (AOM) decreased dramatically. Yet complications still occur, some life-threatening. Intracranial complications of AOM are even less frequent but are also encountered in clinical practice. Because of the rarity of these complications, few large series have been reported in the literature, and individual clinicians do not have extensive experience treating these patients. Our objective was to review our experience with diagnosis and treatment in children with acute mastoiditis, facial paralysis, serous or suppurative labyrinthitis, and acute petrositis at Children’s Hospital of Pittsburgh over the past 15 years. By reviewing the clinical presentation, treatment course, complications, and treatment outcomes of our patients, we were able to make recommendations regarding management of these complications in children. METHODS AND MATERIAL We conducted a retrospective chart review to identify all children admitted to Children’s Hospital between 1980 and 1995 with a complication of AOM. Although intracranial complications were not the focus of this study, we wanted to compare the frequencies of intracranial and intratemporal complications. The following diagnoses were included as intratemporal: acute mastoiditis, facial paralysis resulting from AOM, serous labyrinthitis, acute suppurative labyrinthitis, and acute petrositis. Patients were identified by their hospital-discharge ICD codes, and the charts were reviewed to ensure diagnostic accuracy. Patients with intracranial complications of AOM, acute mastoiditis, or both were excluded from analysis but described separately. Patients with both acute petrositis and intracranial complications were included because most patients with acute petrositis had simultaneous intracranial complications. A standardized data form was used to record each patient’s medical history, antecedent otologic history, presenting symptoms, prior treatment, physical-examination and laboratory results, radiologic findings, audiologic results, surgical therapy, medical therapy, duration of hospitalization, treatment outcomes, and culture results. We conducted statistical analysis of the patients with acute mastoiditis to determine which clinical features were associated with the need for mastoidectomy and with hospital stay of 7 days or longer. Proportions were compared with the use of the χ2 statistic, or Fisher’s exact test in cases of small sample size.
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Table 1. Demographics and type of intratemporal complications in 100 infants and children at Children’s Hospital of Pittsburgh, 1980–1995 Race
Diagnosis
No. of patients
Mean age (yr) (range)
Sex (M/F)
White
Black
Asian
Acute mastoiditis
72
5.5 (0.08-17.4)
51/21
66
5
1
Facial paralysis
22
5.1 (0.42-16.4)
12/10
18
4
0
Labyrinthitis Serous Suppurative Acute petrositis
6.9 (1.7-10.5)
3/ 2
4
0
1
3 2 4
7.4 (5.8-9.3)
3/1
4
0
0
67/33
89
9
2
Total*
100
5.3 (0.08-17.4)
Concomitant diagnoses
Subperiosteal abscess (n =10), cholesteatoma (n = 4), facial paralysis (n = 3), histiocytosis X (n = 1), Bezold’s abscess & parapharyngeal space abscess (n = 1) Acute mastoiditis (n = 2), acute mastoiditis & subperiosteal abscess (n = 1) None
Acute mastoiditis (n = 4), otic hydrocephalus (n = 3), sigmoid-sinus thrombosis (n = 2), epidural abscess (n = 1), cholesteatoma (n = 1) 25
*Total patients less than sum of rows because of patients with multiple diagnoses (see text).
Means were compared with the use of ANOVA. All reported significance levels are two-sided. RESULTS
During the 15-year study period, 113 children were admitted with a complication of AOM. Of the 113, 97 (85.8%) had an intratemporal complication alone, 2 (1.8%) had an intracranial complication alone, and 14 (12.4%) had both (11 with acute mastoiditis, 3 with acute petrositis). There were therefore a total of 111 intratemporal complications and 16 intracranial complications. Intracranial complications were otic hydrocephalus (n = 7), sigmoid sinus thrombosis (n = 5), internal jugular thrombosis (n = 1), cavernous sinus thrombosis (n = 1), epidural abscess (n = 7), temporallobe abscess (n = 1), and meningitis (n = 2); six patients had multiple diagnoses. Of the 14 patients with both intratemporal and intracranial complications, only the 3 who presented with acute petrositis are included in the review of intratemporal complications. Therefore, of the 100 infants and children included in our review, 97 had an intratemporal complication alone and 3 had both acute petrositis and an intracranial complication. Of the 100 children, 72 (72.0%) had acute mastoiditis, 22 (22.0%) had acute facial paralysis, 5 (5.0%) had labyrinthitis, and 4 (4.0%) had acute petrositis (3 with intracranial complications; Table 1). Three patients had both acute mastoiditis and facial paralysis; they are included in both analyses. For each complication, mean age ranged from 5.1 to 7.4 years, and boys were affected more frequently than girls. Right and left ears were equally affected in children with acute mastoiditis (36 right, 36 left) and facial paralysis (13 right, 9 left), whereas the left ear was more frequently affected in children with labyrinthitis (1 right, 4 left) and only the
right ear was affected in children with acute petrositis. Concomitant otologic diagnoses were present in 18 children with mastoiditis (25.0%), 3 children with facial paralysis (13.6%), and all children with acute petrositis (100.0%). The incidence of intratemporal complications was relatively stable over the years of the study, although acute petrositis was only diagnosed after 1991 (Fig. 1). Acute Mastoiditis
Seventy-two children were admitted with acute mastoiditis. The children’s ages and presenting symptoms and signs are shown in Table 2. Thirty-six children (50.0%) were 3 years of age or younger. Otalgia, postauricular pain, and fever were the most common symptoms. The mean duration of ear symptoms was 3.5 days (range 1.0 to 21.0 days). Thirty-two patients (44.4%) had received prior oral antibiotic therapy. Of the 21 patients with ear symptoms present for 5 days or longer, 16 had had prior antibiotic therapy, most commonly amoxicillin, amoxicillin/clavulanate potassium, cefixime, or erythromycin. Ipsilateral middle-ear abnormalities were found in 69 patients (95.8%), and contralateral middle-ear abnormalities were found in 35 patients (48.6%). Thirty-one patients (43.1%) had a history of frequent otitis media, but only 19 (26.4%) had a history of tympanostomy tubes. Four children had a history of cholesteatoma, although one was intratympanic only, and three had undergone prior mastoidectomy for cholesteatoma on the affected side. Four children (one each with acute lymphoblastic leukemia, acute myelogenous leukemia, neuroblastoma, and histiocytosis X) were known to be immunocompromised at the time of admission. The diagnosis of histiocytosis X (HandSchüller-Christian disease) in the affected child had
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Fig. 1. Incidence of intratemporal complications.
been made 3 years earlier when she presented with lytic skull and spinal lesions. Biopsy of her middle ear during tympanostomy-tube placement for treatment of her acute mastoiditis showed a histiocytosis X lesion. Sixteen patients (22.2%), all but two admitted in the 1980s, had mastoid radiographs. Findings were nonspecific and not associated with the need for mastoid surgery. Fifty-three patients (73.6%) had undergone CT of the temporal bones. Nonspecific findings included soft-tissue density in the middle ear in 49 patients (92.5%) and soft-tissue density in the mastoid in 51 patients (96.2%). However, CT findings from 13 patients (24.5%) demonstrated bony destruction of mastoid cells and in 8 (15.1%) demonstrated a subperiosteal abscess (Fig. 2), which were associated with the need for mastoidectomy. Audiograms were performed in 41 patients (56.9%), and results are presented in Table 3. Audiograms were normal in 21 patients (51.2%), abnormal in 20 (48.8%). The one patient with profound sensorineural hearing loss was undergoing chemotherapy for acute lymphoblastic leukemia. She also had complete facial paralysis and at mastoidectomy was found to have granulation tissue in her oval and round windows. Seventy-one patients (98.6%) were treated with broad-spectrum intravenous antibiotics for a mean duration of 7.3 days (range 2.0 to 20.0 days). Forty-nine patients (68.1%) were treated with single drug therapy, usually cefuroxime sodium or ticarcillin disodium and clavulanate potassium. The other 22 (30.6%) were treated with combination therapy.
Fifty-four patients (75.0%) responded to conservative therapy with antibiotics (intravenous in all but one patient) and either tympanocentesis or myringotomy with or without tube placement. Of these 54 patients, 3 had a subperiosteal abscess. Eighteen (25.0%) required mastoidectomy. Six patients with acute mastoiditis accompanied by a subperiosteal abscess underwent simple mastoidectomy and drainage of the abscess. Four patients with acute mastoiditis without an accompanying subperiosteal abscess required a simple mastoidectomy on a mean hospitalization day of 7.0 (range 2.0 to 11.0 days) because of poor response to conservative therapy. CT scans from three of these four patients demonstrated bony destruction of mastoid cells. One patient underwent incision and drainage of a Bezold abscess and parapharyngeal space abscess. Four patients who presented with acute mastoiditis and newly diagnosed cholesteatoma underwent mastoidectomy; two had cholesteatomas that were excised initially by way of modified radical mastoidectomy, and the other two underwent simple mastoidectomy with partial excision of the cholesteatoma on hospital day 2, and definitive management of the cholesteatoma was delayed. Three patients with acute mastoiditis and facial paralysis, including one patient with a subperiosteal abscess, underwent mastoid surgery (see “Facial paralysis”). Findings from middle-ear effusions, otorrhea, and mastoid cultures are presented in Table 4. The most common organisms were Streptococcus pneumoniae, Pseudomonas aeruginosa, and Streptococcus pyogenes.
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Table 2. Age, presenting symptoms, and signs in 72 infants and children with acute mastoiditis Characteristics
Age (yr) 0–3 4–6 7–12 13–18 Symptoms Otalgia Postauricular pain Fever Otorrhea Upper-respiratory infection Irritability Hearing loss Signs Postauricular tenderness Pinna protrusion Postauricular erythema Middle-ear effusion Tympanic membrane erythema Contralateral middle-ear abnormalities Middle-ear effusion Tympanic-membrane bulging Tympanic-membrane erythema Tympanic-membrane perforation Tympanic-membrane bulging Otorrhea Fever ≥ 38.3° C Tympanic-membrane perforation Postauricular mass Cervical adenopathy Postauricular abscess Sagging of posterior auditory canal wall
Patients (%)
36 (50.0) 12 (16.7) 17 (23.6) 7 (9.7) 62 (86.1) 58 (80.6) 51 (70.8) 29 (40.3) 17 (23.6) 16 (22.2) 6 (8.3) 58 (80.6) 51 (70.8) 51 (70.8) 48 (66.7) 42 (58.3) 35 (48.6) 20 (27.8) 8 (11.1) 6 (8.3) 1 (1.4) 34 (47.2) 24 (33.3) 24 (33.3) 13 (18.1) 13 (18.1) 12 (16.7) 9 (12.5) 2 (2.8)
Of the 21 cultures that grew S. pneumoniae, sensitivities were assessed in 13; 2 (15.4%) were resistant to penicillin. Culture results were not significantly different in patients treated with antibiotics and those who were not treated. All patients recovered completely, except for four patients with persistent hearing loss. Hospital stay averaged 7.9 days (range 2.0 to 37.0 days). We investigated clinical variables—diagnosis, age, sex, antecedent otologic history, presenting symptoms, prior antibiotic use, presenting signs, laboratory results, radiographic findings, culture results, and surgical procedures—to determine associations with the need for mastoidectomy and hospital stay of 7 days or longer. Clinical factors associated with the need for mastoidectomy included subperiosteal abscess or cholesteatoma (p < 0.001), mean older age (7.5 versus 4.7 years, p = 0.03), postauricular mass on physical examination (p < 0.001), and bony destruction on CT scan (p < 0.001). No clinical factor
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Table 3. Hearing status in 41 infants and children with acute mastoiditis Audiologic findings
Patients (%)
Normal range Abnormal Conductive loss (dB) 30–39 40–49 50–59 Mixed loss (dB) 60–79 80–99 Sensorineural (dB) 40–49 Profound
21 (51.2) 20 (48.8) 4 (9.8) 8 (19.5) 2 (4.9) 2 (4.9) 2 (4.9) 1 (2.4) 1 (2.4)
Table 4. Bacteriologic findings in effusions, otorrhea, and mastoids in 65 infants & children with acute mastoiditis Organism
Streptococcus pneumoniae Pseudomonas aeruginosa Streptococcus pyogenes Diphtheroids Anaerobes Others* No growth TOTAL†
Patients (%)
21 (32.3) 19 (29.2) 12 (18.5) 9 (13.9) 7 (10.8) 39 (60.0) 6 (9.2) 113
*Staphylococcus coagulase–negative (n = 23), α-hemolytic Streptococcus (n = 4), Haemophilus influenzae (n = 3), Micrococcus spp (n = 2), Moraxella catarrhalis (n = 1), Staphylococcus aureus (n = 1), Staphylococcus spp (n = 1), Enterobacter cloacae (n = 1), Neisseria spp (n = 1), Enterococcus spp (n = 1), Citrobacter diversus (n =1). †Total patients exceeded 65 and percentage totaled greater than 100 because some cultures were polymicrobial.
was significantly associated with a hospital stay of 7 days or longer. Facial Paralysis
Twenty-two patients presented with facial paralysis—incomplete in 17 (77.3%) and complete (House grade VI) in 5 (22.7%). Two patients had simultaneous acute mastoiditis, and one had acute mastoiditis and a subperiosteal abscess. The children’s ages, presenting symptoms, and signs are shown in Table 5. Eleven children (50.0%) were 3 years of age or younger. Facial weakness, otalgia, otorrhea, concomitant upper-respiratory symptoms, and fever were the most common symptoms. The mean duration of ear symptoms was 6.3 days (range 0 to 30.0 days), and the mean duration of facial weakness was 3.7 days (range 0.5 to 19 days).
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Table 5. Age, presenting, symptoms, and signs in 22 infants and children with acute facial paralysis Characteristics
Age (yr) 0–3 4–6 7–12 13–18 Symptoms Facial weakness Otalgia Otorrhea Upper-respiratory infection Fever Hearing loss Irritability Signs Facial paralysis Middle-ear effusion Contralateral middle-ear abnormalities Middle-ear effusion Tympanic-membrane erythema Tympanic-membrane perforation Otorrhea Tympanic-membrane erythema Otorrhea Tympanic-membrane perforation Tympanic-membrane bulging Fever ≥ 38.3° C Postauricular erythema, tenderness, mass
Patients (%)
11 (50.0) 6 (27.3) 3 (13.6) 2 (9.1) 22 (100.00) 15 (68.2) 8 (36.4) 8 (36.4) 7 (31.8) 2 (9.1) 2 (9.1) 22 (100.0) 16 (72.7) 15 (68.2) 13 (59.1) 1 (4.6) 1 (4.6) 1 (4.6) 11 (50.0) 9 (40.9) 8 (36.4) 7 (31.8) 4 (18.2) 2 (9.1)
Table 6. Evoked electromyography, surgical, therapy, and recovery of facial-nerve function in 22 infants and children with acute facial paralysis Initial House grade
Evoked electromyography (% of normal side)
Surgical procedures
Final House grade
II Patient 1 Patient 2 Patient 3 Patient 4 Total = 4 (18.2%) III Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Total = 7 (31.8%) IV Patient 1 Patient 2 Patient 3 Patient 4
10.5 — — —
M&T M M M&T
— 66.7 — — — — —
M&T T, M&T M M&T M&T M&T No surgery
0 — — —
I I I I
Unknown I Unknown I I I I
Patient 5 Total = 5 (22.7%)
—
M&T I M&T Unknown M&T I M, ICW, II tympanomastoidectomy M, SM I
Patient 1 Total = 1 (4.6%) VI Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Total = 5 (22.7%)
—
M&T
II
— 0 19.2 36.1 0
T, M&T M&T, SM M&T M&T RM, FND, L
II I I I V
V
Thirteen patients (59.1%) had received prior oral antibiotic therapy. Of the 12 patients with ear symptoms lasting 5 days or longer, 10 were already receiving antibiotic therapy, most commonly amoxicillin. Ipsilateral middle-ear abnormalities were found in 21 patients (95.5%), and contralateral middle-ear abnormalities were found in 15 patients (68.2%). Seven patients had a history of frequent otitis media. One patient had prior tympanostomy-tube placement, and one patient had undergone intact canal-wall tympanomastoidectomy for a congenital cholesteatoma 8 months before admission. One patient was immunocompromised; this child had acute lymphoblastic leukemia, facial paralysis, acute mastoiditis, and profound sensorineural hearing loss. Of the children with facial paralysis, CT was performed in 13 (59.1%). Nonspecific findings included soft-tissue density in the middle ear and mastoid in 11 patients (84.6%) and a dehiscent facial nerve in one (7.7%) (Fig. 3). Audiograms were performed in 18 patients (82.0%). Of the 18 children, 7 had normal audiograms, 5 had hearing loss between 21 and 39 dB, 2 had hearing loss between 40 and 49 dB, and one had profound sensorineural hearing loss (as mentioned previously). Nerve conduction tests were performed in
M&T, Myringotomy and tube; M, myringotomy; T, tympanocentesis; ICW, intact canal-wall; SM, simple mastoidectomy; RM, radical mastoidectomy; FND, facial-nerve decompression; L, labyrinthectomy.
seven patients (31.8%); four of these children had complete paralysis, one had House grade IV paralysis, one had House grade III paralysis, and one had House grade II paralysis. Results are presented in Table 6. All patients were treated with broad-spectrum antibiotics. Eighteen patients were treated with single-drug therapy—cefuroxime sodium, ticarcillin disodium and clavulanate potassium, or ampicillin sodium. Four patients were treated with combination therapy. Only nine patients required eye protection, consisting of artificial tears, ophthalmic ointment, or both. Eighteen patients (81.8%) were treated conservatively with intravenous antibiotics; 17 of these patients also
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underwent myringotomy, with or without insertion of a tympanostomy tube; 4 patients (18.2%) required mastoidectomy, and 1 child required facial-nerve decompression (Table 6). The one patient with complete facialnerve paralysis, acute lymphoblastic leukemia, and profound sensorineural hearing loss underwent radical mastoidectomy, facial-nerve decompression, and labyrinthectomy. Granulation tissue was found in the mastoid, middle ear, and the oval window compressing the facial nerve, and the facial nerve was found to be dehiscent at the second genu. Two patients, one with complete paralysis and one with House grade IV paralysis, underwent cortical mastoidectomy without facial nerve decompression. One patient with a history of intact canal-wall tympanomastoidectomy for cholesteatoma who presented with a subperiosteal abscess and House grade IV paralysis underwent incision and drainage of the subperiosteal abscess, along with revision tympanomastoidectomy. Granulation tissue was found in all mastoidectomy cases without evidence of cholesteatoma. Findings from middle-ear effusions, otorrhea, and mastoid cultures are presented in Table 7. One S. pneumoniae isolate was sensitive to penicillin, and sensitivities assays were not performed on the other isolate. Culture results were not significantly different in patients treated with antibiotics compared with those not treated, except that all the negative cultures were obtained from patients who were already receiving antibiotic therapy. The mean duration of hospital stay was 7.0 days (range 1.0 to 18.0 days). Recovery of facial-nerve function is presented in Table 6. Data was unavailable for 3 patients because of lack of follow-up. Of the remaining 19 patients, fifteen recovered completely at a mean duration of 133.5 days (range 10.0 to 365.0 days). Of the fully recovered patients, three presented with a complete paralysis and twelve presented with an incomplete paralysis. Of the 4 patients who did not recover completely, two presented with a complete paralysis and two presented with an incomplete paralysis. Final facial function was Grade V in one patient and Grade II in 3 patients. Recovery of facial function was analyzed in comparison to results of nerve conduction testing and patient management. One patient with an intermediate (10.5%) response and a Grade II paralysis, one patient with an intermediate response (66.7%) and a grade III paralysis, and one patient with no response and a grade IV paralysis were managed conservatively with intravenous antibiotics and myringotomy and tube placement; all 3 patients recovered normal facial function. Two patients with intermediate responses (19.2% and 36.1%) and complete paralysis recovered normal function with conservative
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Fig. 2. A, Axial CT scan of patient with acute mastoiditis and subperiosteal abscess (short arrow). B, Long arrow demonstrates bony erosion of cortical bone.
therapy. Two patients with complete paralysis and no response to evoked electromyography on the involved side underwent mastoidectomy; one patient recovered full facial function and one had House grade V paralysis. Posttreatment audiograms were obtained in nine patients; in all cases the findings were normal, except for the patient who presented with profound sensorineural hearing loss. Labyrinthitis
Three patients were admitted with serous labyrinthitis, and two patients were admitted with suppurative
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Table 7. Bacteriologic findings in effusions,|otorrhea, and mastoids from 21 infants and children with acute facial paralysis Organism
Streptococcus pneumoniae Pseudomonas aeruginosa Anaerobes Others* No growth Total†
Patients (%)
2 (9.5) 2 (9.5) 2 (9.5) 19 (90.5) 8 (38.1) 33
*Staphylococcus coagulase–negative (n = 8), diptheroids (n = 7), Haemophilus influenzae (n = 1), α-hemolytic Streptococcus (n = 1), Enterobacter cloacae (n = 1), Klebsiella oxytoca (n = 1). †Total patients exceeded 21 and percentage totaled greater than 100 because some cultures were polymicrobial.
Fig. 3. Coronal CT scan in patient with complete facial paralysis, demonstrating soft-tissue density in middle ear and mastoid and dehiscence of second portion of facial-nerve canal (arrow).
Fig. 4. Axial MRI in patient with suppurative labyrinthitis. Arrow demonstrates enhancement of internal auditory canal, cochlea, and vestibule.
labyrinthitis. Mean patient age was 6.9 years; two patients were aged 3 years or younger. All patients had symptoms of otalgia, dizziness, nausea, and vomiting; four had fever and otorrhea. The mean duration of ear
symptoms was 4.4 days (range 1.0 to 10.0 days), and the mean duration of dizziness was 3.6 days (range 1.0 to 14.0 days). Four patients had received prior oral antibiotic therapy, including the two patients with ear symptoms lasting 5 days or longer. Otorrhea and tympanic membrane erythema were found in four patients, middle-ear effusions and fever of 38.3° C or greater were found in three, and tympanic-membrane perforations were found in two. Fistula testing was not performed in any patient. Three patients had a history of frequent otitis media, and two patients had a prior history of tympanostomy tubes. No child was immunocompromised. One patient with serous labyrinthitis and both patients with suppurative labyrinthitis had nonspecific temporal-bone CT results, demonstrating soft-tissue density in the middle ear and mastoid. One patient with suppurative labyrinthitis underwent MRI, which showed enhancement of the inner-ear structures and the internal auditory canal (Fig. 4). Of the patients with serous labyrinthitis, audiologic testing in two revealed 20- to 39-dB hearing loss. Both patients with suppurative labyrinthitis had profound sensorineural hearing loss. All patients were treated with broad-spectrum intravenous antibiotics for a mean duration of 8.4 days (range 6.0 to 10.0 days). Two patients, one with serous and one with suppurative labyrinthitis were treated with cefuroxime sodium alone. The other three patients were treated with combination therapy. Four patients responded to conservative therapy with intravenous antibiotics and myringotomy with tympanostomy-tube placement. The one patient with suppurative labyrinthitis and the MRI showing inner-ear and internal auditory-canal enhancement required an intact canal-wall tympanomastoidectomy with cochleotomy and removal of the incus and stapedectomy. Surgical
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findings included retropositioned oval and round windows, hypertrophic mucosa in the cochlea, and granulation tissue in the middle ear and mastoid. Because of the suspicion that a congenital perilymphatic fistula served as a preformed pathway resulting in suppurative labyrinthitis’ complicating an episode of AOM, the patient underwent contralateral exploratory tympanotomy with patching of his oval and round windows with temporalis muscle 3 months later. A specimen from his oval window, taken during the second procedure, was positive for β2-transferrin on assay. Bacteriologic study of middle-ear effusions and otorrhea revealed P. aeruginosa (n = 2), Staphylococcus coagulase-negative (n = 2), S. pyogenes (n = 2), S. pneumoniae (n = 1) and Staphylococcus coagulase–positive (n = 1). All patients had at least one positive culture. The S. pneumoniae isolate was sensitive to penicillin. Hospital stay averaged 8.4 days (range 7.0 to 11.0 days). Except for hearing loss, recovery was complete for all patients. The average duration of dizziness was 4.2 days (range 2.0 to 6.0 days). The two patients with serous labyrinthitis who underwent audiologic testing had normal hearing in the affected ear after treatment. The two patients with suppurative labyrinthitis had permanent profound sensorineural hearing loss in the affected ears. Acute Petrositis
Four patients presented with acute petrositis, although none had the classic triad of Gradenigo’s syndrome (otorrhea, deep facial pain, abducens palsy). Three patients had additional intracranial complications of mastoiditis, including one patient with otic hydrocephalus, one patient with otic hydrocephalus and sigmoid sinus thrombosis, and one patient with an epidural abscess, otic hydrocephalus, and sigmoid-sinus thrombosis. Mean patient age was 7.4 years (range 5.8 to 9.3 years). All four patients had otalgia and diplopia; three had retro-ocular pain and fever and one had jaw pain, but none had otorrhea or fever of 38.3° C or greater. The mean duration of ear symptoms was 10.2 days (range 7.0 to 16.0 days). All patients had received prior antibiotic therapy, either amoxicillin or amoxicillin and clavulanate potassium. Ipsilateral sixth-nerve weakness was found in all four patients, papilledema was found in three, esotropia and postauricular tenderness were found in two, and abnormal visual-field testing, vision loss, and a contralateral sixth-nerve weakness were found in one patient each. Three children had a history of frequent otitis media, but none had undergone prior tympanostomytube placement. No child was immunocompromised. Temporal-bone CT was performed in all four patients; in all four the scan demonstrated soft-tissue density in the
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Fig. 5. Axial CT scan in patient with acute petrositis and sigmoid-sinus thrombosis (long arrow). Short arrow demonstrates bony destruction of petrous apex.
petrous apex, and, in two, bony destruction of the petrous apex was seen (Fig. 5). MRI was performed to evaluate suspected intracranial complications in three patients. Audiologic testing was performed on admission in three patients; the findings were normal in one patient but the other two had 21- to 39-dB conductive hearing loss. Lumbar puncture was performed in each patient; findings were normal in all, except for increased intracranial pressure in three. These three patients each had otic hydrocephalus, and two had sigmoid-sinus thrombosis. The number of lumbar punctures performed for relief of increased intracranial pressure in these three patients averaged 4.7 (range 2.0 to 10.0). All patients were treated with broad-spectrum intravenous antibiotics for a mean duration of 19.6 days (range 8.0 to 35.0 days). Single-drug therapy with ticarcillin disodium and clavulanate potassium was used in two patients; combination drug therapy was used in the other two. Additional medical therapies included acetazolamide sodium (n = 3) and mannitol (n = 1). Myringotomy and tube placement and mastoid surgery were performed in all four patients. One patient underwent modified radical mastoidectomy, one underwent intact canal-wall tympanomastoidectomy with drainage of an epidural abscess, one underwent simple mastoidectomy, and one underwent intact canal-wall
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mastoidectomy, partial removal of cholesteatoma, and needle aspiration of the sigmoid-sinus thrombosis. This last patient subsequently underwent radical mastoidectomy with complete removal of cholesteatoma 4 weeks later. Bony destruction of the petrous apex was identified in all patients. Bacteriology from middle-ear effusions or mastoid cultures showed no growth in three patients and P. aeruginosa in one patient. Hospital stay averaged 9.8 days (range 8.0 to 11.0 days). All patients recovered completely, except for two patients with hearing loss. The mean duration of sixthnerve weakness was 22.5 days (range 2.0 to 52.0 days), and papilledema lasted an average of 38.3 days (range 19.0 to 66.0 days). DISCUSSION
During the 15-year period of this study, approximately 255,000 patients were evaluated at the Children’s Hospital of Pittsburgh outpatient clinics for treatment of otitis media, but only 113 were admitted for treatment of the intratemporal or intracranial complications of AOM. The 100 intratemporal complications presented in our analysis occurred in otherwise healthy children; only 4 (4.0%) were known to be immunocompromised. Thirtyseven patients (37.0 %) had symptoms lasting 5 days or longer, and of these 37 patients, 32 (86.5 %) were treated with oral antibiotics before admission. Although difficult to assess retrospectively, these patients were most likely inadequately treated because of the prolonged duration of their symptoms. Acute mastoiditis
Fifty-four children with acute mastoiditis (75%) were treated conservatively with intravenous antibiotics and myringotomy, with or without tympanostomy-tube insertion. Seventeen of the 18 children who required mastoidectomy (94%) had one or more of the following conditions: subperiosteal abscess, cholesteatoma, another suppurative complication (e.g., facial paralysis), or mastoid osteitis demonstrated on CT. Whereas some authors have also reported that most patients may be treated conservatively,1-4 others have reported that most of their patients required mastoidectomy.5-7 These conflicting reports are most likely the result of a lack of uniform definition of the disease, differences in presentation of cases, and variation in management. In our experience, patients with acute mastoiditis with only periostitis (spread of the infection to the periosteum from the mastoid cells by venous channels) usually respond to conservative therapy, whereas patients with acute mastoid osteitis (destruction of the bony trabeculae that separate the mastoid cells resulting in “coalescence”) usually require mastoidectomy.
Most CT scans demonstrated middle-ear and mastoid soft-tissue density, which is nonspecific and found in uncomplicated otitis media. However, CT scans were useful in demonstrating intracranial complications, bony destruction of mastoid trabeculae, and subperiosteal or neck abscesses. CT should be performed in all patients with suspected intracranial complications, all patients requiring mastoidectomy to demonstrate normal anatomic landmarks and the extent and nature of disease, and all patients who do not rapidly respond to conservative therapy. Audiologic testing most frequently demonstrated conductive hearing loss, which is nonspecific and also found in patients with uncomplicated otitis media. Audiograms should be obtained before mastoidectomy as a baseline. Culture results were in agreement with prior reports,1-8 but, in contrast to the findings of earlier studies, prior antibiotic therapy did not influence culture results.2,8 The mean rate of penicillin-resistant middle ear isolates of S. pneumoniae at Children’ s Hospital of Pittsburgh over the past 9 years was 22.2 % (range 6.0% to 38.0 %). The rate of penicillin-resistant isolates (15.4%) from patients with acute mastoiditis obtained in this study is consistent with the hospital rate, demonstrating that acute mastoiditis is not developing as a result of the presence of resistant organisms. Facial paralysis
Intravenous antibiotics and myringotomy with or without tube insertion is the initial conservative therapy for treatment of acute facial paralysis complicating AOM agreed on by most authors.9-13 The need for mastoidectomy is still controversial. Some authors advocate cortical mastoidectomy, with facial-nerve decompression within a few days if there is complete loss of facial function accompanied by a poor prognostic indicator (decreased tearing, decreased submandibular flow, abnormal electric testing).10,12 Still others favor a more conservative approach, recommending mastoidectomy without facial-nerve decompression in the acute setting and reserving facial-nerve decompression for patients with persistent paralysis after several months.11 Others favor mastoidectomy without decompression only for those patients with continued signs of infection with complete or progressive paralysis if there is no response to medical therapy.9,13 From our experience, almost all patients with incomplete paralysis should regain normal or near-normal facial function with conservative therapy, and mastoidectomy is not indicated. The recovery of patients with complete paralysis is extremely variable, but consideration of mastoidectomy without decompression should be given in patients whose condition does not improve with conservative therapy.
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CT was performed if the patient’s paralysis did not resolve rapidly with conservative therapy. CT scans were useful in ruling out other causes of facial-nerve paralysis such as tumor or unsuspected temporal-bone fracture; in evaluating intracranial complications, if suspected; or before mastoidectomy to map the course of the facial nerve and evaluate potential bony dehiscences before surgery. Although audiologic testing was nonspecific, it was useful in evaluating potential sensorineural hearing loss and served as a baseline in case of the need for mastoidectomy. Evoked electromyography was not predictive of ultimate facial function in the three patients with incomplete paralysis who underwent electrical testing; all patients regained normal function even if there was no response on evoked electromyography. However, although the numbers are small, electrical testing did prove useful in patients with complete paralysis in predicting ultimate facial function. The two patients with intermediate responses regained normal function with conservative therapy. One patient with no response also regained normal function after mastoidectomy without facial-nerve decompression, whereas the other patient was left with House grade V paralysis after mastoidectomy with facialnerve decompression. Therefore, as reported previously, absence of response on evoked electromyography may be an indication for mastoidectomy.9-12 Our culture results were in agreement with the findings of Elliot et al.,9 showing predominantly no growth. Prior antibiotic therapy did influence the culture results; all negative cultures involved specimens from patients who had been treated with antibiotics before admission. Labyrinthitis
Although serous labyrinthitis is reported to be one of the most common complications of otitis media, only three patients required acute hospitalization over the 15 years we reviewed. Presumably, most patients with serous labyrinthitis resulting from AOM, otitis media with effusion, or chronic suppurative otitis media respond to outpatient medical therapy or elective surgical procedures treating the underlying medical condition. All three patients in this series responded to conservative therapy. There have been few recent reviews of suppurative labyrinthitis.14,15 Only two patients were found in our series. One patient responded to conservative therapy, and the other required intact canal-wall mastoidectomy with cochleotomy. Both patients had permanent, profound sensorineural hearing loss on the affected side. The differentiation between serous and suppurative labyrinthitis can only be made clinically by the response to treatment and audiologic improvement in patients with serous labyrinthitis.
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Suppurative labyrinthitis is a potentially life-threatening complication of otitis media; infection in the inner ear can spread to the subarachnoid space, leading to meningitis. The disease must be treated aggressively, and early surgical intervention is usually warranted. As evidenced by our one patient with a congenital perilymphatic fistula, which predisposed him to suppurative labyrinthitis during an episode of AOM, in patients with both serous and suppurative labyrinthitis without other predisposing conditions such as cholesteatoma, chronic suppurative otitis media, or immunodeficiency a congenital defect should be suspected. Serial audiologic testing to document progression of sensorineural hearing loss, temporal-bone CT, and even exploratory tympanotomy may be indicated. Acute Petrositis
In 1907,16 Gradenigo described his classic triad of abducens nerve paralysis, severe pain in the distribution of the trigeminal nerve, and acute suppurative otitis media, and the symptoms were attributed to suppurative disease of the petrous apex. As demonstrated in our study and in prior reports, most patients do not present with the classic triad.17-19 Three of four patients also had simultaneous intracranial complications. Petrous apicitis was documented in all cases on CT. Early reports emphasized the need for radical surgery with access to the petrous apex.17,18 More recent reports have documented the success of more conservative therapy of high-dose broad-spectrum antibiotics with intracranial penetration and less aggressive surgery.19,20 All of our patients recovered with antibiotic therapy and more conservative mastoidectomies without drainage of the petrous apex. CONCLUSION
In summary, the intratemporal complications of AOM, although rare, still exist in the healthy pediatric population and often follow inadequately treated AOM. Practitioners must be aware of their presenting symptoms and signs and management. Although recommendations for initial management are universally accepted, there is still some controversy regarding the timing and extent of more invasive surgery. We thank Susan Strelinski for assistance with data entry and Avrum Pollack, MD, for review of radiographic studies. REFERENCES 1. Harley EH, Sdralis T, Berkowitz RG. Acute mastoiditis in children: a 12-year retrospective study. Otolaryngol Head Neck Surg 1997;116:26-30. 2. Hawkins DB, Dru D, House JW, et al. Acute mastoiditis in children: a review of 54 cases. Laryngoscope 1983;93:568-72.
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3. Ogle JW, Lauer BA. Acute mastoiditis: diagnosis and complications. Am J Dis Child 1986;140:1178-82. 4. Rosen A, Ophir D, Marshak G. Acute mastoiditis: a review of 69 cases. Ann Otol Rhinol Laryngol 1986;95:222-4. 5. Gliklich RE, Eavey RD, Iannuzzi RA, et al. A contemporary analysis of acute mastoiditis. Arch Otolaryngol Head Neck Surg 1996;122:135-9. 6. Luntz M, Keren G, Nusem S, et al. Acute mastoiditis—revisited. Ear Nose Throat J 1994;73:648-54. 7. Nadal D, Herrmann P, Baumann A, et al. Acute mastoiditis: clinical, microbiological, and therapeutic aspects. Eur J Pediatr 1990;149:560-4. 8. Prellner K, Rydell R. Acute mastoiditis: influence of antibiotic treatment on the bacterial spectrum. Acta Otolaryngol (Stockh) 1986;102:52-6. 9. Elliot CA, Zalzal GH, Gottlieb WR. Acute otitis media and facial paralysis in children. Ann Otol Rhinol Laryngol 1996;105:58-62. 10. Hof E. Facial palsy of infectious origin in children. In: Fisch U, editor. Facial nerve surgery. Birmingham, Ala.: Aesculapius, 1977:414-8. 11. Kamitsuka M, Feldman K, Richardson M. Facial paralysis associated with otitis media. Pediatr Infect Dis 1985;4:682-4.
12. Shott SR, Myer CM. Otitis media and facial paralysis. Pediatr Infect Dis 1986;5:494-5. 13. Takahashi H, Nakamura H, Yui M, et al. Analysis of fifty cases of facial palsy due to otitis media. Arch Otorhinolaryngol 1985; 241:163-8. 14. Juselius H, Kaltiokallio K. Complications of acute and chronic otitis media in the antibiotic era. Acta Otolaryngol (Stockh) 1972;74:445-50. 15. Kangsanarak J, Fooanant S, Ruckphaopunt K, et al. Extracranial and intracranial complications of suppurative otitis media. report of 102 cases. J Laryngol Otol 1993;107:999-1004. 16. Gradenigo G. Ueber circumscripte Leptomeningitis mit spinalen Symptomen. Arch Ohrenheilk 1904;51:60-2. 17. Chole RA, Donald PJ. Petrous apicitis: clinical considerations. Ann Otol Rhinol Laryngol 1983;92:544-51. 18. Hendershot EL, Wood JW, Bennhoff D. The middle cranial fossa approach to the petrous apex. Laryngoscope 1976;86:658-63. 19. Tutuncuoglu S, Uran N, Kavas I, Ozgur T. Gradenigo syndrome: a case report. Pediatr Radiol 1993;23:556. 20. Hardjasudarma M, Edwards RL, Ganley JP, et al. Magnetic resonance imaging features of Gradenigo’s syndrome. Am J Otolaryngol 1995;16:247-50.
Temporal Bone Surgical Dissection Courses
These courses, presented by Memorial Georgia Ear Institute, will be held Dec. 59, 1998. For further information, contact Shirley Johnson, RN, MSA: (912)3507365; fax (912)350-8998; e-mail: [email protected].
We reviewed our experience with 100 children admitted to Children’s Hospital of Pittsburgh between 1980 and 1995 with an intratemporal complication of acute otitis media. Seventy-two patients were treated for acute mastoiditis. Of these 72 children, 54 (75.0%) were treated conservatively with broad-spectrum intravenous antibiotics and myringotomy. Eighteen (25.0%) required mastoidectomy for treatment of a subperiosteal or Bezold’s abscess or cholesteatoma, or because of poor response to conservative therapy. Twenty-two children presented with facial paralysis, complete in 5 (22.7%) and incomplete in 17 (77.3%). Eighteen (81.8%) were treated conservatively, but four required mastoid surgery. Nineteen patients had adequate follow-up; of these, 15 recovered normal facial function but 4 were left with partial paralysis. Three patients presented with serous labyrinthitis and recovered completely with conservative therapy. Of the two patients who presented with suppurative labyrinthitis, one was treated conservatively, but the other required tympanomastoidectomy with cochleotomy; both patients had permanent, profound sensorineural hearing loss in the affected ear. Four patients presented with acute petrositis, and in all four it resolved with mastoidectomy. In the antibiotic era, intratemporal complications of acute otitis media still occur in otherwise healthy children, often after inadequate treatment of acute otitis media. (Otolaryngol Head Neck Surg 1998; 119:444-54.)
From the Department of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh (Drs. Goldstein, Casselbrant, Bluestone); the Department of Otolaryngology, University of Pittsburgh School of Medicine (Drs. Goldstein, Casselbrant, Bluestone); and the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (Ms. Kurs-Lasky). Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Washington, D.C., Sept. 29–Oct. 2, 1996. Reprint requests: Nira A. Goldstein, MD, Department of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh, 3705 Fifth Ave., Pittsburgh, PA 15213-2583. Copyright © 1998 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/98/$5.00 + 0 23/1/87028 444
With the introduction of modern antibiotic therapy in the 1940s, the incidence of intratemporal (i.e., extracranial) complications of acute otitis media (AOM) decreased dramatically. Yet complications still occur, some life-threatening. Intracranial complications of AOM are even less frequent but are also encountered in clinical practice. Because of the rarity of these complications, few large series have been reported in the literature, and individual clinicians do not have extensive experience treating these patients. Our objective was to review our experience with diagnosis and treatment in children with acute mastoiditis, facial paralysis, serous or suppurative labyrinthitis, and acute petrositis at Children’s Hospital of Pittsburgh over the past 15 years. By reviewing the clinical presentation, treatment course, complications, and treatment outcomes of our patients, we were able to make recommendations regarding management of these complications in children. METHODS AND MATERIAL We conducted a retrospective chart review to identify all children admitted to Children’s Hospital between 1980 and 1995 with a complication of AOM. Although intracranial complications were not the focus of this study, we wanted to compare the frequencies of intracranial and intratemporal complications. The following diagnoses were included as intratemporal: acute mastoiditis, facial paralysis resulting from AOM, serous labyrinthitis, acute suppurative labyrinthitis, and acute petrositis. Patients were identified by their hospital-discharge ICD codes, and the charts were reviewed to ensure diagnostic accuracy. Patients with intracranial complications of AOM, acute mastoiditis, or both were excluded from analysis but described separately. Patients with both acute petrositis and intracranial complications were included because most patients with acute petrositis had simultaneous intracranial complications. A standardized data form was used to record each patient’s medical history, antecedent otologic history, presenting symptoms, prior treatment, physical-examination and laboratory results, radiologic findings, audiologic results, surgical therapy, medical therapy, duration of hospitalization, treatment outcomes, and culture results. We conducted statistical analysis of the patients with acute mastoiditis to determine which clinical features were associated with the need for mastoidectomy and with hospital stay of 7 days or longer. Proportions were compared with the use of the χ2 statistic, or Fisher’s exact test in cases of small sample size.
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Table 1. Demographics and type of intratemporal complications in 100 infants and children at Children’s Hospital of Pittsburgh, 1980–1995 Race
Diagnosis
No. of patients
Mean age (yr) (range)
Sex (M/F)
White
Black
Asian
Acute mastoiditis
72
5.5 (0.08-17.4)
51/21
66
5
1
Facial paralysis
22
5.1 (0.42-16.4)
12/10
18
4
0
Labyrinthitis Serous Suppurative Acute petrositis
6.9 (1.7-10.5)
3/ 2
4
0
1
3 2 4
7.4 (5.8-9.3)
3/1
4
0
0
67/33
89
9
2
Total*
100
5.3 (0.08-17.4)
Concomitant diagnoses
Subperiosteal abscess (n =10), cholesteatoma (n = 4), facial paralysis (n = 3), histiocytosis X (n = 1), Bezold’s abscess & parapharyngeal space abscess (n = 1) Acute mastoiditis (n = 2), acute mastoiditis & subperiosteal abscess (n = 1) None
Acute mastoiditis (n = 4), otic hydrocephalus (n = 3), sigmoid-sinus thrombosis (n = 2), epidural abscess (n = 1), cholesteatoma (n = 1) 25
*Total patients less than sum of rows because of patients with multiple diagnoses (see text).
Means were compared with the use of ANOVA. All reported significance levels are two-sided. RESULTS
During the 15-year study period, 113 children were admitted with a complication of AOM. Of the 113, 97 (85.8%) had an intratemporal complication alone, 2 (1.8%) had an intracranial complication alone, and 14 (12.4%) had both (11 with acute mastoiditis, 3 with acute petrositis). There were therefore a total of 111 intratemporal complications and 16 intracranial complications. Intracranial complications were otic hydrocephalus (n = 7), sigmoid sinus thrombosis (n = 5), internal jugular thrombosis (n = 1), cavernous sinus thrombosis (n = 1), epidural abscess (n = 7), temporallobe abscess (n = 1), and meningitis (n = 2); six patients had multiple diagnoses. Of the 14 patients with both intratemporal and intracranial complications, only the 3 who presented with acute petrositis are included in the review of intratemporal complications. Therefore, of the 100 infants and children included in our review, 97 had an intratemporal complication alone and 3 had both acute petrositis and an intracranial complication. Of the 100 children, 72 (72.0%) had acute mastoiditis, 22 (22.0%) had acute facial paralysis, 5 (5.0%) had labyrinthitis, and 4 (4.0%) had acute petrositis (3 with intracranial complications; Table 1). Three patients had both acute mastoiditis and facial paralysis; they are included in both analyses. For each complication, mean age ranged from 5.1 to 7.4 years, and boys were affected more frequently than girls. Right and left ears were equally affected in children with acute mastoiditis (36 right, 36 left) and facial paralysis (13 right, 9 left), whereas the left ear was more frequently affected in children with labyrinthitis (1 right, 4 left) and only the
right ear was affected in children with acute petrositis. Concomitant otologic diagnoses were present in 18 children with mastoiditis (25.0%), 3 children with facial paralysis (13.6%), and all children with acute petrositis (100.0%). The incidence of intratemporal complications was relatively stable over the years of the study, although acute petrositis was only diagnosed after 1991 (Fig. 1). Acute Mastoiditis
Seventy-two children were admitted with acute mastoiditis. The children’s ages and presenting symptoms and signs are shown in Table 2. Thirty-six children (50.0%) were 3 years of age or younger. Otalgia, postauricular pain, and fever were the most common symptoms. The mean duration of ear symptoms was 3.5 days (range 1.0 to 21.0 days). Thirty-two patients (44.4%) had received prior oral antibiotic therapy. Of the 21 patients with ear symptoms present for 5 days or longer, 16 had had prior antibiotic therapy, most commonly amoxicillin, amoxicillin/clavulanate potassium, cefixime, or erythromycin. Ipsilateral middle-ear abnormalities were found in 69 patients (95.8%), and contralateral middle-ear abnormalities were found in 35 patients (48.6%). Thirty-one patients (43.1%) had a history of frequent otitis media, but only 19 (26.4%) had a history of tympanostomy tubes. Four children had a history of cholesteatoma, although one was intratympanic only, and three had undergone prior mastoidectomy for cholesteatoma on the affected side. Four children (one each with acute lymphoblastic leukemia, acute myelogenous leukemia, neuroblastoma, and histiocytosis X) were known to be immunocompromised at the time of admission. The diagnosis of histiocytosis X (HandSchüller-Christian disease) in the affected child had
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Fig. 1. Incidence of intratemporal complications.
been made 3 years earlier when she presented with lytic skull and spinal lesions. Biopsy of her middle ear during tympanostomy-tube placement for treatment of her acute mastoiditis showed a histiocytosis X lesion. Sixteen patients (22.2%), all but two admitted in the 1980s, had mastoid radiographs. Findings were nonspecific and not associated with the need for mastoid surgery. Fifty-three patients (73.6%) had undergone CT of the temporal bones. Nonspecific findings included soft-tissue density in the middle ear in 49 patients (92.5%) and soft-tissue density in the mastoid in 51 patients (96.2%). However, CT findings from 13 patients (24.5%) demonstrated bony destruction of mastoid cells and in 8 (15.1%) demonstrated a subperiosteal abscess (Fig. 2), which were associated with the need for mastoidectomy. Audiograms were performed in 41 patients (56.9%), and results are presented in Table 3. Audiograms were normal in 21 patients (51.2%), abnormal in 20 (48.8%). The one patient with profound sensorineural hearing loss was undergoing chemotherapy for acute lymphoblastic leukemia. She also had complete facial paralysis and at mastoidectomy was found to have granulation tissue in her oval and round windows. Seventy-one patients (98.6%) were treated with broad-spectrum intravenous antibiotics for a mean duration of 7.3 days (range 2.0 to 20.0 days). Forty-nine patients (68.1%) were treated with single drug therapy, usually cefuroxime sodium or ticarcillin disodium and clavulanate potassium. The other 22 (30.6%) were treated with combination therapy.
Fifty-four patients (75.0%) responded to conservative therapy with antibiotics (intravenous in all but one patient) and either tympanocentesis or myringotomy with or without tube placement. Of these 54 patients, 3 had a subperiosteal abscess. Eighteen (25.0%) required mastoidectomy. Six patients with acute mastoiditis accompanied by a subperiosteal abscess underwent simple mastoidectomy and drainage of the abscess. Four patients with acute mastoiditis without an accompanying subperiosteal abscess required a simple mastoidectomy on a mean hospitalization day of 7.0 (range 2.0 to 11.0 days) because of poor response to conservative therapy. CT scans from three of these four patients demonstrated bony destruction of mastoid cells. One patient underwent incision and drainage of a Bezold abscess and parapharyngeal space abscess. Four patients who presented with acute mastoiditis and newly diagnosed cholesteatoma underwent mastoidectomy; two had cholesteatomas that were excised initially by way of modified radical mastoidectomy, and the other two underwent simple mastoidectomy with partial excision of the cholesteatoma on hospital day 2, and definitive management of the cholesteatoma was delayed. Three patients with acute mastoiditis and facial paralysis, including one patient with a subperiosteal abscess, underwent mastoid surgery (see “Facial paralysis”). Findings from middle-ear effusions, otorrhea, and mastoid cultures are presented in Table 4. The most common organisms were Streptococcus pneumoniae, Pseudomonas aeruginosa, and Streptococcus pyogenes.
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Table 2. Age, presenting symptoms, and signs in 72 infants and children with acute mastoiditis Characteristics
Age (yr) 0–3 4–6 7–12 13–18 Symptoms Otalgia Postauricular pain Fever Otorrhea Upper-respiratory infection Irritability Hearing loss Signs Postauricular tenderness Pinna protrusion Postauricular erythema Middle-ear effusion Tympanic membrane erythema Contralateral middle-ear abnormalities Middle-ear effusion Tympanic-membrane bulging Tympanic-membrane erythema Tympanic-membrane perforation Tympanic-membrane bulging Otorrhea Fever ≥ 38.3° C Tympanic-membrane perforation Postauricular mass Cervical adenopathy Postauricular abscess Sagging of posterior auditory canal wall
Patients (%)
36 (50.0) 12 (16.7) 17 (23.6) 7 (9.7) 62 (86.1) 58 (80.6) 51 (70.8) 29 (40.3) 17 (23.6) 16 (22.2) 6 (8.3) 58 (80.6) 51 (70.8) 51 (70.8) 48 (66.7) 42 (58.3) 35 (48.6) 20 (27.8) 8 (11.1) 6 (8.3) 1 (1.4) 34 (47.2) 24 (33.3) 24 (33.3) 13 (18.1) 13 (18.1) 12 (16.7) 9 (12.5) 2 (2.8)
Of the 21 cultures that grew S. pneumoniae, sensitivities were assessed in 13; 2 (15.4%) were resistant to penicillin. Culture results were not significantly different in patients treated with antibiotics and those who were not treated. All patients recovered completely, except for four patients with persistent hearing loss. Hospital stay averaged 7.9 days (range 2.0 to 37.0 days). We investigated clinical variables—diagnosis, age, sex, antecedent otologic history, presenting symptoms, prior antibiotic use, presenting signs, laboratory results, radiographic findings, culture results, and surgical procedures—to determine associations with the need for mastoidectomy and hospital stay of 7 days or longer. Clinical factors associated with the need for mastoidectomy included subperiosteal abscess or cholesteatoma (p < 0.001), mean older age (7.5 versus 4.7 years, p = 0.03), postauricular mass on physical examination (p < 0.001), and bony destruction on CT scan (p < 0.001). No clinical factor
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Table 3. Hearing status in 41 infants and children with acute mastoiditis Audiologic findings
Patients (%)
Normal range Abnormal Conductive loss (dB) 30–39 40–49 50–59 Mixed loss (dB) 60–79 80–99 Sensorineural (dB) 40–49 Profound
21 (51.2) 20 (48.8) 4 (9.8) 8 (19.5) 2 (4.9) 2 (4.9) 2 (4.9) 1 (2.4) 1 (2.4)
Table 4. Bacteriologic findings in effusions, otorrhea, and mastoids in 65 infants & children with acute mastoiditis Organism
Streptococcus pneumoniae Pseudomonas aeruginosa Streptococcus pyogenes Diphtheroids Anaerobes Others* No growth TOTAL†
Patients (%)
21 (32.3) 19 (29.2) 12 (18.5) 9 (13.9) 7 (10.8) 39 (60.0) 6 (9.2) 113
*Staphylococcus coagulase–negative (n = 23), α-hemolytic Streptococcus (n = 4), Haemophilus influenzae (n = 3), Micrococcus spp (n = 2), Moraxella catarrhalis (n = 1), Staphylococcus aureus (n = 1), Staphylococcus spp (n = 1), Enterobacter cloacae (n = 1), Neisseria spp (n = 1), Enterococcus spp (n = 1), Citrobacter diversus (n =1). †Total patients exceeded 65 and percentage totaled greater than 100 because some cultures were polymicrobial.
was significantly associated with a hospital stay of 7 days or longer. Facial Paralysis
Twenty-two patients presented with facial paralysis—incomplete in 17 (77.3%) and complete (House grade VI) in 5 (22.7%). Two patients had simultaneous acute mastoiditis, and one had acute mastoiditis and a subperiosteal abscess. The children’s ages, presenting symptoms, and signs are shown in Table 5. Eleven children (50.0%) were 3 years of age or younger. Facial weakness, otalgia, otorrhea, concomitant upper-respiratory symptoms, and fever were the most common symptoms. The mean duration of ear symptoms was 6.3 days (range 0 to 30.0 days), and the mean duration of facial weakness was 3.7 days (range 0.5 to 19 days).
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Table 5. Age, presenting, symptoms, and signs in 22 infants and children with acute facial paralysis Characteristics
Age (yr) 0–3 4–6 7–12 13–18 Symptoms Facial weakness Otalgia Otorrhea Upper-respiratory infection Fever Hearing loss Irritability Signs Facial paralysis Middle-ear effusion Contralateral middle-ear abnormalities Middle-ear effusion Tympanic-membrane erythema Tympanic-membrane perforation Otorrhea Tympanic-membrane erythema Otorrhea Tympanic-membrane perforation Tympanic-membrane bulging Fever ≥ 38.3° C Postauricular erythema, tenderness, mass
Patients (%)
11 (50.0) 6 (27.3) 3 (13.6) 2 (9.1) 22 (100.00) 15 (68.2) 8 (36.4) 8 (36.4) 7 (31.8) 2 (9.1) 2 (9.1) 22 (100.0) 16 (72.7) 15 (68.2) 13 (59.1) 1 (4.6) 1 (4.6) 1 (4.6) 11 (50.0) 9 (40.9) 8 (36.4) 7 (31.8) 4 (18.2) 2 (9.1)
Table 6. Evoked electromyography, surgical, therapy, and recovery of facial-nerve function in 22 infants and children with acute facial paralysis Initial House grade
Evoked electromyography (% of normal side)
Surgical procedures
Final House grade
II Patient 1 Patient 2 Patient 3 Patient 4 Total = 4 (18.2%) III Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Total = 7 (31.8%) IV Patient 1 Patient 2 Patient 3 Patient 4
10.5 — — —
M&T M M M&T
— 66.7 — — — — —
M&T T, M&T M M&T M&T M&T No surgery
0 — — —
I I I I
Unknown I Unknown I I I I
Patient 5 Total = 5 (22.7%)
—
M&T I M&T Unknown M&T I M, ICW, II tympanomastoidectomy M, SM I
Patient 1 Total = 1 (4.6%) VI Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Total = 5 (22.7%)
—
M&T
II
— 0 19.2 36.1 0
T, M&T M&T, SM M&T M&T RM, FND, L
II I I I V
V
Thirteen patients (59.1%) had received prior oral antibiotic therapy. Of the 12 patients with ear symptoms lasting 5 days or longer, 10 were already receiving antibiotic therapy, most commonly amoxicillin. Ipsilateral middle-ear abnormalities were found in 21 patients (95.5%), and contralateral middle-ear abnormalities were found in 15 patients (68.2%). Seven patients had a history of frequent otitis media. One patient had prior tympanostomy-tube placement, and one patient had undergone intact canal-wall tympanomastoidectomy for a congenital cholesteatoma 8 months before admission. One patient was immunocompromised; this child had acute lymphoblastic leukemia, facial paralysis, acute mastoiditis, and profound sensorineural hearing loss. Of the children with facial paralysis, CT was performed in 13 (59.1%). Nonspecific findings included soft-tissue density in the middle ear and mastoid in 11 patients (84.6%) and a dehiscent facial nerve in one (7.7%) (Fig. 3). Audiograms were performed in 18 patients (82.0%). Of the 18 children, 7 had normal audiograms, 5 had hearing loss between 21 and 39 dB, 2 had hearing loss between 40 and 49 dB, and one had profound sensorineural hearing loss (as mentioned previously). Nerve conduction tests were performed in
M&T, Myringotomy and tube; M, myringotomy; T, tympanocentesis; ICW, intact canal-wall; SM, simple mastoidectomy; RM, radical mastoidectomy; FND, facial-nerve decompression; L, labyrinthectomy.
seven patients (31.8%); four of these children had complete paralysis, one had House grade IV paralysis, one had House grade III paralysis, and one had House grade II paralysis. Results are presented in Table 6. All patients were treated with broad-spectrum antibiotics. Eighteen patients were treated with single-drug therapy—cefuroxime sodium, ticarcillin disodium and clavulanate potassium, or ampicillin sodium. Four patients were treated with combination therapy. Only nine patients required eye protection, consisting of artificial tears, ophthalmic ointment, or both. Eighteen patients (81.8%) were treated conservatively with intravenous antibiotics; 17 of these patients also
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underwent myringotomy, with or without insertion of a tympanostomy tube; 4 patients (18.2%) required mastoidectomy, and 1 child required facial-nerve decompression (Table 6). The one patient with complete facialnerve paralysis, acute lymphoblastic leukemia, and profound sensorineural hearing loss underwent radical mastoidectomy, facial-nerve decompression, and labyrinthectomy. Granulation tissue was found in the mastoid, middle ear, and the oval window compressing the facial nerve, and the facial nerve was found to be dehiscent at the second genu. Two patients, one with complete paralysis and one with House grade IV paralysis, underwent cortical mastoidectomy without facial nerve decompression. One patient with a history of intact canal-wall tympanomastoidectomy for cholesteatoma who presented with a subperiosteal abscess and House grade IV paralysis underwent incision and drainage of the subperiosteal abscess, along with revision tympanomastoidectomy. Granulation tissue was found in all mastoidectomy cases without evidence of cholesteatoma. Findings from middle-ear effusions, otorrhea, and mastoid cultures are presented in Table 7. One S. pneumoniae isolate was sensitive to penicillin, and sensitivities assays were not performed on the other isolate. Culture results were not significantly different in patients treated with antibiotics compared with those not treated, except that all the negative cultures were obtained from patients who were already receiving antibiotic therapy. The mean duration of hospital stay was 7.0 days (range 1.0 to 18.0 days). Recovery of facial-nerve function is presented in Table 6. Data was unavailable for 3 patients because of lack of follow-up. Of the remaining 19 patients, fifteen recovered completely at a mean duration of 133.5 days (range 10.0 to 365.0 days). Of the fully recovered patients, three presented with a complete paralysis and twelve presented with an incomplete paralysis. Of the 4 patients who did not recover completely, two presented with a complete paralysis and two presented with an incomplete paralysis. Final facial function was Grade V in one patient and Grade II in 3 patients. Recovery of facial function was analyzed in comparison to results of nerve conduction testing and patient management. One patient with an intermediate (10.5%) response and a Grade II paralysis, one patient with an intermediate response (66.7%) and a grade III paralysis, and one patient with no response and a grade IV paralysis were managed conservatively with intravenous antibiotics and myringotomy and tube placement; all 3 patients recovered normal facial function. Two patients with intermediate responses (19.2% and 36.1%) and complete paralysis recovered normal function with conservative
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Fig. 2. A, Axial CT scan of patient with acute mastoiditis and subperiosteal abscess (short arrow). B, Long arrow demonstrates bony erosion of cortical bone.
therapy. Two patients with complete paralysis and no response to evoked electromyography on the involved side underwent mastoidectomy; one patient recovered full facial function and one had House grade V paralysis. Posttreatment audiograms were obtained in nine patients; in all cases the findings were normal, except for the patient who presented with profound sensorineural hearing loss. Labyrinthitis
Three patients were admitted with serous labyrinthitis, and two patients were admitted with suppurative
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Table 7. Bacteriologic findings in effusions,|otorrhea, and mastoids from 21 infants and children with acute facial paralysis Organism
Streptococcus pneumoniae Pseudomonas aeruginosa Anaerobes Others* No growth Total†
Patients (%)
2 (9.5) 2 (9.5) 2 (9.5) 19 (90.5) 8 (38.1) 33
*Staphylococcus coagulase–negative (n = 8), diptheroids (n = 7), Haemophilus influenzae (n = 1), α-hemolytic Streptococcus (n = 1), Enterobacter cloacae (n = 1), Klebsiella oxytoca (n = 1). †Total patients exceeded 21 and percentage totaled greater than 100 because some cultures were polymicrobial.
Fig. 3. Coronal CT scan in patient with complete facial paralysis, demonstrating soft-tissue density in middle ear and mastoid and dehiscence of second portion of facial-nerve canal (arrow).
Fig. 4. Axial MRI in patient with suppurative labyrinthitis. Arrow demonstrates enhancement of internal auditory canal, cochlea, and vestibule.
labyrinthitis. Mean patient age was 6.9 years; two patients were aged 3 years or younger. All patients had symptoms of otalgia, dizziness, nausea, and vomiting; four had fever and otorrhea. The mean duration of ear
symptoms was 4.4 days (range 1.0 to 10.0 days), and the mean duration of dizziness was 3.6 days (range 1.0 to 14.0 days). Four patients had received prior oral antibiotic therapy, including the two patients with ear symptoms lasting 5 days or longer. Otorrhea and tympanic membrane erythema were found in four patients, middle-ear effusions and fever of 38.3° C or greater were found in three, and tympanic-membrane perforations were found in two. Fistula testing was not performed in any patient. Three patients had a history of frequent otitis media, and two patients had a prior history of tympanostomy tubes. No child was immunocompromised. One patient with serous labyrinthitis and both patients with suppurative labyrinthitis had nonspecific temporal-bone CT results, demonstrating soft-tissue density in the middle ear and mastoid. One patient with suppurative labyrinthitis underwent MRI, which showed enhancement of the inner-ear structures and the internal auditory canal (Fig. 4). Of the patients with serous labyrinthitis, audiologic testing in two revealed 20- to 39-dB hearing loss. Both patients with suppurative labyrinthitis had profound sensorineural hearing loss. All patients were treated with broad-spectrum intravenous antibiotics for a mean duration of 8.4 days (range 6.0 to 10.0 days). Two patients, one with serous and one with suppurative labyrinthitis were treated with cefuroxime sodium alone. The other three patients were treated with combination therapy. Four patients responded to conservative therapy with intravenous antibiotics and myringotomy with tympanostomy-tube placement. The one patient with suppurative labyrinthitis and the MRI showing inner-ear and internal auditory-canal enhancement required an intact canal-wall tympanomastoidectomy with cochleotomy and removal of the incus and stapedectomy. Surgical
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findings included retropositioned oval and round windows, hypertrophic mucosa in the cochlea, and granulation tissue in the middle ear and mastoid. Because of the suspicion that a congenital perilymphatic fistula served as a preformed pathway resulting in suppurative labyrinthitis’ complicating an episode of AOM, the patient underwent contralateral exploratory tympanotomy with patching of his oval and round windows with temporalis muscle 3 months later. A specimen from his oval window, taken during the second procedure, was positive for β2-transferrin on assay. Bacteriologic study of middle-ear effusions and otorrhea revealed P. aeruginosa (n = 2), Staphylococcus coagulase-negative (n = 2), S. pyogenes (n = 2), S. pneumoniae (n = 1) and Staphylococcus coagulase–positive (n = 1). All patients had at least one positive culture. The S. pneumoniae isolate was sensitive to penicillin. Hospital stay averaged 8.4 days (range 7.0 to 11.0 days). Except for hearing loss, recovery was complete for all patients. The average duration of dizziness was 4.2 days (range 2.0 to 6.0 days). The two patients with serous labyrinthitis who underwent audiologic testing had normal hearing in the affected ear after treatment. The two patients with suppurative labyrinthitis had permanent profound sensorineural hearing loss in the affected ears. Acute Petrositis
Four patients presented with acute petrositis, although none had the classic triad of Gradenigo’s syndrome (otorrhea, deep facial pain, abducens palsy). Three patients had additional intracranial complications of mastoiditis, including one patient with otic hydrocephalus, one patient with otic hydrocephalus and sigmoid sinus thrombosis, and one patient with an epidural abscess, otic hydrocephalus, and sigmoid-sinus thrombosis. Mean patient age was 7.4 years (range 5.8 to 9.3 years). All four patients had otalgia and diplopia; three had retro-ocular pain and fever and one had jaw pain, but none had otorrhea or fever of 38.3° C or greater. The mean duration of ear symptoms was 10.2 days (range 7.0 to 16.0 days). All patients had received prior antibiotic therapy, either amoxicillin or amoxicillin and clavulanate potassium. Ipsilateral sixth-nerve weakness was found in all four patients, papilledema was found in three, esotropia and postauricular tenderness were found in two, and abnormal visual-field testing, vision loss, and a contralateral sixth-nerve weakness were found in one patient each. Three children had a history of frequent otitis media, but none had undergone prior tympanostomytube placement. No child was immunocompromised. Temporal-bone CT was performed in all four patients; in all four the scan demonstrated soft-tissue density in the
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Fig. 5. Axial CT scan in patient with acute petrositis and sigmoid-sinus thrombosis (long arrow). Short arrow demonstrates bony destruction of petrous apex.
petrous apex, and, in two, bony destruction of the petrous apex was seen (Fig. 5). MRI was performed to evaluate suspected intracranial complications in three patients. Audiologic testing was performed on admission in three patients; the findings were normal in one patient but the other two had 21- to 39-dB conductive hearing loss. Lumbar puncture was performed in each patient; findings were normal in all, except for increased intracranial pressure in three. These three patients each had otic hydrocephalus, and two had sigmoid-sinus thrombosis. The number of lumbar punctures performed for relief of increased intracranial pressure in these three patients averaged 4.7 (range 2.0 to 10.0). All patients were treated with broad-spectrum intravenous antibiotics for a mean duration of 19.6 days (range 8.0 to 35.0 days). Single-drug therapy with ticarcillin disodium and clavulanate potassium was used in two patients; combination drug therapy was used in the other two. Additional medical therapies included acetazolamide sodium (n = 3) and mannitol (n = 1). Myringotomy and tube placement and mastoid surgery were performed in all four patients. One patient underwent modified radical mastoidectomy, one underwent intact canal-wall tympanomastoidectomy with drainage of an epidural abscess, one underwent simple mastoidectomy, and one underwent intact canal-wall
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mastoidectomy, partial removal of cholesteatoma, and needle aspiration of the sigmoid-sinus thrombosis. This last patient subsequently underwent radical mastoidectomy with complete removal of cholesteatoma 4 weeks later. Bony destruction of the petrous apex was identified in all patients. Bacteriology from middle-ear effusions or mastoid cultures showed no growth in three patients and P. aeruginosa in one patient. Hospital stay averaged 9.8 days (range 8.0 to 11.0 days). All patients recovered completely, except for two patients with hearing loss. The mean duration of sixthnerve weakness was 22.5 days (range 2.0 to 52.0 days), and papilledema lasted an average of 38.3 days (range 19.0 to 66.0 days). DISCUSSION
During the 15-year period of this study, approximately 255,000 patients were evaluated at the Children’s Hospital of Pittsburgh outpatient clinics for treatment of otitis media, but only 113 were admitted for treatment of the intratemporal or intracranial complications of AOM. The 100 intratemporal complications presented in our analysis occurred in otherwise healthy children; only 4 (4.0%) were known to be immunocompromised. Thirtyseven patients (37.0 %) had symptoms lasting 5 days or longer, and of these 37 patients, 32 (86.5 %) were treated with oral antibiotics before admission. Although difficult to assess retrospectively, these patients were most likely inadequately treated because of the prolonged duration of their symptoms. Acute mastoiditis
Fifty-four children with acute mastoiditis (75%) were treated conservatively with intravenous antibiotics and myringotomy, with or without tympanostomy-tube insertion. Seventeen of the 18 children who required mastoidectomy (94%) had one or more of the following conditions: subperiosteal abscess, cholesteatoma, another suppurative complication (e.g., facial paralysis), or mastoid osteitis demonstrated on CT. Whereas some authors have also reported that most patients may be treated conservatively,1-4 others have reported that most of their patients required mastoidectomy.5-7 These conflicting reports are most likely the result of a lack of uniform definition of the disease, differences in presentation of cases, and variation in management. In our experience, patients with acute mastoiditis with only periostitis (spread of the infection to the periosteum from the mastoid cells by venous channels) usually respond to conservative therapy, whereas patients with acute mastoid osteitis (destruction of the bony trabeculae that separate the mastoid cells resulting in “coalescence”) usually require mastoidectomy.
Most CT scans demonstrated middle-ear and mastoid soft-tissue density, which is nonspecific and found in uncomplicated otitis media. However, CT scans were useful in demonstrating intracranial complications, bony destruction of mastoid trabeculae, and subperiosteal or neck abscesses. CT should be performed in all patients with suspected intracranial complications, all patients requiring mastoidectomy to demonstrate normal anatomic landmarks and the extent and nature of disease, and all patients who do not rapidly respond to conservative therapy. Audiologic testing most frequently demonstrated conductive hearing loss, which is nonspecific and also found in patients with uncomplicated otitis media. Audiograms should be obtained before mastoidectomy as a baseline. Culture results were in agreement with prior reports,1-8 but, in contrast to the findings of earlier studies, prior antibiotic therapy did not influence culture results.2,8 The mean rate of penicillin-resistant middle ear isolates of S. pneumoniae at Children’ s Hospital of Pittsburgh over the past 9 years was 22.2 % (range 6.0% to 38.0 %). The rate of penicillin-resistant isolates (15.4%) from patients with acute mastoiditis obtained in this study is consistent with the hospital rate, demonstrating that acute mastoiditis is not developing as a result of the presence of resistant organisms. Facial paralysis
Intravenous antibiotics and myringotomy with or without tube insertion is the initial conservative therapy for treatment of acute facial paralysis complicating AOM agreed on by most authors.9-13 The need for mastoidectomy is still controversial. Some authors advocate cortical mastoidectomy, with facial-nerve decompression within a few days if there is complete loss of facial function accompanied by a poor prognostic indicator (decreased tearing, decreased submandibular flow, abnormal electric testing).10,12 Still others favor a more conservative approach, recommending mastoidectomy without facial-nerve decompression in the acute setting and reserving facial-nerve decompression for patients with persistent paralysis after several months.11 Others favor mastoidectomy without decompression only for those patients with continued signs of infection with complete or progressive paralysis if there is no response to medical therapy.9,13 From our experience, almost all patients with incomplete paralysis should regain normal or near-normal facial function with conservative therapy, and mastoidectomy is not indicated. The recovery of patients with complete paralysis is extremely variable, but consideration of mastoidectomy without decompression should be given in patients whose condition does not improve with conservative therapy.
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CT was performed if the patient’s paralysis did not resolve rapidly with conservative therapy. CT scans were useful in ruling out other causes of facial-nerve paralysis such as tumor or unsuspected temporal-bone fracture; in evaluating intracranial complications, if suspected; or before mastoidectomy to map the course of the facial nerve and evaluate potential bony dehiscences before surgery. Although audiologic testing was nonspecific, it was useful in evaluating potential sensorineural hearing loss and served as a baseline in case of the need for mastoidectomy. Evoked electromyography was not predictive of ultimate facial function in the three patients with incomplete paralysis who underwent electrical testing; all patients regained normal function even if there was no response on evoked electromyography. However, although the numbers are small, electrical testing did prove useful in patients with complete paralysis in predicting ultimate facial function. The two patients with intermediate responses regained normal function with conservative therapy. One patient with no response also regained normal function after mastoidectomy without facial-nerve decompression, whereas the other patient was left with House grade V paralysis after mastoidectomy with facialnerve decompression. Therefore, as reported previously, absence of response on evoked electromyography may be an indication for mastoidectomy.9-12 Our culture results were in agreement with the findings of Elliot et al.,9 showing predominantly no growth. Prior antibiotic therapy did influence the culture results; all negative cultures involved specimens from patients who had been treated with antibiotics before admission. Labyrinthitis
Although serous labyrinthitis is reported to be one of the most common complications of otitis media, only three patients required acute hospitalization over the 15 years we reviewed. Presumably, most patients with serous labyrinthitis resulting from AOM, otitis media with effusion, or chronic suppurative otitis media respond to outpatient medical therapy or elective surgical procedures treating the underlying medical condition. All three patients in this series responded to conservative therapy. There have been few recent reviews of suppurative labyrinthitis.14,15 Only two patients were found in our series. One patient responded to conservative therapy, and the other required intact canal-wall mastoidectomy with cochleotomy. Both patients had permanent, profound sensorineural hearing loss on the affected side. The differentiation between serous and suppurative labyrinthitis can only be made clinically by the response to treatment and audiologic improvement in patients with serous labyrinthitis.
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Suppurative labyrinthitis is a potentially life-threatening complication of otitis media; infection in the inner ear can spread to the subarachnoid space, leading to meningitis. The disease must be treated aggressively, and early surgical intervention is usually warranted. As evidenced by our one patient with a congenital perilymphatic fistula, which predisposed him to suppurative labyrinthitis during an episode of AOM, in patients with both serous and suppurative labyrinthitis without other predisposing conditions such as cholesteatoma, chronic suppurative otitis media, or immunodeficiency a congenital defect should be suspected. Serial audiologic testing to document progression of sensorineural hearing loss, temporal-bone CT, and even exploratory tympanotomy may be indicated. Acute Petrositis
In 1907,16 Gradenigo described his classic triad of abducens nerve paralysis, severe pain in the distribution of the trigeminal nerve, and acute suppurative otitis media, and the symptoms were attributed to suppurative disease of the petrous apex. As demonstrated in our study and in prior reports, most patients do not present with the classic triad.17-19 Three of four patients also had simultaneous intracranial complications. Petrous apicitis was documented in all cases on CT. Early reports emphasized the need for radical surgery with access to the petrous apex.17,18 More recent reports have documented the success of more conservative therapy of high-dose broad-spectrum antibiotics with intracranial penetration and less aggressive surgery.19,20 All of our patients recovered with antibiotic therapy and more conservative mastoidectomies without drainage of the petrous apex. CONCLUSION
In summary, the intratemporal complications of AOM, although rare, still exist in the healthy pediatric population and often follow inadequately treated AOM. Practitioners must be aware of their presenting symptoms and signs and management. Although recommendations for initial management are universally accepted, there is still some controversy regarding the timing and extent of more invasive surgery. We thank Susan Strelinski for assistance with data entry and Avrum Pollack, MD, for review of radiographic studies. REFERENCES 1. Harley EH, Sdralis T, Berkowitz RG. Acute mastoiditis in children: a 12-year retrospective study. Otolaryngol Head Neck Surg 1997;116:26-30. 2. Hawkins DB, Dru D, House JW, et al. Acute mastoiditis in children: a review of 54 cases. Laryngoscope 1983;93:568-72.
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3. Ogle JW, Lauer BA. Acute mastoiditis: diagnosis and complications. Am J Dis Child 1986;140:1178-82. 4. Rosen A, Ophir D, Marshak G. Acute mastoiditis: a review of 69 cases. Ann Otol Rhinol Laryngol 1986;95:222-4. 5. Gliklich RE, Eavey RD, Iannuzzi RA, et al. A contemporary analysis of acute mastoiditis. Arch Otolaryngol Head Neck Surg 1996;122:135-9. 6. Luntz M, Keren G, Nusem S, et al. Acute mastoiditis—revisited. Ear Nose Throat J 1994;73:648-54. 7. Nadal D, Herrmann P, Baumann A, et al. Acute mastoiditis: clinical, microbiological, and therapeutic aspects. Eur J Pediatr 1990;149:560-4. 8. Prellner K, Rydell R. Acute mastoiditis: influence of antibiotic treatment on the bacterial spectrum. Acta Otolaryngol (Stockh) 1986;102:52-6. 9. Elliot CA, Zalzal GH, Gottlieb WR. Acute otitis media and facial paralysis in children. Ann Otol Rhinol Laryngol 1996;105:58-62. 10. Hof E. Facial palsy of infectious origin in children. In: Fisch U, editor. Facial nerve surgery. Birmingham, Ala.: Aesculapius, 1977:414-8. 11. Kamitsuka M, Feldman K, Richardson M. Facial paralysis associated with otitis media. Pediatr Infect Dis 1985;4:682-4.
12. Shott SR, Myer CM. Otitis media and facial paralysis. Pediatr Infect Dis 1986;5:494-5. 13. Takahashi H, Nakamura H, Yui M, et al. Analysis of fifty cases of facial palsy due to otitis media. Arch Otorhinolaryngol 1985; 241:163-8. 14. Juselius H, Kaltiokallio K. Complications of acute and chronic otitis media in the antibiotic era. Acta Otolaryngol (Stockh) 1972;74:445-50. 15. Kangsanarak J, Fooanant S, Ruckphaopunt K, et al. Extracranial and intracranial complications of suppurative otitis media. report of 102 cases. J Laryngol Otol 1993;107:999-1004. 16. Gradenigo G. Ueber circumscripte Leptomeningitis mit spinalen Symptomen. Arch Ohrenheilk 1904;51:60-2. 17. Chole RA, Donald PJ. Petrous apicitis: clinical considerations. Ann Otol Rhinol Laryngol 1983;92:544-51. 18. Hendershot EL, Wood JW, Bennhoff D. The middle cranial fossa approach to the petrous apex. Laryngoscope 1976;86:658-63. 19. Tutuncuoglu S, Uran N, Kavas I, Ozgur T. Gradenigo syndrome: a case report. Pediatr Radiol 1993;23:556. 20. Hardjasudarma M, Edwards RL, Ganley JP, et al. Magnetic resonance imaging features of Gradenigo’s syndrome. Am J Otolaryngol 1995;16:247-50.
Temporal Bone Surgical Dissection Courses
These courses, presented by Memorial Georgia Ear Institute, will be held Dec. 59, 1998. For further information, contact Shirley Johnson, RN, MSA: (912)3507365; fax (912)350-8998; e-mail: [email protected].