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Masked mastoiditis
MASKED MASTOIDITIS HARRY BLOCH, M.D., AND E. F. M~ROLLA, M.D. BROOKLYN,N. Y. A S K E D mastoiditis is commonly defined as a mastoid infection oc-
M curring in infants and is characterized by the symptoms o:f a gas-
tro.intestinal intoxication and otitis media.. Its existence, however, is still controversial. H a r t m a n n , 1 Marriott, 2 Alden and Lyman, 3 Floyd, 4 L y m a n ; ~ 0doneal, 6 and Pease ~ observed that mastoiditis may be the p r i m a r y infection when it occurs in association with infantile gastroenteritis. On the other hand, Maybaum, s Johnston and his coworkers, ~ and Wishart 1~ were unable to establish any relationship between intestinal intoxication and mastoiditis in infancy. The evidence of Johnston and his associates against the existence, o.f masked mastoiditis consisted of bacteria o~ the colon-paratyphoiddysentery group of bacilli, which they isolated from the stools in acute intestinal intoxication. Wishart, 1~ working with the same school, submitted the question to a practical test. Bilateral mastoid antrotomy was performed on thirteen severely toxic infants. He failed to influence the course of the toxemia, and only one infant recovered. H e concluded that masked mastoiditis was no~ the cause of the intestinal disturbance. Th~ largo number of cases o~ otitis media with gastroenteritis axailable at the Kings County Hospital offered an opportunity for several clinical and pathologic observations. They are presented as evidence in favor of the clinical entity o~ masked mastoiditis. D E S C R I P T I O N O F CASES
One h u n d r e d nineteen infants with gastroenteritis and o~itis media came u n d e r observation from 1930 to 1934. These patients were admitted from the free dispensary whose clientele is composed largely of underweight, undernourished infants. Their ages varied from a few weeks to. thirteen months. Approximately one-third were females, and about one-fifth were negro infants. CLINICAL COURSE AND SYMPTOMS
The clinical course in our patients revealed three ss In stage 1 the nutritional progress of the infant was suddenly halted by fever. Examination revealed olitis media. Following myringotomy or spontaneous perforation of the eardrum, fever subsided, and the few-ounce loss was frequently regained. The ear drainage persisted. Stage 2 was characterized by occasional vomiting, an increase in the number of 9
t h e P e d i a t r i c S e r v i c e , K i n g s C o u n t y H o s p i t a l , ]:)r. P. L. P a r r i s h , chief. 630
BLOCH AND MEROLLA :
I~r
MASTOIDITIS
631
stools, which became slightly watery, a gradual loss of weight, and a low-grade fever. Stage 3 set in from severM days to two or three weeks following the opening of the eardlmm. The onset was notably tempestuous. The temperature rose acutely from three to five degrees, and simultaneously the weight fell 8 to 30 ounces. The infant now presented the common picture of acute intestinal intoxication. D i a r r h e a and vomiting became severe; dehydration was rapid; weight fell in spite of supportive therapy; anorexia was common; the infant was apathetic and rarely cried. Unoperated or late operated cases usually proceeded to athrepsia, cachexia, and death. Two variations from the customary clinical course were noted. In some instances stage I was rapidly followed by stage 3. In another small group a milder course was observed, in whom dietetic measures proved unavailing, whereas mastoid antrotomy resulted in rapid recovery. It is our opinion that the mastoid infeetion set in coincident with stage 2; but the failure of the infants' resistance precipitated the p r o f o u n d toxemia of stage 3. DIAGNOSIS
The diagnosis of masked mastoiditis depended entirely upon the clinical picture described. The classical symptoms and signs of mastoiditis were t a r d y present. The x-ray examination was not relied upon since m a n y proved mastoid infections produced normal roentgenograms. The swelling of the posterior superior canal described by L y m a n s frequently occurred too late to be of value. ANAL~ZSIS OF CASES
A. Analysis of Surgically Treated Cases. F i f t y patients were submitted to operation. This consisted of bilateral mastoid antrotomy and in a few instances, o.f unilateral antrotomy. At operation pus, granulations, and sequestrums of bone were found. There were twenty-three recoveries, a mortality of 54 per cent. These cases were studied to determine the conditions that iIffiuence the prognosis. One factor appeared to exert a striking effect upon the mortality. Calculating the percentage of loss of weight, determined from the onset of the ear infectio~ to the day of operation, it was evident that an acute loss of weight of more than 10 per cent frequently foreshadowed a fatal outcome for the patient. Upon this basis, f u r t h e r analysis of the fifty cases submitted to operation disclosed that of twentysix patients who had lost less t h a u 10 per cent of weight at the time of operation, there were twenty-one recoveries, a 19 per cent mortality; while of twenty-four patients who had lost more than 10 per cent of weight, there were only two recoveries, a 92 per cent mortality. B. Analysis of Medically Treated Cases. Sixty-nine patients presented the, syndrome, described but were not operated upon. Only ten infants recovered, a mortality o.f 85.5 p e r cent. These patients were
632
THE
J O U R N A L OF P E D I A T R I C S
treated with transfusions, dietetic changes, hypodermoelysis and phleboclysis. The mortality of this group and that of the group operated upon after a 10 per cent loss of weight appeared significantly alike. A N A L Y S I S OF A U T O P S I E S
There were twenty-five autopsies in this series--eleven from the surgically treated group, and fourteen from the medically treated group. In the former the operative diagnosis was verified. An acute inflammation of the meninges was present in one patient. In the medically treated group otitis media and mastoiditis were demonstrated in all. In addition, osteomyelitis of the petrous bone was discovered in two patients and a sinus thrombosis, in one. Many otologists are under the impression that the antrum of aa infant ~orma]ly contains d6bris and cloudy material. On this basis they are frequently skeptical of the diaglqosis of mastoiditis made at the operating or autopsy table. Wishart 1~ made a controlled study of the infant antrum at autopsy. He observed that the mastoid antrums of infants at autopsy were as a rule healthy and that the presence of infection or accumulations was antemortem in origin. Our own observations confirm these conclusions. TREATiVs
The operation consisted of bilateral mastoid antrotomy and drainage performed, in most instances, under local anesthesia. The simplicity of the procedure offered practically no operative risk. Rabbined 1 reported nine cases of masked mastoiditis. He concluded that unilateral antrotomy in the presence of bilateral otitis media proved inadequate. Our experience coincides with this view, for it is possible that there may be a localized pocketing of pus on the other side. Supportive measures were used before and after operation. It served to, increase and elevate the patient's resistance until the infection subsided. Many physicians unfortmmtely believe that operation is indicated only if the patient has the classical signs of mastoiditis: or that operation is not necessarily urgent and should be postponed as long as possible. Such temporizing seems to carry a high mortality rate and is contrary to the general surgical principle that an operative procedure offers less risk before the infant has become cachectic and athreptic. The ototogist and pediatrician should realize that this disease represeats an emergency comparable to an acute appendicitis. SurgicM intervention should be instituted before there is a severe loss of weight. It is only in this way that the mortality can be appreciably diminished. CONCLUSIONS AND SU1VIlCIARY Undernourished, underweight infants were found especially susceptible to masked mastoiditis.
BLOCH AND ]~qEROLLA: MASKED MASTOIDITIS
633
The disease secmed to follow a distinct clinical course and was manifested by otitis media and gastroenteritis. The prognosis depended upon early bilateral mastoid antrotomy, as evidenced by our m o r t a l i t y statistics. The mortality in the medically treated group was 85.5 p e r cent. Bilateral mastoid a n t r o t o m y carried a mortality of 54 p e r cent. Operation p e r f o r m e d before there was an acute loss of more t h a n 10 per cent of the body weight carried only a 19 per cent mortality. Operation p e r f o r m e d a f t e r there was an acute loss of more than 10 p e r cent of the body weight carried a 92 per cent mortality. The response to early operation evidenced by the r a p i d regression of the intestinal symptoms and p r o m p t response to supportive t h e r a p y warranted the diagnosis and defended the treatment. We are indebted to Dr. George ]~rockway, attending ii1 pediatrics, for helpful advice and guidance in this study. REFERENCES 1. ]-Iartmann~ A.: Z.tschr. f. Ohrenh. 34: 1, 1898. 2. Mariott~ W. IV[cKim- Laryngoscope 35" ~92, 1925. Idem: South. M. J. 24" 278, 1931. 3. Alden, A. M., and Lyre]n, tI. W." L~ryngoseope 35" 586, ]925. 4. Floyd, 1~. L.: Arch. Otolaryng. 1: 411, ]925. 5. Lyman, It. W.: Arch. Otolaryng. 6: 526, 1927. 6. Odoneal, T . H . : Arch. Otolaryng. 7" 623, 1928. 7. Pease, 1VL C.: New York State Y. Med. 34: 146, 1931. 8. ~ a y b a u m , J. I~.: Arch. Otolaryng. 15: 418, 1932. 9. Johnston, M. M., Brown, Alan, and Kauke, 1Vi. J.: Am. J. Dis. Child. 45: 495, ]933. 10. Wishart,. D. E. S.: J. A. NI. A. 95: 1084, ]930. ]1. Rabbiner, M.: Laryngoscope 43: 274, 1933. 1668 PaESlDE~T STa~ET 305 OOEAN PARKWAY
M curring in infants and is characterized by the symptoms o:f a gas-
tro.intestinal intoxication and otitis media.. Its existence, however, is still controversial. H a r t m a n n , 1 Marriott, 2 Alden and Lyman, 3 Floyd, 4 L y m a n ; ~ 0doneal, 6 and Pease ~ observed that mastoiditis may be the p r i m a r y infection when it occurs in association with infantile gastroenteritis. On the other hand, Maybaum, s Johnston and his coworkers, ~ and Wishart 1~ were unable to establish any relationship between intestinal intoxication and mastoiditis in infancy. The evidence of Johnston and his associates against the existence, o.f masked mastoiditis consisted of bacteria o~ the colon-paratyphoiddysentery group of bacilli, which they isolated from the stools in acute intestinal intoxication. Wishart, 1~ working with the same school, submitted the question to a practical test. Bilateral mastoid antrotomy was performed on thirteen severely toxic infants. He failed to influence the course of the toxemia, and only one infant recovered. H e concluded that masked mastoiditis was no~ the cause of the intestinal disturbance. Th~ largo number of cases o~ otitis media with gastroenteritis axailable at the Kings County Hospital offered an opportunity for several clinical and pathologic observations. They are presented as evidence in favor of the clinical entity o~ masked mastoiditis. D E S C R I P T I O N O F CASES
One h u n d r e d nineteen infants with gastroenteritis and o~itis media came u n d e r observation from 1930 to 1934. These patients were admitted from the free dispensary whose clientele is composed largely of underweight, undernourished infants. Their ages varied from a few weeks to. thirteen months. Approximately one-third were females, and about one-fifth were negro infants. CLINICAL COURSE AND SYMPTOMS
The clinical course in our patients revealed three ss In stage 1 the nutritional progress of the infant was suddenly halted by fever. Examination revealed olitis media. Following myringotomy or spontaneous perforation of the eardrum, fever subsided, and the few-ounce loss was frequently regained. The ear drainage persisted. Stage 2 was characterized by occasional vomiting, an increase in the number of 9
t h e P e d i a t r i c S e r v i c e , K i n g s C o u n t y H o s p i t a l , ]:)r. P. L. P a r r i s h , chief. 630
BLOCH AND MEROLLA :
I~r
MASTOIDITIS
631
stools, which became slightly watery, a gradual loss of weight, and a low-grade fever. Stage 3 set in from severM days to two or three weeks following the opening of the eardlmm. The onset was notably tempestuous. The temperature rose acutely from three to five degrees, and simultaneously the weight fell 8 to 30 ounces. The infant now presented the common picture of acute intestinal intoxication. D i a r r h e a and vomiting became severe; dehydration was rapid; weight fell in spite of supportive therapy; anorexia was common; the infant was apathetic and rarely cried. Unoperated or late operated cases usually proceeded to athrepsia, cachexia, and death. Two variations from the customary clinical course were noted. In some instances stage I was rapidly followed by stage 3. In another small group a milder course was observed, in whom dietetic measures proved unavailing, whereas mastoid antrotomy resulted in rapid recovery. It is our opinion that the mastoid infeetion set in coincident with stage 2; but the failure of the infants' resistance precipitated the p r o f o u n d toxemia of stage 3. DIAGNOSIS
The diagnosis of masked mastoiditis depended entirely upon the clinical picture described. The classical symptoms and signs of mastoiditis were t a r d y present. The x-ray examination was not relied upon since m a n y proved mastoid infections produced normal roentgenograms. The swelling of the posterior superior canal described by L y m a n s frequently occurred too late to be of value. ANAL~ZSIS OF CASES
A. Analysis of Surgically Treated Cases. F i f t y patients were submitted to operation. This consisted of bilateral mastoid antrotomy and in a few instances, o.f unilateral antrotomy. At operation pus, granulations, and sequestrums of bone were found. There were twenty-three recoveries, a mortality of 54 per cent. These cases were studied to determine the conditions that iIffiuence the prognosis. One factor appeared to exert a striking effect upon the mortality. Calculating the percentage of loss of weight, determined from the onset of the ear infectio~ to the day of operation, it was evident that an acute loss of weight of more than 10 per cent frequently foreshadowed a fatal outcome for the patient. Upon this basis, f u r t h e r analysis of the fifty cases submitted to operation disclosed that of twentysix patients who had lost less t h a u 10 per cent of weight at the time of operation, there were twenty-one recoveries, a 19 per cent mortality; while of twenty-four patients who had lost more than 10 per cent of weight, there were only two recoveries, a 92 per cent mortality. B. Analysis of Medically Treated Cases. Sixty-nine patients presented the, syndrome, described but were not operated upon. Only ten infants recovered, a mortality o.f 85.5 p e r cent. These patients were
632
THE
J O U R N A L OF P E D I A T R I C S
treated with transfusions, dietetic changes, hypodermoelysis and phleboclysis. The mortality of this group and that of the group operated upon after a 10 per cent loss of weight appeared significantly alike. A N A L Y S I S OF A U T O P S I E S
There were twenty-five autopsies in this series--eleven from the surgically treated group, and fourteen from the medically treated group. In the former the operative diagnosis was verified. An acute inflammation of the meninges was present in one patient. In the medically treated group otitis media and mastoiditis were demonstrated in all. In addition, osteomyelitis of the petrous bone was discovered in two patients and a sinus thrombosis, in one. Many otologists are under the impression that the antrum of aa infant ~orma]ly contains d6bris and cloudy material. On this basis they are frequently skeptical of the diaglqosis of mastoiditis made at the operating or autopsy table. Wishart 1~ made a controlled study of the infant antrum at autopsy. He observed that the mastoid antrums of infants at autopsy were as a rule healthy and that the presence of infection or accumulations was antemortem in origin. Our own observations confirm these conclusions. TREATiVs
The operation consisted of bilateral mastoid antrotomy and drainage performed, in most instances, under local anesthesia. The simplicity of the procedure offered practically no operative risk. Rabbined 1 reported nine cases of masked mastoiditis. He concluded that unilateral antrotomy in the presence of bilateral otitis media proved inadequate. Our experience coincides with this view, for it is possible that there may be a localized pocketing of pus on the other side. Supportive measures were used before and after operation. It served to, increase and elevate the patient's resistance until the infection subsided. Many physicians unfortmmtely believe that operation is indicated only if the patient has the classical signs of mastoiditis: or that operation is not necessarily urgent and should be postponed as long as possible. Such temporizing seems to carry a high mortality rate and is contrary to the general surgical principle that an operative procedure offers less risk before the infant has become cachectic and athreptic. The ototogist and pediatrician should realize that this disease represeats an emergency comparable to an acute appendicitis. SurgicM intervention should be instituted before there is a severe loss of weight. It is only in this way that the mortality can be appreciably diminished. CONCLUSIONS AND SU1VIlCIARY Undernourished, underweight infants were found especially susceptible to masked mastoiditis.
BLOCH AND ]~qEROLLA: MASKED MASTOIDITIS
633
The disease secmed to follow a distinct clinical course and was manifested by otitis media and gastroenteritis. The prognosis depended upon early bilateral mastoid antrotomy, as evidenced by our m o r t a l i t y statistics. The mortality in the medically treated group was 85.5 p e r cent. Bilateral mastoid a n t r o t o m y carried a mortality of 54 p e r cent. Operation p e r f o r m e d before there was an acute loss of more t h a n 10 per cent of the body weight carried only a 19 per cent mortality. Operation p e r f o r m e d a f t e r there was an acute loss of more than 10 p e r cent of the body weight carried a 92 per cent mortality. The response to early operation evidenced by the r a p i d regression of the intestinal symptoms and p r o m p t response to supportive t h e r a p y warranted the diagnosis and defended the treatment. We are indebted to Dr. George ]~rockway, attending ii1 pediatrics, for helpful advice and guidance in this study. REFERENCES 1. ]-Iartmann~ A.: Z.tschr. f. Ohrenh. 34: 1, 1898. 2. Mariott~ W. IV[cKim- Laryngoscope 35" ~92, 1925. Idem: South. M. J. 24" 278, 1931. 3. Alden, A. M., and Lyre]n, tI. W." L~ryngoseope 35" 586, ]925. 4. Floyd, 1~. L.: Arch. Otolaryng. 1: 411, ]925. 5. Lyman, It. W.: Arch. Otolaryng. 6: 526, 1927. 6. Odoneal, T . H . : Arch. Otolaryng. 7" 623, 1928. 7. Pease, 1VL C.: New York State Y. Med. 34: 146, 1931. 8. ~ a y b a u m , J. I~.: Arch. Otolaryng. 15: 418, 1932. 9. Johnston, M. M., Brown, Alan, and Kauke, 1Vi. J.: Am. J. Dis. Child. 45: 495, ]933. 10. Wishart,. D. E. S.: J. A. NI. A. 95: 1084, ]930. ]1. Rabbiner, M.: Laryngoscope 43: 274, 1933. 1668 PaESlDE~T STa~ET 305 OOEAN PARKWAY