Use of antibiotics and chemotherapy in sinus and mastoid infections

USE OF ANTIBIOTICS AND CHEMOTHERAPY AND MASTOID INFECTIONS* ANCHISE A.

IN SINUS

CIRILLO, M.D.

Jamaica, New York

T

HIS article wiII endeavor to show the importance of evaIuating every case of otitis media and its complications individuaIIy and the danger in reIying on chemotherapy and antibiotics aIone as a cure-a11 for a11 mastoiditis and its comp1ications. The promiscuous use of chemotherapy and its masking of symptoms were stressed in 1942~ but antibiotics have come to the fore since and that experience deserves renewed reiteration. Since the advent of chemotherapy and peniciIIin there has been some controversy concerning the treatment of otitis media and earIy mastoiditis. Before subscribing to any new form of treatment for a disease the mortaIity and morbidity of the previous forms of therapy shouId be compared. Acute suppurative otitis media as a ruIe is a seIf-Iimiting disease; 80 per cent of unsdected cIinic patients get we11in Iess than four weeks. A higher percentage get well if the externaI auditory cana is kept clean, the mucosa of the nose shrunken and care is administered to the eustachian tube. The percentage of naturaI arrests is. stiII greater if the disease is non-suppurative. A Iarge per cent of cures attributed to chemotherapy and antibiotic therapy undoubtedIy incIude such spontaneous regressions. Since the advent of chemotherapy and antibiotics the cIassic signs and symptoms of the comphcations of otitis media are often disguised so as to render a positive diagnosis difIicuIt. The promiscuous use of these drugs in cases of otitis media tends to delay accurate diagnosis and necessary surgicaI intervention. The deIay in surgica1 intervention accounts for some of the serious compIications and some of the present mortality of otitis. DanieI S. Cunning2 noted that in 2,260 cases of otitis meningitis from 1901 to 1935 there were onIy sixty-six instances of recovery or a morta1ity of 97 per cent. Josephine Nea13 of the New York City Department of HeaIth cohected 238 cases from rgro to 1935, with a mortahty of g5 per cent. * From the OtoIaryngoIogicaI

In the Johns Hopkins HospitaI from 1925 to 1935 not a sing1e patient survived. At Manhattan Eye, Ear, Nose and Throat HospitaI from 1926 to rg36 in IO I cases onIy two patients got weI1. In contrast, the present era has removed the dread of otitis and the most serious compIications offer a better prognosis with the efficient antibiotics and proper surgery at the proper time. The foIIowing cases are cited to show that undue reliance on drugs often deIays necessary surgery, with a IethaI outcome: CASE REPORTS CASE I. A five-month aid femaIe child entered the Mary ImmacuIate HospitaI on ApriI 15, 1948, with a swelling behind the Ieft ear of one day’s duration. The chiId had a temperature of IOO’F., a cough for severa days and tenderness over the antrum, in addition to a puru1ent discharge. The roentgnogram showed the Ieft mastoid to be cIoudy, a Ieukocytosis of 13,650, with 5 I per cent poIymorphonucIears and 48 per cent lymphocytes. The smear reveaIed StaphyIococcus albus hemoIyticus. The chi1d received 35,000 units of peniciIIin every three hours, the temperature remained normal, the drainage from the ear stopped and the swehing subsided within nine days after admission. On the eIeventh day the child died suddemy. At autopsy the patient showed necrosis of the Ieft mastoid grossIy and microscopicaIIy, round ceIIs, pIasma ceIIs and chronic biIatera1 mastoiditis. At consuItation nine days before death when the chiId had the subperiostea1 abscess, operation was advised. CASE II. N. L., age twenty, had a right simple mastoidectomy on March 3, 1945. On June 18, 1948, his right ear began discharging profuseIy. Chemotherapy and peniciIIin were instituted in large doses. On August 14, 1948, he was again operated upon for a right secondary mastoiditis. Four days Iater his tempera-

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ture was 107.5%. At this time he had chi1Is lasting five minutes and a temperature of 105’F. which would intermit to normaI. The opinion was expressed that “the boy. has a IateraI sinus thrombosis, and, unIess the focus is removed, the antibiotics alone will be ineffective.” The surgeon in charge was urged to do a juguIar Iigation. In spite of the tremendous doses of chemotherapy, penicilIin and transfusions, the boy continued downhill, with temperature, chiIIs and paIIor. On August 27th the cons&ant was again called and feIt that the jugmar vein was not successfuIIy ligated. The neck wound was reopened and the carotid sheath was intact. After ligating the internal juguIar vein the IateraI sinus was inspected and repacked and the boy made an uneventfu1 recovery. CASE III. C. K., a fifty year oId white femaIe, presented a history of a running Ieft ear for forty years and a chiI1 that lasted five minutes. The patient refused hospitalization and the famiIy physician treated her with Iarge doses of suIfaniIimide. Nine days Iater this patient was admitted to the Queens General HospitaI, Iethargic, with nuchaI rigidity, weakness of the right upper extremity and the movements were uncertain with tremor dysdiadokokinesia with the reflexes sIightIy more active than on the Ieft. On June I I, 1939, the spina tap showed 6,360 celIs per cm., with go per cent poIynucIears. Smear showed a few gram-positive cocci. At operation, immediateIy on entering the mastoid cortex, pus was seen coming from the region of the temporosphenoida1 cavity and this was traced to the middIe cranial fossa. A needle passed through the temporosphenoida1 Iobe obtained 30 cc. of pus. Pus was found in the antrum (otitic) as we11as a choIesteatoma. The next day the spina tap showed 7,400 ceIIs with 87 per cent polynuclears. The left mastoid culture showed Proteus vuIgaris. By July 16, 1939, the condition began to improve and on July 27th the neuroIogic examination was negative except for a centra1 facia.1 weakness and aphasia. Her spina Auid cIeared and on September g, 1939, the patient was discharged and she has been we11 for the past ten years. CASE IV. A male, N. S., fifty-eight years of age, was admitted to Queens General Hospital on May 12, 1948, with a simiIar story and aIso a proteus organism. He had a running right ear for the past three years. A progressive September,

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stupor and Iethargy gradualty deveIoped but no fever or chiIIs and then menta1 confusion and generahzed weakness. Pus was obtained from the right temperosphenoida1 Iobe during the needhng of the brain for a ventriculography. The patient could withstand a modified radical mastoidectomy onIy. The right temporosphenoidal Iobe was needIed and a greenish pus was obtained. The abscess cavity was opened wideIy and appeared to measure 2.5 by 2.5 by 25 cc. It appeared to be we11 waIIed off. A No. 14 catheter was Ieft as a drain. The wound was packed and the patient returned to the ward in very poor condition. The patient appeared to improve for about ten days when he began to show evidence of bIockage again, with lethargy and unresponsiveness, despite the massive doses of penicihin, smfadiazine and streptomycin. The patient suddenIy went into a coma during irrigation of the abscess. The wound was reopened wideIy on May 28th and much necrotic brain tissue was gentIy suctioned from the brain cavity and a Iarge Mosher basket sutured into the abscess cavity. PostoperativeIy he received large doses of penicillin and smfadiazine. The patient was discharged on June 18, 1948, with onIy a minima1 residua1 weakness of right hand. The two instances of temperosphenoida1 lobe abscesses cited faiIed to respond to chemotherapy and antibiotics aIone and accent the need for surgica1 drainage. CASE v. A. F., a fifty-eight year old white maIe, was admitted to Mary ImmacuIate Hospital on February 15, 1950, in a critica condition with a clinica diagnosis of acute rightsided suppurative pansinusitis, with a probabIe earIy brain abscess. He had been iII at home for a period of three weeks. The sinuses discIosed an empyema of the right maxiIIary and fronta sinuses by x-ray. The right middIe turbinate was infracted to estabhsh drainage of the frontal sinus and the maxillary sinus was irrigated. The patient was given intravenous ffuids and massive antibiotic therapy to which he responded promptIy. On February 23rd he began to run a temperature once again and the antibiotics were increased but within twentyfour hours suppurative meningitis deveIoped in the patient. The spinal ffuid was positive for pneumococci. He did not show a satisfactory response so a radical right frontal sinusotomy was performed on March I, 1950, at which time a pathoIogic break-through of the posterior sinus pIate was found. The necrotic bone sur-

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rounding this dehiscence was removed over an area equa1 to a haIf-doIIar exposing the dura over the right fronta Iobe tip. There was no extradura1 abscess present. The patient improved considerabIy postoperativeIy for thirtysix hours but then again ran a stormy course. On March I Ith the right frontal Iobe was once again exposed and the brain was needled in various directions unti1 a Iarge abscess was found and 35 cc. of frank yeIIow pus were aspirated. A No. 14 French catheter was inserted into the abscess cavity for drainage and irrigation with antibiotics. The postoperative course was stormy and the patient finaIIy Iapsed into a comatose state and died on March

units peniciIIin every four hours and suIfadiazine 15 gr. every four hours. The patient’s temperature was norma for two days and she was fairly comfortabIe except for intermittent episodes of severe fronta headache associated with vomiting and increasing deafness. On the third day she was symptomaticaIIy weI1, with Iess resistance to neck ffexion but persistence of biIatera1 papiIIedema. There were no foca1 signs of brain abscess. The spina tap was repeated. The initia1 reading this time was 600 mm., varying to 300 mm. The ceII count was 597 ceIIs per cu. mm., with go poIynucIears per cu. cm. and 14 percent Iymphocytes. A ventricuIogram reveaIed no abnormaIities and it was believed that this ruIed out a foca1 brain ab20, 1940. Autopsy reveaIed an acute brain abscess of scess. An otoIogic examination reveaIed that the right fronta Iobe, with compIicating sup- the right ear (Iong history of discharge) had purative meningitis, generaIized, secondary to pus under pressure, in spite of chemotherapy suppurative right fronta sinusitis. and antibiotics, and it was thought that the CASE VI. M. S., a twenty-five year oId true picture was obscured by chemotherapy female, was admitted on December 28, 1949, and peniciIIin. The patient had a right chronic to Mary Immaculate Hospital, with headache mastoiditis with an acute exacerbation and an and vomiting going back approximateIy six associated meningitis that required surgica1 intervention. The presence of a miId facial weeks. The patient was treated with suIfa and peniciIIin (amounts unknown) with a diagnosis paraIysis was noted at this time. On the tweIfth of virus X. Vomiting subsided but a few days hospita1 day a radica1 mastoidectomy was perIater the patient began to compIain of severe formed and scIerotic bone was removed and the fronta headaches and pain in the Ieft eye surgeon entered a cavity containing a considerwhich awakened her at night. Photophobia was able amount of pus which terminated in the region of the zygoma and the antrum. Necrotic present. Sinuses were x-rayed and bIood count bone and a choIesteatoma were noted Ieading done, and both were reportedIy normaI. The past history was significant in that the patient to the middIe ear. complained of a chronic discharge from the FoIIowing operation the patient was kept on peniciIIin and suIfadiazine. The temperature right ear for a Iong period of time (exact duraremained eIevated (gg” to 102’F.) for two days tion unknown). On admission the temperature was IOI’F. and the puIse rate 84. The genera1 but her genera1 condition was good. The facia1 appearance was that of a we11 oriented, we11 paraIysis persisted but graduaIIy decreased. nourished white femaIe somewhat hard of hear- The patient was discharged on the nineteenth ing. The fundi showed biIatera1 papiIIedema. hospita1 day. CASE VII. R. P., a thirty-nine year old white The reflexes were a11normal except for a positive Kernig and Brudzinski. The diagnosis on maIe, was admitted to Mary ImmacuIate Hospita1 disoriented with marked paIIor and sweatadmission was cerebrospina1 meningitis and ing. There was a history of acute bronchitis, possibIe brain tumor. The urine was compIeteIy negative. There were 12,650 white bIood cells pharyngitis and sinusitis one month prior to admission which responded we11to IocaI therapy with 84 per cent poIynucIears and 16 per cent Iymphocytes. The spina tap showed an initia1 and bed rest. Six days before admission the patient began to compIain of pain in the right pressure of 460 mm. and was grossIy turbid ear which graduaIIy increased in severity. The with a fina pressure of 160 mm. of water. The ceII count was 2,523 cek3 per cc., with go per patient was on sulfa drugs and peniciIIin. Five days before admission the drum membrane cent poIynucIears and IO per cent Iymphocytes. ruptured spontaneously, with relief of pain The protein showed 1,680 mg. per cent and the sugar and chlorides were 17 and 745 mg. per and a puruIent discharge. The patient concent respectiveIy. There was no growth on tinued on chemotherapy and seemed to be cuIture. The patient was pIaced on IOO,OOO fairIy we11when suddenIy on the night before

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admission he compIained of severe fronta pain which persisted. The patient became semicomatose and disoriented. His te’mperature was 103OF., his p&e g6, his respiration 20. The right ear was fiIIed with a puruIent discharge. Marked nucha1 rigidity was present. The patient was started on SOO,OOO units peniciIIin every three hours and I gm. of sodium suIfadiazine every four hours intravenousIy. A spina tap showed a ceII count of 3,505 ceIIs per cu. mm., I00 per cent poIynucIears, 9.0 mg. of sugar, a tota protein of 432.0 mg. and 725 mg. of chIorides. The white bIood ceil count was 27,150, with 84 per cent poIynucIears. A diagnosis of acute puruIent meningitis secondary to otitis media and mastoiditis was made. The mastoid was found to be necrotic with free pus and a smaI1 exposed area of dura was injected and red between the sinodura1 angIe and the zygomatic area. The patient was continued on peniciIIin and suIfadiazine. The temperature remained elevated for ten days. When a spina tap showed no abnorma1 findings, the patient was discharged and has been we11 since, with no evidence of a discharge from the ear. CASE VIII. J. M., age sixty-seven, was admitted on March 7, 1949, from a IocaI hospita1 in which he had been treated for acute coronary occIusion and meningitis. He showed a stiff neck, a high temperature and a persistent fronta headache. The spinal tap showed a high ceI1 count, mostIy polynuclears. The smear reveaIed meningococci. He was given Iarge doses of peniciIIin and the temperature became normaI, but the patient went into a coma. He had a discharging ear for years. At an emergency consuItation the ear showed pus under pressure, a sagging canal waI1 with perforations of the Ieft ear and the firm opinion that this was a case of otitic meningitis was expressed. SurgicaI intervention on the right was favored aIthough the x-rays showed nothing. The true cIinica1 evaIuation was masked by chemotherapy and peniciIIin. The cuhure of the spina fluid was negative, possibIy due to the chemotherapy; the cuIture from the ear showed staphyIococcus. The spina fluid showed 6o mg. of sugar, 195 mg. of protein and 103 mg. of chIorides. The ceI1 count on March I 8th showed 36,050 ceIIs whiIe after operation on March 10th the count was 450 ceIIs. Four days Iater it was 208 ce1I.sand then the spina fluid became cIear. The x-ray showed s&rosis of the right mastoid. On March 3Ist the cortex was en-

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tered, the tegmen tympani was eroded and the brain herniated into the mastoid wound. The dura was covered with a fibrinous exudate. When the dura was incised, the spina fluid was cIear. The patient’s condition did not warrant further procedure at this time and the wound was packed and Ieft open with drainage we11 estabIished. On ApriI 1st a radica1 mastoidectomy was done and the patient made an uneventful recovery and was discharged on ApriI 15, 1949, as cured. CASE IX. On June 13, 1950, J. M., a sixtyfour year oId femaIe, was admitted with severe left-sided headache and a Ieft earache. She was we11 unti1 one week before admission when a severe head and chest coId, tinnitus and generaIized headache deveIoped. Boric acid and peroxide soaks were prescribed by a IocaI physician as were aIso piIIs and peniciIIin. The patient progressed to a Iethargic state and then went into a coma. On admission the temperature was IO~..L$~F., the puIse was IIO, the patient was semicomatose but responded to painfu1 stimuIi. She was irritabIe and restIess and disoriented. There was marked. neck rigidity and reflexes were hyperactive. The pupiIs were equa1 and reacted. A puruIent exudate was seen in Ieft ear canat. A central perforation was found in the drum. No mastoid tenderness or sweIIing was evidenced. The sinuses and the mastoid bone showed no abnormaIities on x-ray. The spina tap on admission showed 1,700 ceIIs with 90 per cent poIynucIears, IO per cent Iymphocytes. The sugar was negative and extraceIIuIar dipIococci, morphoIogicaIIy suggesting pneumococci, were seen. The patient was operated upon June 15th and a simpIe mastoidectomy was done for an acute hemorrhagic mastoiditis and meningitis. This patient received on June 13th I miIIion units of peniciIIin at once and I,OOO,OOOevery two hours; sulfadiazine 5 gm. intravenousIy at once, I gm. every four hours; 500 mg. aureomycin oraIIy every four hours; ~OO,OOOunits peniciIIin and x gm. aureomycin were given preoperativeIy. The patient improved and on June 26th the spina tap was cIear, with norma pressure and twenty-five Iy,mphocytes per cu. mm. The patient was treated with Iarge doses of peniciIIin, 200,000 units every four hours, pIus supportive therapy. The patient was discharged on JuIy 8, 1950, as fuIIy recovered. CASE x. E. R. had evidence of an upper respiratory infection on June 17, 1950. qfter two days she compIained of Ieft earache and

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headache. Her temperature was IO$‘F., the bIood pressure was 200/90, the left ear was draining bIood and pus; there was a sagging of the cana walI, and the foIIowing morning she was comatose. At this time her neck was rigid and a spinal tap showed 560,000 ceIIs with 97 per cent poIynucIears and the Auid coaguIated. ImmediateIy 500,000 units of peniciIIin were prescribed and 200,000 units every two hours. The next day the patient was operated upon and immediateIy upon entering the mastoid cavity the foIIowing was noted : (I) Necrosis of bone pIus free pus, (2) pathoIogic exposure of dura extending from the Ieft sinus dura1 angle to the temporosphenoida1 Iobe of the brain, (3) a pathoIogic exposure of the IateraI sinus, (4) necrotic zygomatic ceIIs, (5) the antrum fiIIed with pus. The cuIture showed pneumococci Type III. The patient was treated postoperativeIy medicaIIy with peniciIIin 200,000 units every two hours, suIfadiazine 4 gm. at once, 2 gm. every two hours, gIucose 5 per cent intravenousIy, and sedation. The temperature dropped to norma within four days. The spina tap three days after showed eighty ceIIs. The patient improved rapidIy and was discharged within ten days after admission. COMMENTS It is not the intention to detract from the obvious benefit and known advantages of proper dosages of chemotherapy and antibiotic therapy in the many cases of earIy mastoiditis or of meningitis of otitic origin. The purpose of the aforementioned cases is to caI1 attention to the hazards of inadequate dosage and of undue reIiance upon any form of therapy in the face of obvious progression and compIication of a suppurative nature in otitic infections. The importance of the earIy recognition of a compIieating meningitis, brain abscess or sinus thrombosis is obvious. The remova of a suppurative seeding focus, not responding to chemotherapy or antibiotics alone, is imperative. The diagnosis of these compIications has been rendered more diffIcuIt because of the variations in the known clinical picture produced by such drugs. Despite the disguising and confusing clinica course, which can foIIow as a resuIt of drug therapy, the fundamental principles of diagnosis remain appIicabIe. Each complication is distinctive in the genera1 ap-

Infections

pearance, in the temperature curve and the spina Auid findings. The duI1, apathetic patient who has a brain abscess is in contrast to the anxious, restIess victim of meningitis or the bright animation of the patient III with Iateral sinus thrombosis. The norma or subnormal temperature of the case of brain abscess differs from the continuous high temperature of the acute meningitic and this is easily distinguished from the picket fence curve of the infected thrombophlebitis. There stiI1 remains room for good cIinica1 judgment and the determination of the exact pathoIogic disorder present rather than bIind dependence on drug administration. The diagnostic acumen of the otoIogist is now taxed to the extreme because of the masking of symptoms and the pathoIogic state by proximate aIIeviation of symptoms and signs by the drugs used whiIe the causative pathoIogic disorder stiI1 remains unresoIved. The abuse of the drug therapy by piddling dosage maintained for inadequate periods with premature cessation often does more harm than good by rendering the causative organism drug-fast and resistant. The boon of these powerful therapeutic agents is then Iost to the patient when it is needed most for the more serious compIications. CONCLUSION

Ten cases demonstrating varying compIications of otitic infection in the face of chemotherapy and antibiotic therapy are presented. It is urged that the powerfu1 therapeutic agents now avaiIabIe be used with discrimination. A specific diagnosis shouId be estabIished, with due consideration for the known compIications of mastoiditis. It is urged that adequate dosage be administered, with particuIar care to avoid premature cessation. Suppurative foci, apparentIy not responding, shouId be exposed in keeping with the we11 estabIished principles of otologic surgery. Acknowledgment: I shouId Iike to express my sincere appreciation to the Attending Pathologist, Aifred Angrist, at Queens Genera1 HOSpitaI, for his vaIuabIe cooperation in evaIuating the pathoiogic findings. REFERENCES

Masking of the pathoIogic status in otitis media by chemotherapy. Arch Otolaryng., 36: 541-547. 1942.

1. CIRILLO,

ANCHISE.

2. CUNNING, DANIEL S. Treatment of otitic meningitis. Arcb.‘Otolaryng., 30: gp-g7o, 1939. 3. NEAL, J. Arch Otolasyng., 30: gso-g?o, 1939.

American Journal of Surgery