Acute mastoiditis in children: Middle ear cultures may help in reducing use of broad spectrum antibiotics

Abstract

a b s t r a c tBackground: Acute mastoiditis (AM) is a suppurative infection of the mastoid air cells, representing the most frequent complication of acute otitis media. AM remains an important entity in children due to its potential complications and sequelae. We aim to describe the cases of AM admitted at our department, identify risk factors potentially associated with complications and analyse the changes in clinical approach of AM over time. Methods: Case review of clinical files of children admitted with acute mastoiditis from June 1996 to May 2013 at a Lisbon metropolitan area hospital. Data was divided into two groups (prior and after May 2005) in order to evaluate changes in AM approach over the years. Results: 135 AM episodes were included. The median age was 3.8 years and 42% children were less than 24 months of age. Symptoms at presentation included fever (69%), ear pain (56%) and otorrhea (40%). Complications occurred in 22% patients and were more common in children under 24 months (33% vs 15%, p 0.01). Leukocyte count was significantly higher in children with complications (16.7 vs 14.5 Â 10 9 /mL, p 0.05) as was C-Reactive Protein value (13 vs 6.3 mg/dL, p 0.001). There was a significant association between the development of complications and C-Reactive Protein value at admission (OR 1.892; IC95%: 1.018 e2.493, p 0.01). The optimal cut-off value was 7.21 mg/dL. Over time there was a significant increase in middle ear cultures obtained by tympanocentesis during surgery (2% vs 16%, p 0,01) and also a decrease in the use of broad spectrum antibiotherapy as initial treatment (52% vs 25%,p 0,001). Conclusions: Children under 24 months, with high leukocyte count or with high C-Reactive Protein value should be monitored closely since complications tend to be more frequent. A CRP value of 7.21 mg/dL at admission seems to be a good cut-off to monitor children for potential complications. Throughout the period analysed more cultures were performed allowing identification of the pathogens and implementation of appropriate antibiotic therapy.

The Prevalence of Incidental Mastoid Opacification and the Need for Intervention: A Meta‐Analysis

“…35 Most clinicians would however agree that imaging is indicated when the clinical course is complicated or prolonged, or when clinical signs suggest complications. 33 Our meta-analysis showed that age group was an influential factor in IMO prevalence. Placanica et al 24 and Lafferty et al 23 demonstrated an inverse linear correlation between age and IMO.…”

“…Some authors advocate an early CT scan in all patients to classify true mastoiditis into incipient or coalescent subtypes, 34 while others argue imaging is not mandatory 35 . Most clinicians would however agree that imaging is indicated when the clinical course is complicated or prolonged, or when clinical signs suggest complications 33 …”

“…Silent mastoiditis is a potential consideration when IMO is identified; however, our review of the available evidence did not identify any such cases. One would expect radiological features beyond simple opacification, particularly as bony destruction of the mastoid air cells is a feature of coalescent mastoiditis 33 . Pastuszek et al 25 showed mastoid septa erosion was a feature found only in cases that were suspected and confirmed to have acute mastoiditis, and this feature was absent in all cases of IMO, of which none had true mastoiditis.…”

“…One would expect radiological features beyond simple opacification, particularly as bony destruction of the mastoid air cells is a feature of coalescent mastoiditis. 33 Pastuszek et al 25 showed mastoid septa erosion was a feature found only in cases that were suspected and confirmed to have acute mastoiditis, and this feature was absent in all cases of IMO, of which none had true mastoiditis. Saat et al 27 compared MRI findings between a group of patients with a clinical diagnosis of acute mastoiditis and a control group.…”

Otitis Media in Fully Vaccinated Preschool Children in the Pneumococcal Conjugate Vaccine Era

“…[42][43][44][45][46] A shift in etiology of bacterial AOM in the PCV and HiB vaccination era may also explain why an ear infection, though very rarely, is still complicated by mastoiditis, and extremely rarely by meningitis and other forms of intracranial extension of infection. [47][48][49] A cross-sectional analysis of the US Kids National Inpatient Database had demonstrated a reduction in the incidence of acute mastoiditis from 8 per 10 000 hospital discharges in 1997 to 3.4 per 10 000 hospital discharges in 2009 in patients aged between 1 and 4 years. 50 Even in the Pittsburg cohort, among children treated with watchful waiting, only 1 (0.7%) developed mastoiditis.…”