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Acute Mastoiditis in
Children:Epidemiologic,Clinical,
Microbiologic,and Therapeutic Aspects over Past
Years

M. Nussinovitch, MD R. Voeli, MD
K. Elishkevitz, MD
I. Varsano, MD

Summary: Recent studies have indicated possible changes in the incidence of acute
maswiditis.A retrospective review of children discharged with a diagnosis of acute
mastoiditis was undertaken to describe the epidemiology, clinical presentation,
microbiology, and treatment of acute mastoiditis over past years. Demographic
historic, clinical, and laboratory data were collected. Eigh tv-six children (88
episodes of acute mastoiditis) were identified (1 month-16 years) (median 3.3
years). Almost half had a history of middle ear disease; 8% recurrent episodes
and 68.2% received antibiotics preadmission, 91.2% for acute otitis media.
Bacterial etiology was established in 43 patients (68.2% isolation rate). Pseudomonas
aeruginosa and Streptococcus pnrumoniae were the most frequently isolated agents.
This review showed a significant increase (150%) in the number of patients with
acute mastoidifis. Clin Pediatr. 2004;43:261-267

Introduction
Acute mastoiditis is an inflammatory process in t he mast oi d bone and middle ear
and is usually but not neces s ar i l y pr eceded by an episode of acute suppurative
or subacute otitis media.It has no uniform definition in the literalure. The local
signs of inflammation include anterior, lateral, and inferior displacement of the
auricle; postauricular or supraauricular tenderness; with possible erythema and edema
in these areas and fever.
1-7
Other reported diagnostic criteria
7-9
are radiographic
evidences and compatible pathologic findings in surgery:
1
'
112
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In the preantibiotic era, up to 20% of cases of acute otitis medi a (A. 0114)
evol ved i nt o acute mastoiditis and were frequently associated with more sever e
i nt r acr ani al compl i ca tions." The reported incidence decreased from 0.4% in
1959
14
to 0.004% in the 1980s.
15
Since 1989, however, several investigat ors have
document ed an i ncreased frequency of acute mast oi di ti s i n chi 1dren.
6
. ".
15
-
17

Some studies have implicated the common practice of administering broad-
spectrum antibiotics in increasi ng t he prevalence of resistant bacteria that can
spread t he i nfecti on i nt o the mastoid bone.
18-22

Additionally, antibiotic treatment before hospital admission may mask the classic
signs of acut e mast oi di t i s requi ri ng a higher degree of awareness by clinicians.
1.11,2
There is also evidence that unusual pathogens that do not respond to empiric
antibiotic therapy for ADM can cause acute mastoidilis.
25

The aim of the present study was to review the patients admitted to our center with a
diagnosis of acute mastoiditis to characterize possible changes in the epidemiologic,
clinical, and micmbiologic aspects of the disease, over past years.
Methods
The medical records of the Rabin Medical Center were reviewed for pediatric patients
(<18 years old) with acute mastoiditis admitted between January 1983 and December
1985 and January 1993 and December 1995. Those who met the following criteria
were included in the analysis: presence of at least one physical finding compatible with
acute mastoiditis. retroattricular swelling, retroauricular erythema with or without local
tenderness, or displacement of the atnicle; dinical and otoscopic evidence of AOM on
admission or within 2 weeks before admission. A mastoid subperiosteal abscess was
diagnosed if the retroanricular swelling fluctuated.
Demographic, historic, clinical, and laboratory data were collected for all patients
using a detailed form and analyzed with the liNTDP statistical program.
2
e. Frequencies
were statistically compared using ANOVA, chi-square test, and Fisher exact test.
Pearson correlation was used to measure the significance of correlations. A p value of
<0.01 was considered significant.
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Results
One hundred six children with acute mastoiditis according to the medical records were
identified. 33 in 1983-1985 and 73 in 1993-1995. Of these, 86 met our diagnostic
criteria, 25 in 1983-1985 and 61 in 1993-1995.
There were no changes in the proportion of non-Jewish children between the 2
periods. Two children had recurrences during the study periods for a total of 88
episodes. The number of total hospital admissions and the rate of emergency
department and outpatient clinic visits between the 2 periods increased by 20% and
the number of admissions for acute mastoiditis increased by 130%. The left ear was
affected in 53% of episodes, the right ear in 45%, and both in 1.14%. Patient ages
ranged from 1 month to 16 years (mean 4.8 Years; median 3.3 years). Thirty-one
children (33.2%) were <24 months old; 31 (35.2%) between 2 and 6 years old, and 26
(29.6%) >6 years old. Forty-two patients (47.7%) had a history of otologic problems,
mostly re-current otitis media: 10 were treated with transtympanic ventilating tubes;
and 5 had had acute mastoiditis (1-8 years before).
The distribution of symptoms is shown in Table 1. Sixty patients (68.2%) were treated
with antibiotics within 3 weeks before entry to the study, mostly for ipsilateral AOM.
Fifty percent received amoxicillin or amoxicillin combined with clayulanic acid; 10
children failed to respond to the initial agent and were switched to another. Duration
of therapy was 1-17 days (median 3 days); only 14 children (23.3%) were treated for
more than 1 week.
Physical findings on admis-sion are presented in Table I. Pathologic changes in the
tympanic membrane were found in all patients, including 5 patients with spontaneous
perforation and 4 post-myringotomy. Radiography performed in 87 patients showed
pathologic changes compatible with acute mastoiditis in 82.8%. These included
clouding of the mastoid, 57 (66%); absent pneumatization, 10 (11,4%); and s clerosis,
5 (5.4%). Computed tomography scans were performed in only 3 patients who did not
respond to antibiotic treatment. None showed evidence of intracranial complications.
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Culture specimens were obtained from 63 patients. Specimens were taken from the
purulent discharge in the external auditory canal or from the middle ear during
myringotomy. Forty-three culture results (68.2%) were positive; 1 positive culture
result was aspirated from a retroauricular abscess. Figure 1 shows the most common
bacteria and their incidence. Thirty-one of the positive culture results were taken from
patients who had received antibiotic therapy before admission. Twenty-two grew
resistant bacteria, mostly Meadomonas.
All patients were treated with intravenous antibiotics: 49 (57%) cefuroxime. 22
(25.7%) cloxacillin and ampicillin. 7 (8.1%) cef-triaxone, 5 (5.8%) ceitazidine, and 3
(3.4%) cefatoxitne. Treatment was switched in 23 cases including 7 in which the
culture result was positive for Pseudomonas resistant to the empiric antibiotic therapy.
Surgery was performed in 75 patients (85.2%):miringotomy in 70 (79.5%);
transtympanic ventilating tube implantation in 2 (2.2%); radical mastoidectomy in 2
(2.2%); and polypectomy from the middle ear in 1 (1.1%).
Mean duration of symptoms during hospitalization was 5.7days; mean duration of
hospitalization was 8 days. Two children had facial nerve palsy that did not completel y
improve with treat ment. No other extra- or intracranial complications were noted.
Comparison by Period

No differences in age or gender of the patients were found. The later period was
characterized by significantly higher rates of retroauricular erythema and attrical
displacement (54% vs 20%, 13=0.0014, and 63.5% vs l6. p=0.0001, respectively)
and .administration of antibiotics before admi ssion (77% vs 44%, p=0.0058).
There were no significant differences in physical, laboratory, radiologic, or
microbiology findings. The most common antibiotic agents used were ampicillin
and cloxacillin in 1983-1985 and cefuroxime in 1993-1995. However, no
differences in duration of symptoms. duration of' hospitalization, occurrence of
complications, or recurrence of acute mastoiditis were found.
Comparison by Age
Thirty-one of the acute mastoiditis episodes occurred in children <2 years and 57 in
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children >2 years. The older group was characterized by higher rates of pr evi ous
ot ol ogi c pr obl ems (56.6% vs 22.6%, p=0.0064), implantation of ventilating
tubes (17.5% vs 0.0%, 1)=0.0132). and earache and purulent discharge (p=0.0063,
p<0.00001, respectively). The younger group had a greater prevalence of irritability,
anorexia, upper respiratory tract infection, and displacement of the auricle
(p=0.0141, p=0.0048, p=0.0135, p=0.0002, respectively), in addition to higher fever
on admission. The laboratory findings in the 2 groups are presented in Table 2.
Significant differences were fotind for erythrocyte Sedimentation rate, white blood
cell count, and percent neutrophils.
There was no significant difference in the rate of positive culture results between the
2 groups, but t he di s t r i but i on of t he causative bacteria was different: Streptococcus
pneu towline was the most common bacteria in chil dren aged <2 years, and Pwrudo-
monas arruginosa in children aged >2 years (Figure 2). Roth age and streptococcus
pneumoniae were associated with surgical treat ment independently but strepto-
coccus pneumoni ae was more commonly found in the younger children.
Surgical treatment was more prevalent in children aged <2 years (83.9% vs 38.6%,
p<0.00001). There were no between-group differences in duration of symptoms,
hospitalization, or occurrence of complications.

Comparison by Pathogen

Seven different bacteria were isolated in 43 positive culture specimens. The most
common bacteria were P aeruginnsa in 24 cases (34%), and S. pneumoniae in 10
cases ( 14 % ). A history of recurrent. otitis media was more often associated with
Pseudamonas isolation ((2.5% vs 10%, p=0.0052) as was earache (79.2% vs 20%,
p=0.0 0 1 2) and purulent discharge (79.2% vs 20%, 13=0 .00 1 2 ) wheres signs of
upper respira-tory tract infection were more frequent with pneumococcal isolation
(30% vs 4.2%, p=0.0331). In addition to tympanic bulging ( 309'c vs 8.3%,
p=0.03), the otologic symptoms lasted longer when the culprit organism was
Pseudomonas versus S. pneunumine (6 6 days vs 2.3 2 days, respectively,
p=0.011). There was no significant difference between the isolation rate of
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cultured material of patients with or without previ ous antibiotic therapy. However,
there was a higher incidence of i solation of Streptococcus pneumoniae in patients
who had not previously taken antibiotics. There was no difference between the
organism isolated in the 1980s versus those isolated in the 1990s. The distribution
of the laboratory results by causative organism is shown in Table 2. Surgical
treatment was more prevalent in patients withpneumococcal mastoiditis (90% vs
37.5%,p=0.005). There were no differences by bacteria in duration of symptoms,
hospitalization, or occurrence of complications.
Discussion
Recent studies have indicated possible changes iii the incidence of acute masioiditis
since the introduction of antibiotic use, accompanied by changes in the distribution
of the culprit organisms. Lee and col1eagues
2
reported that the incidence of acute
mastoiditis remained low from 1988 through 1998 but antibiotic-resistant and an
pathogens. Such as .()bac-rrtu.l)euu hi i.s increased.
Kaplan and colleagues found that the number of cases of mastoiditis caused by S.
pnrumoniae remained stable between 1993 and 1998. Other authors noted a linear
increase in both the raw of acute mastoiditis over time (p=0.024) as well as in the rate
of pneumococcal isolation. All but one case of pneumococcal mastoiditis during
1994-1997 was caused by penicillin-resistant strains. Is Van Zuij1en
2-
lin a comparative
study of several European countries, Canada, Australia, and the United States,
demonstrated that the incidence of acute mastoiditis in children in the Netherlands,
Norway, and Denmark, where antibiotics are restricted, was higher than that in the
United Kingdom and United States where almost all children with AOM receive an-
tibiotics. The incidence rate of acute mastoiditis in New York City and adjacent
counties was comparable to those of the Netherlands and Scandinavia (4/100,000
children).
24
This is not the first study that shows that antibiotic treat ment does not
provide full protection against the development of mastoiditis. Other differences
such as an increase in pathogen virulence might play a role.'
In this study, we found an increase of 1.50% in the incidence of acute mastoidit
is between 1983 and 1985 and 1993 and 1995, despite an increased rate of'
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antibiotic prescription for AOM before admission. The number of total hospit al
admissions and the rate of emergency depart -ment and outpatient clinic visits
between the 2 periods increased by 20% and the number of admissions for acute
mastoiditis increased by 150%. The population base for the hospital remained
constant over the period of the study. Interestingly, the rate of positive culture
results was no different with or without previous antibiotic treatment, but the
pathogens isolated were different. The patients treated with antibiotics had a high
rate of pseudomonas mastoiditis. Of the 31 antibiotic-treated patients, 71% had
positive culture results for antibiotic-resistant bacteria, mostly Pseudomonas, and 2
were positive for penicillin
resistant pneumococci. Possible reasons for failure of oral antibi otic therapy are
low compliance, ineffective doses, or low permeability of the inflamed tissues:2
This issue should be investigated in the future.
In our study, 54.4% of the pos-itive culture specimens grew Pseudomonas
aerugino.sa. In the preantibiotic era, the incidence of pseudomonal infections was
as high as 50%. Psundomonas was considered an opportunistic organism that
attacked patients with risk factors, such as diabetes mellitus, prolonged
hospitalization, skin burns, iutd immune suppression due to chemotherapy or
steroid administration. It was also a common isolate in external otitis and chronic
suppurative otitis media. When antibiotics came into common use, Pseadomonas
isolation was still reported, but at much lower rates than in our study (3.6%-16%
Children with Pseudomonas infection in our sample were older (>2 Years) and had
had recurrent otitis media. Most. received antibi otic therapy before admission, and
had probably received several courses in the past.We may assume that these
repeated treat ments caused a change in the natural flora of the ear canal, and
selected resistant bacteria such as Pseudonumas. In 1977, Meyerhoff and colleagues
2

reported 6 cases of acute mastoiditis that did not respond to oral antibiotic therapy,
with positive culture results for Pseudomanas. In 5 of the patients, there was no known
risk factor. The authors found an excessive granulomatous response to infect i on i n
pat hol ogi c speci mens taken during surgery, which suggested the presence of selective
immunologic defects.


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Surprisingly, we found at least 4 other studies from Israel conducted during the past
35 years reporting on acute mastoiditis caused by P aeruginosa.
4
.
22
.
29,30
In 1980,
Ostfeld and colleagues
22
reported 33 patients with AOM and m as t oi d Lis caused by
gram-negative bacilli, mostly (23 cases) P aeruginosa; 15 had Pseudomonas mastoiditis
and had suffered from recurrent otologic problems in the past; 19 had had
prolonged and various antibacterial therapy before admission; 5 received a short
antibiotic course; and 9 were not treated at all. The authors suggested that
antibiotic pressure is not the sole factor responsible for colonization of the middle
ear with this unusual flora and that local immunologic deficiency' may be involved.
22

Several years later. Liberman and F1iss
3
" described 5 children with Pseudo-manta
mastoiditis and no known risk factor, including prolonged antibiotic therapy. Two
children had a partial C2 deficiency combined with dysfunction of the alternative
pathway. All 5 patients had been hospitalized for prol onged per i ods f or
r epeat ed surgery, and had received courses of intravenous antibiotics. Both
Khalif and colleagues
4
in 1998 and Luntz and colleagues m in 2001 found
Pseudomonas aeruginosa to he the most common pathogen in chil dren with acute
.mastoiditis with isolation rates of 38% and 39.5%, respectively. In the latter study,
50% of the cult ure specimens had been taken from the purulent discharge in the
external auditory canal, and the remainder f r om t he mi ddl e ear dur i ng
myringotomy. Additionally, the authors found that 12 of 18 Gents, recovered
without complications after treatment with nonanti -pseudomonas antibiotics,
suggesting that rather than revealing the true causative organisms. the results might
reflect contamination of the smears by external auditory canal flora.''
The children in our study with Pseudomonas mastoiditis presented with relatively
low fever and mild leukocytosis. Most had a natural perforation of the tympanic
membrane or had undergone myringotomy or ventilating tube implantation before
admission. Therefore, some of the clinical signs of infection may have been masked
by the previous antibiotic treatment. In 7 of 24 children, the treatment regimen was
changed to an anti-Pseudomonas agent.. None of these patients had i nt racrani al
compli cat ions or needed prolonged hospitalization. It is unclear whether these
results point to a contamination of cultures by the external auditory canal flora or
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an increasing rate of P aeruginosa in acute imstoiditis in Israel. It is possible that
Pseudomonas is not the primary pathogen, hut ultimately becomes dominant under
the influence of antibiotic therapy. The role of selective immunodeficiencies needs to
be filrther investigated.The findings in the younger patients (<2 years old, 35.2%)
are compatible with those of other studies.
2
.
8
.
9
.".
13
J
9
.
27
Most of these children (87. 4%)
had not had previous otologic problems. They had more severe clinical signs than
the older patients, which were accompanied by systemic inflammation with higher
fever, leukocytosis, and higher erythrocyte sedimentation rate. In 67.7% of the
infants, AOM was diagnosed before admission. The isolation of S. pneumoniae was
much mor e common i n t hi s gr oup (53% vs 4%), and the need for surgical
treatment was more frequent (83.9% vs 38.6%), as reported by others.
13
.
23,27
These
findings may be explained that the immature immune system at this age is
incapable of preventing the spread of the infection from the middle ear.
On the basis of the very low rate of penicillin-resistant S. pneumoniae (1. 1%) in the
Net herlands, where there is a low antibiotic prescription rate, and the i ncreasi ng
number of report s worldwide on penicillin-resistant pneumococci, we suggest that
clinicians may need to practice greater vigilance when choosing antibiotic therapy.
Restriction of antibiotic prescription is a key element in the control of emerging
antibiotic resistance, and its associated morbidity and mortality, and should be
reconsidered as a treatment policy in AOM.
24










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