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ENT Department, P. & A. Kyriakou Childrens Hospital of Athens, Thivon & Levadias St, 11527-Goudi, Athens, Greece
3rd Department of Pediatrics, Athens University Medical School, University General Hospital Attikon, 1 Rimini St, 12464 Chaidari, Athens, Greece
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 11 December 2011
Received in revised form 11 February 2012
Accepted 13 February 2012
Available online xxx
Objective: Today, no uniformly accepted diagnostic and therapeutic criteria have been established for the
management of pediatric acute mastoiditis. The aim of this study is determine the efcacy and safety of
an algorithmic approach for treating pediatric acute mastoiditis.
Methods: The medical records of all children (n = 167) with a diagnosis of AM admitted in our center
during the period 20022010 were retrospectively studied. Data concerning medical history,
symptomatology, laboratory and imaging ndings, presence of complications, treatment methods
and nal outcomes were reviewed and analyzed. Parenteral antibiotics and myringotomy were applied
to all children on the day of admission. Initial surgical approach also included drainage or simple
mastoidectomy for subperiosteal abscesses and simple mastoidectomy for children suffering from
intracranial complications. Finally, simple mastoidectomy was performed as a second line treatment in
children showing poor response to the initial conservative approach.
Results: All children were cured after a mean hospitalization of 9.8 days. The rate of intracranial
complications at admission was 6.5% and the overall rate of the use of mastoidectomy 42%. Following the
presented treatment scheme in all cases, no child developed additional complications while in-hospital
and under treatment or after discharge.
Conclusions: Although simple mastoidectomy represents the most reliable and effective surgical method
to treat acute mastoiditis, a more conservative approach consisting of adequate parenteral antibiotic
coverage and myringotomy can be safely adopted for all children suffering from uncomplicated acute
mastoiditis. Non-responsive cases should undergo simple mastoidectomy within 35 days in order to
avoid further in-hospital acquired complications. Simple mastoidectomy should also be performed in
every case of unsuccessful subperiosteal abscess drainage or presence of intracranial complications.
2012 Elsevier Ireland Ltd. All rights reserved.
Keywords:
Acute mastoiditis
Management
Children
1. Introduction
Acute mastoiditis (AM) is the most common complication of
acute otitis media which mainly affects pediatric age with an
estimated incidence between 1.2 and 4.2/100,000 children/year
[1]. AM should be treated effectively and without delay because
severe intratemporal and potentially lethal intracranial complications can arise from further spreading of the disease.
Despite the extended bibliography relating to pediatric AM,
there are still many areas of controversy. Up to this point no
uniformly accepted diagnostic and therapeutic criteria have been
established. Concerning its management, simple mastoidectomy
0165-5876/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2012.02.042
Please cite this article in press as: I.M. Psarommatis, et al., Algorithmic management of pediatric acute mastoiditis, Int. J. Pediatr.
Otorhinolaryngol. (2012), doi:10.1016/j.ijporl.2012.02.042
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study is to evaluate the effectiveness and safety of the management of pediatric AM we employ in our department for more than
15 years. An attempt is also made to develop an algorithmic
approach in order to formalize the treatment of this disorder.
2. Patients and methods
The medical records of all children (n = 167) admitted to our
department with the diagnosis of AM between January 1st 2002
and December 31st 2010 were retrospectively reviewed. An
Institutional Scientic Board approved the review of the medical
charts of children admitted to our center with the diagnosis of
acute mastoiditis for the period of the study.
Data concerning childrens age, gender, history of pre-admission middle ear infections, clinical signs, treatment before and after
admission, surgical, bacteriological and radiological ndings and
the nal outcome were manually collected and analyzed. Exclusion
criteria included the presence of chronic otitis media with
cholesteatoma, otitis externa and any non-infectious etiology of
mastoiditis.
The diagnosis of AM was based on clinical signs and symptoms
and the criteria applied were recent history/symptoms/signs of
acute otitis media accompanied by retroauricular inammatory
signs (erythema/swelling/pain) and/or antero-inferior protrusion
of the auricle.
Diagnostic imaging, in the form of computed tomography
scan (CT) and/or magnetic resonance imaging (MRI) and/or
magnetic resonance venography (MRV), was performed only in
children with suspected intracranial complications, in recurrent
AMs and in non-typical presentations of AM, when diagnosis was
in doubt.
All children were managed with intravenous (IV) antibiotics
and wide-eld myringotomy with or without ventilating tube
placement within the rst day of hospitalization. Myringotomy
was also performed in cases presented with otorrhea at admission.
Depending on the presence of further intratemporal or intracranial
complications, initial surgical approach also included subperiosteal abscess drainage by incision or aspiration and simple
mastoidectomy. Selecting between abscess drainage and mastoidectomy in children suffering from mastoid subperiosteal abscess
was at the discretion of the attendant ENT surgeon, since both
approaches were used and still are during the years of this
study. However, the presence of an otogenic epidural and perisinus
abscess or lateral sinus thrombosis was considered an indication
for mastoidectomy in this series.
Blood tests, including white blood cell count (WBC) and
differential, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), were performed in all cases. Pus specimens were
obtained from all middle ears during myringotomy and from most
mastoid cavities during mastoidectomy and sent for culture/
sensitivity.
All children were closely followed daily while the decisive reevaluation about the effectiveness of the applied therapeutic
measures was taking place 23 days after admission. Initial
management was considered as successful or not on the basis of
both clinical and laboratory criteria: progressive restoration of
auricular displacement, regression of retroauricular local signs,
partial or complete recovery of the laboratory values of inammatory markers and absence of fever. Cases with persistent clinical
and/or laboratory ndings of AM required further surgical
intervention. Persisting otorrhea for 26 days after myringotomy
and initiation of antibiotic therapy was not considered a denite
criterion for mastoidectomy if the rest of the clinical and laboratory
ndings had been improving or had returned to normal.
Nonetheless, long-lasting otorrhea (7 days) was considered a
positive criterion for performing mastoidectomy.
Please cite this article in press as: I.M. Psarommatis, et al., Algorithmic management of pediatric acute mastoiditis, Int. J. Pediatr.
Otorhinolaryngol. (2012), doi:10.1016/j.ijporl.2012.02.042
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Fig. 2. Presenting symptoms and signs of 155 patients with acute mastoiditis.
Please cite this article in press as: I.M. Psarommatis, et al., Algorithmic management of pediatric acute mastoiditis, Int. J. Pediatr.
Otorhinolaryngol. (2012), doi:10.1016/j.ijporl.2012.02.042
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Fig. 3. Large bi-lobed epidural abscess (A, hollow arrow), pushing the ipsilateral sigmoid infero-medially (A, white long arrow) on brain contrast-MRI at presentation. The
enhanced and thickened overlying dura can also be visualized (A, white short arrow). At the same time, on MR phlebography complete occlusion of right sigmoid sinus can be
seen (B, double arrow). On pre-discharge follow-up imaging study, 20 days after simple mastoidectomy, hyperintense (inammatory) material is still lling the right mastoid
cavity (C, arrow) while partial recanalization of the right sigmoid can be observed (D, double arrow).
It is noteworthy that no child showed a temporary improvement 35 days after the initial therapeutic approach and a reworsening thereafter.
Five children suffered a second episode of uncomplicated AM
within 816 months after the rst episode, showing an asymptomatic in-between period. Three of them belonged to initially
mastoidectomized patients. All ve recurrences were further
managed following the same protocol. All cases of lateral sinus
thrombosis displayed evidence of complete recanalization on
follow-up magnetic resonance venography.
None of our patients was managed on an outpatient basis. There
were no deaths in this series.
4. Discussion
Depending on the presentation, extent of the disease, presence
of further complications and surgeons personal experience and
attitude, the management of pediatric AM may greatly vary among
Please cite this article in press as: I.M. Psarommatis, et al., Algorithmic management of pediatric acute mastoiditis, Int. J. Pediatr.
Otorhinolaryngol. (2012), doi:10.1016/j.ijporl.2012.02.042
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Fig. 5. KaplanMeier plot of estimated time to discharge for the population of the
study.
Please cite this article in press as: I.M. Psarommatis, et al., Algorithmic management of pediatric acute mastoiditis, Int. J. Pediatr.
Otorhinolaryngol. (2012), doi:10.1016/j.ijporl.2012.02.042
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Please cite this article in press as: I.M. Psarommatis, et al., Algorithmic management of pediatric acute mastoiditis, Int. J. Pediatr.
Otorhinolaryngol. (2012), doi:10.1016/j.ijporl.2012.02.042