Otology & Neurotology
29:751Y757 Ó 2008, Otology & Neurotology, Inc.
A Systematic Review of Diagnostic Criteria for Acute
Mastoiditis in Children
*Maaike T. A. van den Aardweg, *†Maroeska M. Rovers, *J. Alexander de Ru,
*Frans W. J. Albers, and *Anne G. M. Schilder
*Department of Otorhinolaryngology, and ÞJulius Centre for Health Sciences and Primary Care, University
Medical Centre Utrecht, Utrecht, The Netherlands
Objective: To review systematically the literature for the cur-
rent criteria and strategies used to diagnose acute mastoiditis in
children.
Method: A comprehensive literature search was performed in
PubMed, Embase, and the Cochrane Library of studies on the
diagnosis of acute mastoiditis in children published between
January 1980 and September 2007. The study type and setting,
diagnostic criteria for acute mastoiditis, disease-specific history,
presenting otologic and systemic signs and symptoms, diagnos-
tic procedures, and final diagnosis were identified.
Results: The initial search resulted in 1,057 articles. The inclu-
sion criteria were met in 65; 44 were retrospective case series,
and 21 were case reports. These studies included 2,109 children
with a median age of 32 months (range, 0 moY18 yr). Only 26
of 65 articles reported the criteria upon which the diagnosis of
acute mastoiditis in children was based. The criteria most fre-
quently used were the clinical signs of postauricular swelling,
erythema, tenderness, and protrusion of the auricle. The most
Until the 1950s, acute mastoiditis was a frequent com-
plication of acute otitis media in children. With the intro-
duction of antibiotics and improved overall health, the
incidence has declined drastically (1Y3). Current inci-
dences of acute mastoiditis in children in Europe, Austra-
lia, Canada, and the United States are estimated at 1.2 to
3.8 per 100,000 person years (4). Recently, some authors
have suggested that the incidence of acute mastoiditis is
rising again in association with growing antimicrobial
resistance (5Y7). However, convincing scientific evidence
has not been provided to date.
The best management of acute mastoiditis in children is
currently an issue of debate. In particular, the indications
for surgical intervention in addition to broad-spectrum
Address correspondence and reprint requests to Anne G. M. Schilder,
M.D., Ph.D., Department of Otorhinolaryngology, Wilhelmina Children’s
hospital, University Medical Center Utrecht, HP nr. 04.140.5, PO Box
85090, 3508 AB Utrecht, The Netherlands; E-mail: A.Schilder@
umcutrecht.nl
751
Copyright @ 2008 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
frequently used imaging modality was computed tomographic
(CT) scanning (reported in 39 of 65 studies, performed in 68%
of patients). The most frequently used laboratory test was white
blood count (100% of patients in 45 of 65 studies). In 63
studies, the result of culturing from the otomastoid was
reported: Streptococcus pneumoniae was the most frequently
isolated bacterium.
Conclusion: Acute mastoiditis in children is an entity that is
poorly evaluated and understood in the modern literature. There
is a lack of consensus regarding the criteria and strategies for
diagnosing acute mastoiditis in the pediatric population. It is
crucial that such criteria are established, and consensus is
achieved so that prognostic and controlled studies can be
initiated to identify risk factors and establish the most effective
management of this condition in children. Key Words: Acute
mastoiditisVAcute otitis mediaVChildrenVDiagnosisVDiagnostic
criteriaVOtomastoiditisVSystematic review.
Otol Neurotol 29:751Y757, 2008.
antibiotics are uncertain. This raises the question whether
there is consensus on the clinical entity acute mastoiditis.
Textbook criteria for diagnosing acute mastoiditis are
either signs of acute otitis media (AOM) on otoscopy
and local inflammatory findings over the mastoid or
local inflammatory signs over the mastoid process and
radiographic or surgical findings of mastoiditis (with no
signs of AOM) (8). These criteria, however, allow a con-
siderable variation regarding the interpretation and appli-
cation in clinical practice.
The aim of this article is to review systematically the
literature for the current criteria and strategies used to
diagnose acute mastoiditis in children.
MATERIALS AND METHODS
Search Strategy
PubMed, EMBASE, and the Cochrane library were searched
to identify articles reporting on the criteria and strategies used
752 M. T. A. VAN DEN AARDWEG ET AL.
FIG. 1. Search strategies.
to diagnose acute mastoiditis in children during the period
January 1980 to September 2007. In addition, a reference
search was performed. The search strategy and syntax are pre-
sented in Figure 1.
Study Selection
Two reviewers (M.T.A.v.d.A. and A.G.M.S.) screened the
identified titles and abstracts independently without blinding
the authorship or the name of the journal. Potentially relevant
studies were selected, and the full text was examined. Discrep-
ancies between reviewers were resolved by discussion. Criteria
for inclusion in this survey were written in the English lan-
guage, available in full text, the topic was acute mastoiditis
or subperiosteal abscess, data concerning acute mastoiditis
were reported separately from those concerning other condi-
tions (e.g., intracranial complications of otitis media), data
were not included in more recent articles, and data were of
children younger than 18 years of age or data concerning chil-
dren were reported separately from those concerning adults.
Data Extraction
The following information was extracted from each article:
study type, period of data sampling, setting and country, the
condition(s) studied in the article, including special inclusion or
exclusion criteria, diagnostic criteria for acute mastoiditis, num-
ber of patients included, their mean age, and sex ratio. Clinical
information were also extracted, including previous history of
AOM, use of antibiotics before hospital admission, duration of
current symptoms of acute mastoiditis, and current otologic and
systemic signs and symptoms; diagnostic information, includ-
ing laboratory tests, the number of children of whom blood,
otomastoid, or cerebrospinal fluid was cultured; and the number
of children who underwent imaging (mastoid radiograph, com-
puted tomography, magnetic resonance imaging), including the
results and the criteria used in these procedures for diagnosing
acute mastoiditis; and the final diagnosis based on the diagnos-
tic workup (mastoiditis, subperiosteal abscess, intracranial
complication).
All percentages included in this systematic review (Fig. 2;
Tables 1 and 2) are averages obtained by adding up all percent-
ages for a particular item and dividing it by the number of
studies that included this item.
Otology & Neurotology, Vol. 29, No. 6, 2008
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Because of significant heterogeneity between the identified
studies, pooling of the outcomes was not possible. The results
of the studies are therefore reported separately.
RESULTS
Search Strategy
With PubMed, 308 articles were identified, of which
59 met the inclusion criteria. A search of EMBASE and
the Cochrane Library revealed no additional studies for
inclusion. A reference search identified 6 related articles
that met the inclusion criteria (Fig. 1) (3,5Y7,9Y69).
Population and Criteria for Acute Mastoiditis
Of the 65 relevant articles, 44 were retrospective case
series, and 21 were case reports (level of evidence, 4)
(70). The period of data sampling ranged from 1955 to
2006 (Table 1). Most of the data reported in the articles
originated from 1980 onward. Most articles concerned
acute mastoiditis in children from the United States, Eu-
rope, and Israel. The conditions studied apart from acute
mastoiditis, otomastoiditis, and subperiosteal abscess
were intratemporal and intracranial complications of
acute otitis media. The criteria upon which the diagnosis
acute mastoiditis was based were included in only 26
articles. These criteria varied strongly. Postauricular
swelling, erythema, tenderness, and protrusion of the
auricle were the most frequently reported diagnostic cri-
teria. A recent episode of AOM was considered a crite-
rion for the diagnosis of acute mastoiditis in 16 articles
and radiologic confirmation in 6.
The studies comprised 2,109 patients (range, 1Y205
patients per article), of which 1,050 were boys and 759
were girls. The average age was 39 months, and the
median was 32 months (range, 0 mo Y18 yr).
Clinical Signs and Symptoms
On average, 42% of the children (range, 0Y100%)
had a previous history of otologic disease. The average
 ACUTE MASTOIDITIS IN CHILDREN 753

duration of symptoms suggestive of acute mastoiditis
was 9.8 days (range, 1Y42 d). At the time of admission,
54% of the patients were on antibiotic therapy (range,
1Y100%).
Otologic signs and symptoms were reported in 59 of
65 studies (Fig. 2). Postauricular swelling or fluctuation,
erythema, tenderness, and abnormal tympanic membrane
were the most frequently reported symptoms in 48, 35,
23, and 17 studies, respectively; on average, they were
present in 85, 82, 81, and 82% of the patients, respec-
tively. Tympanic membrane abnormalities were specified
in 15 studies and reported as 1 entity in 17 studies. A

FIG. 2. A, History and physical examination findings of patients included in the review. B, Diagnostic procedures performed in children
suspected of acute mastoiditis and its results.

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754 M. T. A. VAN DEN AARDWEG ET AL.

FIG. 2. (continued).

recent history or current signs of AOM were reported in Laboratory Testing

only 5 studies; on average, they were present in 80% of
the patients.
Systemic signs and symptoms were reported in 54
studies (Fig. 2). Fever was the most frequent sign, pres-
ent on average in 76% of the patients in 46 of 65 studies.
Forty-five studies included data on hematologic lab-
oratory tests. The most frequently used laboratory test
was white blood count (100% of patients in 45 articles;
Fig. 2). A number of studies reported only the number of
children with abnormal test results without providing the

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 ACUTE MASTOIDITIS IN CHILDREN 755

TABLE 1. Specifications of 65 articles on acute mastoiditis a common pathogen in AOM, was isolated in only 13%
included in the review, diagnostic criteria for acute mastoiditis, of the cultures. No growth was found in 36% of the
and general characteristics of the study population cultures, as reported in 42 studies. It is possible that
Research type (n = 65) n bacteria such as Proteus mirabilis are underestimated
because in some studies, less frequent bacteria are
Retrospective case series 44 grouped under the heading Bother bacteria.[
Retrospective case reports 21
Period of data sampling (overall, 1955Y2003)
1955Y1979 12a Blood and Cerebrospinal Fluid Cultures
1980Y1989 29a Blood cultures were reported in 17 studies and per-
1990Y2006 43a formed on average in 66% of the patients (range,
Setting 1Y100%). Data on cerebrospinal fluid cultures, as ob-
Tertiary/academic center 48
General center/unspecified 17 tained by lumbar puncture, were included in 11 studies,
Primary setting None and the percentage of patients who were tested was 52
Continent/country (range, 5Y100%). In 3 studies, the cultures of otomastoid
Europe 22b fluids, blood, and cerebrospinal fluids were grouped
United States 24b
Israel 12 together and labeled as Ball cultures.[
Australia 3
Asia 4 Imaging
Africa 1 In total, 48 studies reported on performed imaging
Condition studied techniques (Fig. 2). Neither the criteria upon which a
Acute (coalescent) mastoiditis 54
Surgically treated acute mastoiditis 5 positive imaging result was based nor the results of
Subperiosteal abscess 2 imaging were routinely included in these articles. Data
Surgically treated subperiosteal abscess 1 on mastoid radiography were included in 26 studies and
ITC/ICC (suppurative) of AOM or AMc 3 performed in 68% of the patients on average (range,
Diagnostic criteria for acute mastoiditisd (n = 26) 4Y100%). In 39 studies, CT scanning was reported and
Postauricular swelling 22
Postauricular erythema 20 performed in 68% of the patients on average (range,
Postauricular tenderness 19 3Y100%). Magnetic resonance imaging scanning was
Protrusion of auricle 18 reported in 9 studies and performed in 30% of the
Local inflammatory signs over mastoid 1 patients (range, 5Y100%). Magnetic resonance imaging
Sagging external ear canal 1
Recent episode of (sub)acute otitis media 16
was usually performed to diagnose or exclude sigmoid
Middle ear effusion/otorrhea 2 sinus thrombosis.
Blurred tympanic membrane 1
Systemic signs of infection 1
Fever 2 Final Diagnosis
Radiologic confirmation 6 Mastoiditis was the final diagnosis in 100% of the
No. patients patients following the previously mentioned diagnostic
2,109 patients overall (range, 1Y205 patients per article) workup (Table 2). A subperiosteal abscess was diag-
Age (n = 56) nosed in 58% of those patients on average (range,
Mean, 39 mo
Median, 32 mo (range, 0 mo Y18 yr) 3Y100%), as reported in 35 studies.
Sex
1,050 males/759 females TABLE 2. Final diagnosis based on previous diagnostic
a
workup
Most article samples from more than 1 period.
b
One article has setting both in Germany and the United States. Mean, % Range, %
c
Intratemporal complications or intracranial complications of acute
otitis media or acute mastoiditis. Mastoiditis (n = 64) 100 83Y100
d
Most articles report multiple items; therefore, they do not add up Subperiosteal abscess (n = 35) 58 3Y100
to 26. Intracranial complication (n = 42) 17 2Y100
AM indicates acute mastoiditis; AOM, acute otitis media; n, number Sigmoid sinus thrombosis (n = 14) 20 1Y100
of articles reporting item. Meningitis (n = 11) 12 2Y50
Cerebritis (n = 2) 4 3Y5
Epidural abscess (n = 10) 20 1Y100
number of children who underwent such testing. There- Subdural abscess (n = 5) 22 1Y100
fore, it was not possible to extract the number of patients Perisinus empyema (n = 1) 6 6
who underwent laboratory testing and the corresponding Cerebellar abscess (n = 2) 4 2Y6
percentage of children with abnormal results. Intracranial abscess (n = 3) 2 1Y3
Intracranial extension petrous apex empyema 6 6
(n = 1)
Microbiological Cultures Otitic hydrocephalus (n = 2) 1 1
Otomastoid cultures were reported in 63 studies and Raised intracranial pressure (n = 1) 1 1
were performed on average in 88% of patients (range,
All percentages are averages obtained by adding up all percentages
0Y100%). Streptococcus pneumoniae was the most fre- for a particular item and dividing it by the number of studies that
quently cultured pathogen, in 43% of the cultures on included this item.
average, in 50 studies (Fig. 2). Haemophilus influenzae, n indicates number of articles reporting the item.

Otology & Neurotology, Vol. 29, No. 6, 2008

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756 M. T. A. VAN DEN AARDWEG ET AL.
An intracranial complication was diagnosed on aver-
age in 17% of the patients presenting with acute mastoid-
itis (range, 2Y100%) in 42 studies. Sinus thrombosis,
subdural and epidural abscess, and meningitis were the
most commonly reported intracranial complications.
DISCUSSION AND RECOMMENDATIONS
To our knowledge, this is the first systematic review of
strategies for diagnosing acute mastoiditis in children.
All studies included were retrospective case reports or
series, the highest level of evidence being 4 (70).
Current criteria for diagnosing acute mastoiditis in
children are diverse. Therefore, it is not possible to pro-
vide an evidence-based diagnostic algorithm for acute
mastoiditis on the basis of this review.
Four large retrospective case series by Luntz et al. (71),
Migirov et al. (72), Petersen et al. (73), and Vassbotn
et al. (74), reporting data of 223, 49, 79, and 57 patients,
respectively, were excluded from this review because the
study population included both adults and children, and
these data were not reported separately. However, over-
all, the data in these articles correspond with the findings
in this review.
A limitation of this review is that some authors do not
report whether children with cholesteatoma are excluded
from their study. Others explicitly report to have excluded
these children (37,39,41,56,59,69). In the studies pre-
sented by Spratley et al. (7), Cohen-Kerem et al. (20),
Harley et al. (28), Hawkins and Dru (29), and Tarantino
et al. (62), 2 of 43, 1 of 44, 2 of 57, 1 of 54, and 1 of 40
children with acute mastoiditis were found to have a
cholesteatoma, respectively. Because acute mastoiditis
complicating cholesteatoma is a discreet entity, we rec-
ommend that these cases are excluded from future stud-
ies on acute mastoiditis.
Another limitation concerns the fact that significant
heterogeneity between the identified studies prevented
us from pooling the outcomes. Therefore, clinically
important issues such as concordance of clinical findings
with CT evidence of coalescence of the mastoid could
not be studied. We recommend that such relevant disease
characteristics are included in future prospective studies.
In conclusion, acute mastoiditis in children is an entity
that is poorly evaluated and understood in the modern
literature. There is a lack of consensus regarding the
criteria and strategies for diagnosing acute mastoiditis
in the pediatric population. We think it is crucial that
such criteria are established, and consensus is achieved
so that future prognostic and controlled studies can be
initiated to identify risk factors and establish the most
effective management of this condition in children.
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