Indications for surgery in

acute mastoiditis and

their complications in children
 Objective

To review the clinical charts of 45 paediatric

patients treated foracute
otomastoiditis at the ORL Department of the
University of Brescia (Italy) between January 1994
and March 2005 and to discuss the diagnostic
workup and the outcome of treatment.
 26 males

19 females
45 patiens

32 intracranial uncomplication

13 with intracranial complication

3 not operated 20 therapy

conservative

1 with VT

12 myringotomy ± VT
9 with mastoidectomy
 Results:

 Antibiotics alone or with VTs achieved a full

recovery in 28 (uncomplication)
 Mastoidectomy resolved the disease in 13
patients (9 with complications) a canal wall down
(CWD) (n = 2) or an intact canal wall (ICW)
mastoidectomy (n = 7)
 uncomplicated cases that were operated upon,
the mean hospital stay was 7.8
 In children with intracranial complications the
mean hospital stay was 12.8 days
Conclusion:

Acute mastoiditis can fully recover with

conservative treatment or
myringotomy + VTs.

surgical treatment is indicated for intracranial

complications, if the neurological conditions
are not critical

A simple mastoidecto-my tympanoplasty is

warranted in: (1) exteriorization, if the child is
older than 30 months or >15 kg of weight, (2)
intracranial complications (combined with
aneurosurgical procedure as needed) and (3)
cholesteatoma or granulation tissue.
Introduction
The incidence of mastoiditis in
the paediatric age has
consistently increased over
the last two decades even in
industrialized countries .
The same negative trend has
been observed for suppurative
intracranial complications .
Abuse of or inade-
quacy of antibiotic treatment
have been attributed a role in
selecting resistant bacterial
strains.
The dilemmas that the otologist is facing when
ealing with mastoiditis are:
1. the indications for a surgical treatment;
2. the timing of surgery (immediate versus delayed)
3. the choice of the surgical procedure
The objective of this study was to review the
clinical charts of 45 paediatric patients
admitted to the ENT Department of the
University of Brescia for acute otomastoiditis
and discuss the diagnostic workup and the
outcome of treatment.
Materials and methods
45 childrenwere age ranged between 2 months and 15
years(mean 5.2 years). There were 26 males and
19females. Thirteen of them (28.9%) presented a
intracranial complication at admission.
 Exteriorization in the deep neck spaces (Bezold’s
abscess) wasobserved in one 6-year-old boy
 Retroauricular swel-ling

 skin redness

 tenderness

 pain at palpationof the mastoid region was the typical

picture for 30little patients
 while 15 others were admitted withfowl smell otorrhoea
(n = 13) and/or torticollis(n = 3) or trismus (n = 1). Fever
was present in 29patients, headache in 3
At the time of admission, eight patients had been
already taking oral antibiotics for 2—10 days (mean
6.1 days). The drugs prescribed by the family
pediatricians had been cephalosporines (n
=4)macrolides(n = 3) and amoxicillin (n = 1). Swabs
for bacteria culture were obtained in 27 children at
the time ofsurgery either by exploratory puncture or
collection of purulent material from the ear canal.
A computerized tomography (CT) scan of the
brain and a high definition study of the temporal
bone was urgently requested at admission when an
intracranial complication was suspected (n =6)
(Figs. 1 and 2). The CTscan was otherwise postponed
(within 24—72 h) in other 11 children. An imaging
study was not deemed necessary for 28 children
because of the benign clinical course of the disease.
An MRI helped defining the complications.
SIGMOID INUS THROMBOSIS (SST) (N = 7) WAS ASSESSED BY MEANSOF
CTSCAN WITH I.V. CONTRAST AND ANGIO-MR IN SELECTED CASES.
Ultrasound Doppler flowmetrydetected thrombosis
of the internal jugular vein(IJV) in the neck in
three of them. Blood clotting laboratory tests
excluded a thrombophylic diathesis.Two of
thekidswithSST presentedwithVI nervepalsy,due
to theextension of thethrombus to thecavernous
sinus. Three little patients with SST developed
anepidural abscess in the posterior cranial fossa.
Intra-parenchymalmultiple abscesses occurred in
another,without SST. Meningitis, confirmed by
cerebrospinal fluid analysis through lumbar
puncture, was encoun-tered in six patients, two
of which with SST.
All patients underwent immediate i.v. antibiotic
treatment based on regional bacterial prevalence
rates provided by the Institute of Microbiology of the
University of Brescia It consisted of :

ampicillin/
sulbactam (50 mg/kg t.i.d.) during their whole hos-
pital stay, associated, in selected cases with ami-kacin sulphate
(7.5 mg/kg b.i.d.) or netilmicin sul-
phate (3 mg/kg b.i.d.) for 6 days.
 The non-surgical patients were discharged
after an average of 4.45 days and the surgically
treated children after 13.56 days.

All of them continued an oral antibiotic

(40 patients: amoxicillin/clavulanic acid 25 mg/kg
b.i.d.; 4 patients: a third generation cephalosporin
active against Pseudomonas aeruginosa) for 10—15
days. All the non-surgical children were visited in
the office 1 week after discharge and on an indivi-
dualized basis thereafter.
surgery was undertaken within the first 72 h since
admission.

The timing of surgery depended upon the general condition of the

patient and extension and complications associated with the
mastoiditis.
Results
 Long-term follow-up (range 12—37
months) docu-mented a complete recovery
in all 45 children

CT scan identified 13 intracranial

complications.

Twelve out of the 32 patients who had uncompli-

cated mastoiditis (37.5%) and 10 out of 13 children
with an intracranial complication (77%) underwent
surgery (Table 2). A myringoplasty was associated to
themastoidectomy in three instances
seven children with 5 ICW
SST underwent a
mastoi-dectomy

2CWD

Overall, the mean

hospital stay for SST
patients was 7.8 days
 32 uncomplicated cases

20 conservative
12 the surgical
management withantibio-
treatment,. , the mean
tics alone. , the mean
hospital stay 5,6days
hospital stay 4,2 days
Discussion
middle ear infections involves the
mastoid cellular tract, a
subperiosteal abscess or an
exteriorization into the neck
(Bezold’sabscess) .Acute mastoiditis
can develop without a previous
history of recurrent AOM or after a
single episode of AOM. A ‘‘masked’’
mastoiditis should be suspected if
there is persistent pain or otorrhoea
despite 2 weeks of antibiotic
treatment
Antibiotic treatment prior to admission does not
seem to prevent the onset of mastoiditis.
The CT yields a sensitivity of 97% and a positive
predictive value of 94% in detecting intracranial
complications .
SIGN MASTIODITIS

indicated by resorption of bony trabecula and

erosion of the cortical bone
 If a complication is found, MRI should follow,
to help the surgical planning.
The commonest complication in the present
study was SST (n = 7).
Meningitis was the second most common neuro-
ogical complication (n = 6).
some studies point out that no statis-
tically significant differences are observed between
the cure rates for children treated with myringoto-
mies + VTs and those managed more aggressively
with mastoidectomies.
we agree with the
clinical studies that recommend mastoidectomy
only for complications or failures to improve with
antibiotics and myringotomy.
In the uncomplicated cases who were operated
upon, themean hospital stay was 7.8 days versus
4.3 days for the conservative group, whereas for
patients with intracranial complications the mean
hospital stay was 12.8 days (range 8—21), signifi-
cantly less than in the four non-surgical patients,
who remained hospitalized for an average of 18
days
!!!!!
Reluctance to perform a mastoidectomy is mainly
related to the anesthesiological risks in very small
children, although excessive blood loss is absolutely
rare
 Myringo-Tomies ± VTs were
reserved for children with
con-sistent retroauricular
swelling and bulging of
theeardrum.

When intracranial complications are identified,

otologic surgery is carried out soon after the neu-
rosurgical procedure, in order to clear the source of
infection. It can be performed in the same surgical
 Overall, all children with intracranial complica-
tions who submitted to a mastoidectomy, eitherICW
(n = 7) or CWD (n = 2) achieved complete control of
theirmastoiditis.
indi-cations to mastoidectomy for acute mastoiditis are
the following: (1) exteriorized mastoid abscess,
age > 30 months (or weight > 15 kg), (2) intracra-
nial complications, (3) cholesteatoma and (4) puru-
lent otorrhoea and/or granulation tissue, resistant
to topical and systemic antibiotics for more than 2
weeks.
Conclusions
 Mastoidectomy is an effective treatment for acute
mastoiditis associated with one of the following:
subperiosteal abscess or exteriorization, cholestea-
toma, intracranial complications and otorrhoea per-
sisting for more than 2 weeks despite adequate
antibiotic treatment, in children >15 kg of weight.
 procedure is to clear the sup-
purative process in the mastoid cell tract, avoiding
the risk of further intracranial spread, and re-estab-
lish a ventilation route through the aditus ad
antrum.
Mastoydectomi did not add morbid-ity to the pathology and
achieved complete recov-ery in all cases in whom it was
performed. Whenindicated, it is preferably performed within 48—
72 h.
 Early myringotomy is advocated in smaller
babies with the typical acute mastoiditis. Following
these rules, all our children recovered completely at
1 year follow-up. Children with intracranial compli-cations
remained in the hospital for a longer period
if they were not operated upon (18 days versus 12.8
days), related to greater severity of the disease.