Acute mastoiditis in a young child

Salmah M Alharbi; Ahmed Saeed Alasiri; Khalid Talat Ardi; Yahya Dhafer Alahmari

doi:10.4103/sjoh.sjoh_39_22

CASE REPORT

Year : 2023 | Volume : 25 | Issue : 1 | Page : 34-37

Acute mastoiditis in a young child

Salmah M Alharbi¹, Ahmed Saeed Alasiri², Khalid Talat Ardi², Yahya Dhafer Alahmari²
¹ Department of Otorhinolaryngology and Head and Neck Surgery, Asir Central Hospital, Abha, Saudi Arabia
² Department of Otorhinolaryngology and Head and Neck Surgery, Abha Maternity and Children's Hospital, Abha, Saudi Arabia

Date of Submission	31-Aug-2022
Date of Decision	06-Sep-2022
Date of Acceptance	23-Oct-2022
Date of Web Publication	01-Feb-2023

Correspondence Address:
Dr. Salmah M Alharbi
Department of Otorhinolaryngology and Head and Neck Surgery, Asir Central Hospital, Abha
Saudi Arabia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoh.sjoh_39_22

Abstract

Acute mastoiditis is a serious complication of acute otitis media. It is a destructive inflammatory disease of the mastoid bone. There is no consensus on the management of acute mastoiditis in children. Proper choice of the treatment regimen according to the presentation of the patient and the patient's response to therapy is critical to prevent further complications. We report the case of a 3-month-old child with acute otomastoiditis complicated by subperiosteal and subcutaneous abscesses. He was successfully managed with intravenous antibiotics, incision and drainage of the abscesses, and myringotomy tube insertion without the need for mastoidectomy.

Keywords: Antibiotics, grommet insertion, mastoiditis, subperiosteal

How to cite this article:
Alharbi SM, Alasiri AS, Ardi KT, Alahmari YD. Acute mastoiditis in a young child. Saudi J Otorhinolaryngol Head Neck Surg 2023;25:34-7

How to cite this URL:
Alharbi SM, Alasiri AS, Ardi KT, Alahmari YD. Acute mastoiditis in a young child. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2023 [cited 2023 Jun 4];25:34-7. Available from: https://www.sjohns.org/text.asp?2023/25/1/34/369031

Introduction

Otitis media is a very common clinical condition encountered by pediatricians. Acute mastoiditis is a complication of acute otitis media. It is an inflammation of the mastoid periosteum and air cells. Diagnosis of acute mastoiditis is based on clinical evaluation and history, typically by the presence of otitis media (acute or within the past 2 weeks), otalgia, fever, protrusion of the ear pinna, and retro-auricular redness and swelling.^[1]

There are no consensus guidelines currently available for acute otitis media in children. The choice of treatment modality depends on whether the case was complicated or not and on the patient's response to therapy. Regimens include intravenous antibiotics alone or in combination with myringotomy tube placement, incision and drainage in case of abscesses, or the more radical surgical option of mastoidectomy.^[2],[3]

Subperiosteal abscess is a common complication of acute mastoiditis.^[4] Stern Shavit et al. suggested that complicated cases including subperiosteal abscesses may be more appropriately managed by surgical intervention.^[5] Here, we present the case of a 3-month-old child presenting with retro-auricular swelling and fever for 2 weeks not responding to antipyretics. His laboratory investigations showed leukocytosis, and the computer tomography (CT) findings were consistent with mastoiditis. He was successfully treated with intravenous antibiotics, abscess drainage, and myringotomy tube insertion without the need for invasive mastoidectomy. The case highlights the importance of rapid diagnosis and the choice of the right treatment plan in improving the outcome of the patient.

Case Report

A 3-month-old Saudi boy, a full term, born with normal vaginal delivery presented to Abha Maternity and Children Hospital emergency room on February 21, 2022, at 1:00 a.m. with a history of fever for the past 2 weeks not responding to antipyretics. According to his parents, 5 days after the onset of the fever, he developed a left postauricular swelling, increasing in size, and pushing the ear pinna anteriorly and downward. He had no history of lethargy, runny nose, ear discharge, ear pain, neck stiffness, cough, airway symptoms, dysphagia, or facial asymmetry.

On examination, the child was conscious, active, and looking well with average body weight. He had no cyanosis, jaundice, pallor, or facial dysmorphic features. He was vitally stable (temperature, 38 C; heart rate, 142 beats/min; blood pressure, 82/52 mmHg; respiratory rate, 32 cycles/min; and SPO₂, 95% in room air). The ear nose throat and head and neck examination (ENT) showed a left postauricular cystic swelling measuring 3 cm × 2 cm in diameter [Figure 1]. It was fixed and tender with no overlying skin color changes. It pushed the ear pinna outward, forward, and downward. There was no otorrhea or external auditory canal congestion. The tympanic membrane was intact bilaterally with no pus discharge. However, the left tympanic membrane was erythematous and bulging. Head-and-neck examination otherwise revealed no abnormal data.

Figure 1: Left postauricular cystic swelling measuring 3 cm × 2 cm in diameter

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The patient was admitted. On admission, white blood cell count was high (15,700 cells/cm³, mainly neutrophils), hemoglobin level was 9 g/dL, C-reactive protein (CRP) was 12 mg/L, and erythrocyte sedimentation rate (ESR) was 85 mm/h. We requested CT. Temporal CT scan thin cut with contrast showed loss of pneumatization of left mastoid air cells with evidence of bone erosions accompanied by a small soft-tissue component extended to the left middle ear cavity encircling intact ossicles. There was a large accompanying multiseptated cystic lesion with an enhanced wall measuring about 4 cm × 3 cm × 2.5 cm overlying the left mastoid bone, obliterating the subcutaneous fat plane. The CT showed normal and comparable width of the internal auditory canal on both sides with no cerebellopontine angle masses or enhanced lesions. The ossicular chain and inner ear structures appeared normal. There was no focal cerebral area of abnormal density. Normal gray/white matter interface was preserved. There was a normal appearance of the posterior fossa structures [Figure 2]. The findings were likely acute left otomastoiditis complicated with bone erosion and subperiosteal and subcutaneous abscesses.

Figure 2: Temporal CT scan thin cut with contrast showing loss of pneumatization of left mastoid air cells with evidence of bone erosions accompanied by small soft-tissue component extended to the left middle ear cavity encircling intact ossicles. A large accompanying multiseptated cystic lesion with an enhanced wall measuring about 4 cm × 3 cm × 2.5 cm is overlying the left mastoid bone, obliterating the subcutaneous fat plane. CT: Computer tomography

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We started the patient on clindamycin (15 mg/kg two times a day), ceftriaxone (75 mg/kg OD) divided dose, and paracetamol (15 mg/kg). The infectious disease team was consulted for dose adjustments. Clindamycin dose was changed to(10 mg/kg ) three times daily and ceftriaxone dose to (300 mg two times daily).

On February 2, 2021, the patient was transferred to the operating room. Under general anesthesia, incision and drainage of the left postauricular abscess were done. The drained pus amount was about 5 ml. Tube size 5 Fr was inserted as a drain and fixed with a single stitch by Vicryl 4.0 suture, which was removed 2 days postoperative. Myringotomy with Shah grommet size 0.76 insertion in the ipsilateral tympanic membrane was done followed by glue. Pus discharge was seen. The patient was transferred to the pediatric surgical ward.

The white blood cell count 2 days postoperative was 124,600 cells/cm³, hemoglobin level was 9.5 g/dL, and ESR was 90 mm/h. The patient was observed for 7 days. Then, he was discharged from the hospital on analgesia and antibiotics (oral augmentin 15 mg/kg three times daily for 7 days).

A hearing assessment was done on day 5 postoperative. Tympanogram showed type A in the right ear and type B in the left ear. Auditory brainstem response (ABR) assessment was done in natural sleep using click and tone burst stimuli, wave V was traced down to the following:

ABR showed normal hearing sensitivity for the right ear, whereas the left ear showed moderate low-frequency (500) peripheral conductive hearing loss and normal peripheral 2k–4k hearing sensitivity.

In the 3-month postoperative follow-up on May 17, 2022, the patient was improving, and the left postauricular wound healed without a scar. There was no ear discharge and no recollection of pus or otological symptoms. The grommet inserted was intact and dry. The right ear was normal. Repeated tympanogram showed type A in the right ear and type B with a high external canal volume of 2.4 in the left ear (which was consistent with the grommet insertion) [Figure 3], [Figure 4], [Figure 5].

Figure 3: Follow-up of 3 months postoperative. The left postauricular wound healed without a scar

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Figure 4: Follow-up of 3 months postoperative. Normal right tympanic membrane

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Figure 5: Follow-up of 3 months postoperative. Repeated tympanogram showing type A in the right ear and type B with a high external canal volume of 2.4 in the left ear

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Discussion

Acute mastoiditis is the most common intratemporal complication of acute otitis media. It is a destructive inflammatory disease of the mastoid bone. The main pathology responsible for its occurrence is the closure of the aditus ad antrum due to edema or granulation tissue preventing the drainage of the pus from the mastoid air cells.^[6]

Although the incidence of mastoiditis had been decreasing due to the advances in the field of antimicrobial agents, there is a recent increase in the incidence. The reason behind that increase is a matter of research. However, the appearance of unconventional pathogens such as penicillin-resistant pneumococci could be a possible explanation.^[7] The most common organisms associated with acute mastoiditis in children are Streptococcus pneumoniae, Streptococcus pyogenes, and Pseudomonas aeruginosa.^[4]

The initial diagnosis of acute mastoiditis is based mainly on clinical evaluation. The most commonly used diagnostic criteria are a recent episode of acute otitis media with at least two of the following symptoms: protrusion of the pinna; retroauricular (swelling, erythema, and tenderness) or abscess of the external auditory canal; or an intraoperative finding of acute mastoiditis.^[8] In our patient, a fever persisting for 2 weeks and a retroauricular swelling led to high suspicion of acute mastoiditis.

Complications of acute mastoiditis can be intratemporal (hearing loss, facial nerve injury among others) and extratemporal (sigmoid sinus thrombosis, meningitis, etc.).^[1] High fever and profound elevation of infection markers (e.g., neutrophil count and CRP) should prompt investigation for complicated infection. Favre et al. in their study on 2016 HCUB KID stated that the most common complication observed in acute mastoiditis patients was subperiosteal abscess.^[2] Subperiosteal abscess manifests with an erythematous and fluctuating tender mass over the mastoid bone.^[7]

After clinical evaluation and laboratory investigations, CT was then requested for our patient. Although mastoiditis is initially diagnosed clinically, CT is the first choice among imaging modalities. It is also helpful in detecting cranial complications. Imaging should be considered in patients when complications are suspected, patients are not responsive to conservative treatment (within 48 h), or when surgical treatment is indicated.^[9]

There are no consensus guidelines for the management of acute mastoiditis in children. The treatment plan is decided by the physician. Some prefer surgery, whereas others attempt medical therapy and observe the patient's response.^[1] The usual approach for uncomplicated acute mastoiditis is trying conservative management in the form of intravenous antibiotics with myringotomy, with or without pressure equalization tube placement.^[10]

For complicated cases, the choice of treatment modality depends on the presentation. In the case of subperiosteal abscess, the initial treatment should include myringotomy and/or tympanostomy tube placement, intravenous antibiotics, as well as incision and drainage as our patient was managed.^[7] Anne et al. reported this treatment plan to have a success rate of 86.5% in their systematic review to compare medical versus surgical treatment of acute mastoiditis in children.^[1]

Mastoidectomy is the most aggressive surgical option. It should be performed in cases with intracranial complications or in those with intratemporal complications such as petrositis or labyrinthitis. Radical mastoidectomy should be preserved for patients with otorrhea that is refractory to simple mastoidectomy.^[11] Surgery is invasive, duration of anesthesia, costs, and potential increased morbidity need to be considered.^[1]

There is also a lack of consensus about the choice and duration of antibiotic therapy. Antibiotics in acute mastoiditis should be started empirically and should cover the common bacterial pathogens. Antibiotic therapy can then be modified based on culture results.^[7] The suggested duration for therapy ranges from 2 to 4 weeks.^[4] Edwards et al. suggested that a shorter duration of courses (<10 days) can be used in patients with no intracranial extension of infection.^[12]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Anne S, Schwartz S, Ishman SL, Cohen M, Hopkins B. Medical versus surgical treatment of pediatric acute mastoiditis: A systematic review. Laryngoscope 2019;129:754-60.
2.	Favre N, Patel VA, Carr MM. Complications in pediatric acute Mastoiditis: HCUP KID analysis. Otolaryngol Head Neck Surg 2021;165:722-30.
3.	Tawfik KO, Ishman SL, Tabangin ME, Altaye M, Meinzen-Derr J, Choo DI. Pediatric acute mastoiditis in the era of pneumococcal vaccination. Laryngoscope 2018;128:1480-5.
4.	Loh R, Phua M, Shaw CL. Management of paediatric acute mastoiditis: Systematic review. J Laryngol Otol 2018;132:96-104.
5.	Stern Shavit S, Raveh E, Levi L, Sokolov M, Ulanovski D. Surgical intervention for acute mastoiditis: 10 years experience in a tertiary children hospital. Eur Arch Otorhinolaryngol 2019;276:3051-6.
6.	Cassano P, Ciprandi G, Passali D. Acute mastoiditis in children. Acta Biomed 2020;91:54-9.
7.	Tahir E, Kurnaz SÇ, Sprinzl GM. Mastoiditis. In: Pediatric ENT Infections. Nature Switzerland: Springer; 2022. p. 393-406. doi: 10.1007/978-3-030-80691-0 34.
8.	Laulajainen-Hongisto A, Aarnisalo AA, Jero J. Differentiating acute otitis media and acute mastoiditis in hospitalized children. Curr Allergy Asthma Rep 2016;16:72.
9.	Marom T, Roth Y, Boaz M, Shushan S, Oron Y, Goldfarb A, et al. Acute mastoiditis in children: Necessity and timing of imaging. Pediatr Infect Dis J 2016;35:30-4.
10.	Fujiwara RJ, Alonso JE, Ishiyama A. Temporal trends and regionalization of acute mastoiditis management in the United States. Otol Neurotol Publ Am Otol Soc Am Neurotol Soc Eur Acad Otol Neurotol 2021;42:733-9.
11.	Kordeluk S, Kraus M, Leibovitz E. Challenges in the management of acute mastoiditis in children. Curr Infect Dis Rep 2015;17:479.
12.	Edwards S, Kumar S, Lee S, Pali BL, Marek RL, Dutta A. Epidemiology and variability in management of acute mastoiditis in children. Am J Otolaryngol 2022;43:103520.