FALLS CHURCH, Va. - Acute otomastoiditis has reportedly been on the rise among children in a Northern Virginia practice, and should alert physicians that withholding antibiotics in acute otitis media (AOM) cases is not always appropriate, according to Richard H. Schwartz, MD, department of pediatrics, Inova Hospital for Children.
Although mastoiditis was common in the United States before antibiotics were used to treat acute otitis media, it has become rare with the advent of antimicrobial treatment. Some European countries, which do not routinely prescribe antibiotics for AOM, have experienced an increase in mastoiditis, but there are few cases in the United States.
Between 1992 and 1997, a total of 17 previously well, middle-class children, two of whom were pediatric patients from Schwartz's practice, were treated with antibiotics for acute mastoiditis, and most underwent surgical drainage, Schwartz said. The alarming fact, however, is that 12 of the cases were diagnosed between January 1997 and March 1998. Previous studies of mastoiditis have shown an annual incidence of zero to two cases.
Schwartz stressed that the 17 cases represented a significant increase in a serious and previously uncommon disease, and while the reasons for the increase are unclear, he said physicians should reconsider the growing trend to withhold antibiotic therapy from children diagnosed with AOM.
"We do not know the reason for the increase. We suspect it is partially due to resistant pneumococcus in addition to other factors. It is not likely due to just one thing," he said.
Physicians might want to consider discussing with parents the discretionary use of herbal or homeopathic alternative medicines to treat AOM, according to Schwartz.
Schwartz, a member of the Infectious Diseases in Children editorial advisory board, and his colleagues conducted a study on the significant rise in acute mastoiditis cases observed in his practice in suburban Northern Virginia.
An increase in reported acute mastoiditis cases was also noted in San Diego and Houston, according to the study results.
The 17 children in the study, 10 girls and seven boys, ranged in age from 3 months to 12 years with a median age of 26 months. None of the children were immunosuppressed, and none had received corticosteroids prior to the onset of acute mastoiditis.
Twenty percent of the children had history of recurrent AOM, but any child with chronic AOM or cholesteatoma was excluded because of the pathogenesis and bacteriology of these conditions are different from those of acute mastoiditis.
The middle ear or mastoid pathogens are somewhat different than the "big three" usually implicated in uncomplicated acute otitis media, according to the literature. Mastoiditis is generally caused by Streptococcus pneumoniae, S. pyogenes and Staphylococcus aureus, but virtually exclude Haemophilus influenzae and Moraxella catarrhalis. Positive pathogenic bacteriologic specimens were obtained from seven of the 14 patients cultured. S. pneumoniae was cultured in four patients, and S. pyogenes as found in three patients.
Every child presented with distinct signs of forward, and often downward, displacement of the auricle, in addition to painful cellulitis over the mastoid region, Schwartz explained. Thirteen children had recorded temperatures in excess of 38.2° C. Sixteen children had clinical signs of AOM (bulging of the ipsilateral tympanic membrane, opacification, inflammation and immobility during pneumootoscopy). The remaining child presented with otorrhea in addition to signs of acute mastoiditis.
Oral antibiotics were prescribed by pediatricians to eight children for AOM within a few days prior to the development of acute mastoiditis. Computerized tomographs (CT) were obtained on 15 children.
All children received intravenous antibiotics and 14 children underwent some surgical procedure but few required mastoidectomy: myringotomy with tympanostomy tubes (n=7), myringotomy without tympanostomy tubes (n=3), or mastoidectomy, myringotomy and tympanostomy tubes (n=4).
Four children received cortical (simple) mastoidectomy only after these children failed to respond adequately to less invasive management strategies, Schwartz said. If a satisfactory clinical response does not occur within 36-48 hours of initiation of appropriate targeted antimicrobial therapy for acute mastoiditis, contrast-enhanced, thin section CT should be performed promptly and mastoidectomy should be seriously considered if there is a subperiosteal abscess or coalescent mastoiditis.
Mastoid surgery should be limited to children with extensive disease of the mastoid system or to complications such as subperiosteal abscess, coalescent mastoiditis and dural sinus thrombosis. If this condition is discovered early enough, these types of surgeries can be prevented, Schwartz said.
Sixteen children were hospitalized and the remaining child was managed in the otolaryngologist's office and received a course of home intravenous (IV) antibiotics.
At the time of surgery, free suberiosteal pus and/or granulation tissue was found in three patients. One additional children had a negative CT scan, failed to improve after a course of IV antibiotic therapy and was found at surgery to have periostitis of the mastoid bone. Two children had suppurative extra-otomastoid complications that required more than 40 days hospitalization.
One child had dural and internal jugular vein thrombophlebitis and an early Bezold's abscess, resulting in the dissection of the mastoid abscess into the fascial planes of the neck.
The other child also developed dural sinus thrombophlebitis with altered mental status and seizures.
Schwartz said it is possible that not enough pediatricians are aware of this condition. "We get very little training in it. We know what it is and what it's a complication of, but that's it," he said.
For example, there is a condition described as sagging of the posterior canal wall. An extension of the mastoid and middle ear occurs, followed by a draining ear or very inflamed eardrum.
This causes the subcutaneous tissue of the bony part, the inner one-third of the ear canal, to become extremely swollen; the inner canal wall then starts to close. Some physicians then diagnose this as otitis externa and treat it the wrong way, he explained.
"Pediatricians must be aware that this is a possible sign of acute mastoiditis. Just because you do not see the eardrum does not mean the eardrum is not involved in this condition," he said. "If you have a sagging downward and pushing outward of the auricle, that's it until you prove otherwise."
The goal now is to catch it early to reduce the incidence of aggressive mastoid surgery, he added.
For more information:
- Ginsburg CM, Rudoy R, Nelson JD. Acute mastoiditis in infants and children. Clin Pediatr. 1980;19:549-53.
- Bluestone CD, Klein JO. Intratemporal complications and sequelae of otitis medial. In: Blueston CD, Stool SE, Denna MA, eds. Pediatric Otolaryngology. Philadelphia, Pa: WB Saunders; 1996: 618-624.
You can express your views on this article, or other relevant themes, in the Infectious Diseases in Children Specialty Forums.