Scandinavian Journal of Infectious Diseases, 2014; 46: 9–13
ORIGINAL ARTICLE
Changes in acute mastoiditis in a single pediatric tertiary medical center: Our experience during 2008–2009 compared with data for 1983–2007
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ACHYIA Z. AMIR1,2, RONEN POMP1,2 & JACOB AMIR2,3 From the 1Department of Pediatrics B, Schneider Children’s Medical Center of Israel, Petach Tikva, 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, and 3Department of Pediatrics C, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel
Abstract Objective: The objective of this study was to assess clinical reports and bacteriological changes over a 25-y period in children with acute mastoiditis. Methods: The medical files of all children with a discharge diagnosis of mastoiditis, hospitalized in a tertiary pediatric medical center over a 2-y period (2008–2009), were reviewed and compared to previously published data from the same center for the y 1983–1985, 1993–1995, and 2003–2007. Results: One hundred and thirty-four children (143 episodes) with acute mastoiditis were identified during 2008–2009; 81% had fever, 95% auricular displacement, and 80% post-auricular swelling. Forty-nine children were diagnosed with acute otitis media and had been treated with antibiotics prior to hospitalization. However, 22% showed no clinical symptoms preceding ear protrusion. Cultures grew Streptococcus pneumoniae in 32%, Streptococcus pyogenes in 20%, Pseudomonas aeruginosa in 13%, and Haemophilus influenzae in 10% of cases. From 1990 to 2005, the incidence of S. pyogenes isolation increased from approximately 5% to 20%. During this period, the number of cases increased from 8–20 to 67 per y. Conclusions: S. pyogenes has emerged as a significant pathogen. We found that acute mastoiditis may appear without preceding symptoms in approximately 22% of cases.
Keywords: Acute otitis media, mastoiditis
Introduction Acute mastoiditis, the inflammation of the mastoid process of the temporal bone, is a common and serious complication of acute otitis media. Mastoiditis, if not promptly treated, may cause serious complications such as deep neck infection (Bezold’s abscess), meningitis, abscess formation (sub-periosteal, epidural, or subdural), sigmoid sinus thrombosis, hearing loss, vertigo, and facial nerve palsy [1]. In the pre-antibiotic era, acute mastoiditis was a common disease with complications occurring in 20% of acute otitis media episodes [2]. With the introduction of antibiotics and the use of tympanic ventilation tubes, the rate of acute mastoiditis decreased substantially from 0.4% of acute otitis media cases in a series from 1959 to 0.004% in 1989 [3,4].
Complications have been reported in 4–17.9% of cases [5–13]. However, over the past 20 y, several studies have observed ongoing changes in disease epidemiology and natural history, such as an increasing incidence of the disease [4,10,12,14–17], a rapid progressive course independent of antibiotic treatment [18–20], and changing pathogens [14,21]. The goal of this study was to assess clinical reports and bacteriological changes that have occurred over a 25-y period in a single tertiary medical center.
Methods A retrospective study design was used. All medical files of children (⬍ 18 y) with a discharge diagnosis of mastoiditis, diagnosed and hospitalized in the
Correspondence: J. Amir, Department of Pediatrics C, Schneider Children’s Medical Center of Israel, 14 Kaplan Street, Petach Tikva 49202, Israel. Tel: ⫹ 972 3 925 3775. Fax: ⫹ 972 3 925 3801. E-mail: [email protected] (Received 16 May 2013 ; accepted 17 September 2013) ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2013.849814
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A. Amir et al.
Schneider Children’s Medical Center of Israel, a tertiary pediatric medical center located in central Israel, over a 2-y period (1 January 2008 to 31 December 2009) were reviewed. Acute mastoiditis was diagnosed clinically according to physical and otoscopic findings, i.e. otoscopic evidence of acute otitis media on admission or within 2 weeks prior to admission, and the presence of at least 1 physical finding: auricular displacement or post-auricular swelling. Children not meeting these criteria, those without a clear diagnosis of acute mastoiditis, and children with chronic middle ear disease, foreign bodies, cholesteatomas, or cochlear implants were excluded. Data obtained from the medical files included demographics, relevant medical history, treatment prior to hospitalization, signs and symptoms on presentation, clinical data during hospitalization, and outcomes. Cultures were obtained from all patients by tympanic paracentesis, sub-periosteal abscess aspiration, or an ear canal discharge swab. ‘Reliable’ cultures were defined as those taken from tympanic paracenteses or abscess aspirates. No cultures from the external auditory canal were included in the data analysis. Clinical and microbiological data were compared to past published data from the same medical center relating to cases per year of mastoiditis and cultures since 1983 [5,14]. Similar criteria were used to diagnose acute mastoiditis. All data were retrieved only from previous articles.
recurrent otitis media. Other prior medical conditions included hyper-reactive airway disease in 8, prematurity in 6, tonsillectomy and adenoidectomy in 3, and gastroesophageal reflux disease, Pierre Robin sequence, and Warburg syndrome, each occurring once. Clinical and laboratory data We summarized the clinical manifestations of the study group on admission. The most common symptom preceding diagnosis was the appearance of fever, which occurred in 81% of episodes. Auricular displacement or post-auricular swelling was noted on the day of admission in 95% and 80% of the cases, respectively, prompting the diagnosis. Seven children were hyperpyretic (temperature of ⬎ 41.1°C) at diagnosis. Of the 143 episodes of acute mastoiditis, 31 (22%) cases showed no clinical symptoms preceding ear protrusion. The overall length of hospitalization averaged 7 days (median 6 days, range 2–27 days). Maximal values of laboratory results during hospitalization are illustrated in Table I. Ninetynine children (69%) presented with a white blood cell (WBC) count ⬎ 15,000/ml and 81 (57%) presented with an absolute neutrophil count (ANC) ⬎ 10,000/ml (1 child had neutropenia). One hundred and thirteen (79%) children had a maximal C-reactive protein level of ⬎ 4 (normal ⬍ 0.5 mg/dl). Measured acute phase reactants were unaffected by
Statistical analysis A single-tailed equal variance t-test was used for continuous variables; the Chi-square test and Chi-square test for trend were used for non-continuous variables. A p-value of ⬍ 0.05 was considered significant. The study was approved by the local institutional ethics committee.
Results One hundred and eighty-five children were diagnosed at discharge with acute mastoiditis. After reviewing the medical files, 51 children were eliminated due to chronic middle ear disease, presence of cholesteatoma, cochlear implant, ventilation tubes, or diagnosis uncertainty.The remaining 134, enrolled in the study group, had experienced 143 episodes of mastoiditis; 3 had experienced 2 infection episodes and 1 had experienced 3 episodes. The 143 episodes occurred in 74 (52%) boys and 69 girls (48%); median age was 18 months (mean 30 months). In 44 cases, there was a history of at least 1 prior episode of acute otitis media; 8 cases had a history of
Table I. Correlation between clinical data and antibiotic treatment prior to hospitalization in 143 episodes of mastoiditis in children.
All episodes WBC (⫻ 103/ml) Mean 17.9 Median 17.4 ANC (⫻ 103/ml) Mean 10.8 Median 10.2 CRP (mg/dl) Mean 9.2 Median 8.3 Length of hospitalization (days) Mean 7.0 Median 6 Complications 24 (16%) Mastoidectomy 11 (7%)
No antibiotic treatment (n ⫽ 99)
Antibiotic treatments (n ⫽ 46) p-Value
18.4 18.3
16.7 15.1
0.045
11.0 10.6
10.3 8.8
0.192
9.1 8.3
9.6 8.1
0.316
6.7 6 13 (13%) 3 (3%)
7.8 6 11 (25%) 8 (18%)
0.049 0.05 0.01
WBC, white blood cell count; ANC, absolute neutrophil count; CRP, C-reactive protein.
Changes in mastoiditis in a pediatric center antibiotic treatment for acute otitis media prior to hospital admission.
(amoxicillin in 14, amoxicillin–clavulanate in 12, azithromycin in 7, and ceftriaxone on an ambulatory basis in 4). An additional 9 children received antibiotic treatment for a presumed diagnosis of pneumonia. Overall, 46 children were treated with antibiotics prior to hospitalization. Eleven (25%) of these children developed complications, compared to 13 (13%) patients without prior antibiotic treatment (p ⫽ 0.05, Table I).
Microbiological results
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Reliable cultures were obtained in 130 episodes (91%): tympanic membrane paracentesis (n ⫽ 115, 88%) and abscess aspirate (n ⫽ 15, 12%). In 3 cases, more than 1 technique was used; only the abscess aspirate data were used. Sixteen cultures grew 2 bacteria. Only common pathogens were used (contaminants such as Staphylococcus epidermidis were not used). Table II lists the main pathogens identified. Negative cultures were found in 25 episodes (17%); all were taken under antibiotic therapy. Of 105 positive isolates, the most common were Streptococcus pneumoniae (n ⫽ 34, 32% of positive cultures), Streptococcus pyogenes (n ⫽ 21, 20%), Pseudomonas aeruginosa (n ⫽ 14, 13%), and Haemophilus influenzae (n ⫽ 11, 10%). The miscellaneous bacteria were microorganisms that are not known to be a pathogen in otitis and mastoiditis, like S. epidermidis and diphtheroids.
Historical data Acute mastoiditis data from our tertiary medical center have been published in the past and are available for comparison [5,14]. During 1983–1985, 25 cases of mastoiditis were recorded, during 1993–1995 there were 61 cases, during 2003–2007 there were 308, and in the present study covering 2008–2009 there were 134 cases; this reflects yearly cases of 8, 20, 62, and 67 cases per y, respectively. The main clinical differences between the historical and the new data were a decreased mean age of 57 to 30 months at presentation and the complication rate (3.4% in 1993–1995, 17.9% in 2004–2007, and 15.6% in 2008–2009). Figure 1 details the relative incidence of the most prevalent isolated pathogens. The most interesting finding was the increased rate of S. pyogenes as a pathogen in mastoiditis, from about 5% in the early 1990s to 20% 13 y later (Chi-square test for trend p ⫽ 0.016). The incidence of isolation of P. aeruginosa declined dramatically; however we presume that this was related to a better culturing technique. Purulent discharge was used for cultures in previous studies, and all these samples were excluded in the present study [5,14].
Complications During hospitalization, 24 (18%) children underwent head imaging studies (computed tomography scans or magnetic resonance imaging) because of clinically suspected abscesses. Sub-periosteal abscesses were detected in all of these children; in 6 cases, subperiosteal abscesses were accompanied by epidural or deeper abscesses; sinus vein thrombosis appeared in 4 cases, and 1 case of facial nerve palsy was observed. A simple mastoidectomy was performed on 11 (8%) children. Of the 143 episodes, 87 (61%) were examined by a primary pediatrician prior to admission. Forty-nine children had been diagnosed with acute otitis media previously, of whom 37 were prescribed antibiotics
Discussion This retrospective study describes 143 episodes of acute mastoiditis in children requiring hospitalization
Table II. Microbiological data of 143 episodes of mastoiditis in children. Organism
Site cultured Tympanic paracentesis Abscess aspirate Total % of positive cultures aMisc.,
Streptococcus Streptococcus Pseudomonas Haemophilus Moraxella Moraxella Fusobacterium Negative pneumoniae pyogenes aeruginosa influenzae lacunata catarrhalis necrophorum Misc.a culture 29
17
14
9
0
1
0
20
25
5
4
0
2
2
0
2
0
0
34 32
21 20
14 13
11 10
2 2
1 1
2 2
20 19
25
miscellaneous: non-pathogen isolates, i.e. Staphylococcus epidermidis and diphtheroids.
12
A. Amir et al. 60 1983-1995 50
2003-2007 2008-2009
%
40 30 20 10 0 S. pneumoniae
S. pyogenes
P. aeroginosa
H. influenza
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Figure 1. Relative incidence (%) of the primary pathogens isolated from mastoiditis patients from 1983 to 2009.
in a tertiary medical center, over a 2-y period. Cases per y of mastoiditis increased approximately 3-fold from 1983–1995 to 2003–2009. Since the population base referred to our tertiary medical center increased by approximately 40% during the above time period, the increased incidence is partially explained by this. Our tertiary center is the main referral hospital in the region; however more children residing outside of the region may have been hospitalized in our center due to major improvements in transportation facilities. Another explanation may be the increase in antimicrobial resistance rates. Furthermore, delayed antibiotic therapy for acute otitis media by clinicians may also be a possible factor [22]. A significant increasing rate of mastoiditis during 1990–2001 was also reported in southern Israel, with no known cause [10]. However, others have found no trend of increasing numbers of cases per year in spite of restrictive guidelines for antibiotic treatment of acute otitis media, or an increased rate of pneumococcal isolates not susceptible to penicillin [23,24]. The decreasing age of children with mastoiditis over the years can possibly be due to changing day care attendance for young children during the different periods. The cases in this study occurred prior to the introduction of the 13-valent pneumococcal vaccine in Israel. Fever was the most common preceding manifestation, with a median duration of 2 days prior to admission. Diagnosis was made when all children had already experienced a displaced auricle and/or post-auricular swelling. The rate of S. pyogenes isolation increased significantly from 5% in the 1990s to 20% 13 y later. S. pyogenes is not a common cause of acute otitis media and almost all isolates remained susceptible to penicillin. Therefore, it is uncertain why S. pyogenes became a significant pathogen of acute mastoiditis. The higher rate of pre-hospital antibiotic therapy in the historical group compared to the
present study (68% vs 30%) may have affected the isolation rate of S. pyogenes. We may hypothesize that increased virulence of this agent is a possible explanation. A similar observation was reported in southern Israel [10]. Two cases of Fusobacterium necrophorum were recorded in our study (Table II) and 5 more cases were reported 2 y later; 3 of these cases were identified by molecular genetic PCR analysis [25]. We presume that this pathogen is under-diagnosed in cases of acute mastoiditis. P. aeruginosa was isolated in 56% of the positive cultures from 1983 to 1995 and decreased to 13% in the present study (Figure 1). The main reason for this change is the exclusion of ear canal cultures in the present study. In spite of the fact that no anti-Pseudomonas antibiotic regimen was used, all children recovered. We therefore assume that the Pseudomonas cultures that grew from the ear canal in previous studies were not a causative pathogen. In the present study, our cultures probably grew due to contamination of the tympanic membrane cultures. The duration of preceding symptoms prior to diagnosis and hospitalization was relatively short (median 4 days) for non-specific upper respiratory tract infection symptoms, 2 days for fever and earache, and 1 day for spontaneous ear canal discharge, auricular displacement, and post-auricular swelling. These findings imply a rapidly progressive disease of 1–4 days from onset of symptoms to diagnosis and hospitalization, which is in agreement with previously published data [18–20]. The interesting finding that 22% of the children had clinical signs of mastoiditis without other preceding clinical symptoms was unexpected. Given that mastoiditis is a complication of acute otitis media, we assumed that in some of the children a very rapid progression of the infection from the middle ear to the mastoid bone would prevent a clinical diagnosis of otitis media [26]. However, no
Changes in mastoiditis in a pediatric center
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correlation was found between a specific pathogen and this rapid course. The main limitations of this study were the retrospective method and the fact that all the historical data were collected from the published text and not from raw data. In conclusion, our findings of a lack of preceding symptoms in 22% of the cases, and the short duration of symptoms prior to diagnosis, may indicate a rapid course of disease. The main change in the bacteriology profile over the years was an increase in cases of S. pyogenes isolation. Acknowledgement
[11]
[12]
[13]
[14]
[15]
The authors thank Mrs Phyllis Curchack Kornspan for her editorial services. [16]
Declaration of interest: The authors confirm that there was no conflict of interest. None of the authors received financial or material support for this research.
[17]
[18]
References [1] Lin HW, Shargorodsky J, Gopen Q. Clinical strategies for the management of acute mastoiditis in the pediatric population. Clin Pediatr (Phil) 2010;49:110–5. [2] House HP. Otitis media: a comparative study of the results obtained in therapy before and after the introduction of sulfonamide compounds. Arch Otolaryngol Head Neck Surg 1946;43:371–8. [3] Palva T, Pulkkinen K. Mastoiditis. J Laryngol Otol 1959;73:573–88. [4] Faye-Lund H. Acute and latent mastoiditis. J Laryngol Otol 1989;103:1158–60. [5] Bilavsky E,Yarden-Bilavsky H, Samra Z, Amir J, Nussinovitch M. Clinical, laboratory, and microbiological differences between children with simple or complicated mastoiditis. Int J Pediatr Otorhinolaryngol 2009;73:1270–3. [6] Geva A, Oestreicher-Kedem Y, Gisman G, Landsberg R, DeRowe A. Conservative management of acute mastoiditis in children. Int J Pediatr Otorhinolaryngol 2008;72: 629–34. [7] Benito MB, Gorricho BP. Acute mastoiditis: increase in the incidence and complications. Int J Pediatr Otorhinolaryngol 2007;71:1007–11. [8] Palma S, Fiumana E, Borgonzoni M, Bovo R, Rosignoli M, Martini A. Acute mastoiditis in children: the “Ferrara” experience. Int J Pediatr Otorhinolaryngol 2007;71: 1663–9. [9] Oestreicher-Kedem Y, Raveh E, Kornreich L, Popovtzer A, Buller N, Nageris B. Complications of mastoiditis in children at the onset of new millennium. Ann Otol Rhinol Laryngol 2005;114:147–52. [10] Katz A, Leibovitz E, Greenberg D, Raiz S, GreenwaldMaimon M, Leiberman A, et al. Acute mastoiditis in Southern
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Israel: a twelve-year retrospective study (1990 through 2001). Pediatr Infect Dis J 2003;22:878–82. Go C, Bernstein JM, De-Jong AL, Sulek M, Friedman EM. Intracranial complications of acute mastoiditis. Int J Pediatr Otorhinolaryngol 2000;52:143–8. Dhooge IJ, Albers FW, Van Cauwenberge PB. Intratemporal and intracranial complications of acute suppurative otitis media in children: renewed interest. Int J Pediatr Otorhinolaryngol 1999;49:S109–14. Spiegel JH, Lustig LR, Lee KC, Murr AH, Schindler RA. Contemporary presentation and management of a spectrum of mastoid abscesses. Laryngoscope 1998;108: 822–8. Nussinovitch M, Yoeli R, Elishkevitz K, Varsano I. Acute mastoiditis in children: epidemiologic, clinical, microbiologic, and therapeutic aspects over past years. Clin Pediatr (Phil) 2004;43:261–7. Ghaffar FA, Wordemann M, McCracken GH Jr. Acute mastoiditis in children: a seventeen-year experience in Dallas, Texas. Pediatr Infect Dis J 2001;20: 376–80. Spratley J, Silveira H, Alvarez I, Pais-Clemente M. Acute mastoiditis in children. Review of the current status. Int J Pediatr Otorhinolaryngol 2000;56:33–40. Hoppe JE, Koster S, Bootz F, Neithammer D. Acute mastoiditis—relevant once again. Infection 1994;22: 178–82. Ho D, Rotenberg BW, Berkowitz RG. The relationship between acute mastoiditis and antibiotic use for acute otitis media in children. Arch Otolaryngol Head Neck Surg 2008;134:134–45. Van-Zuijlen DA, Schilder AG, Van-Balen FA, Hoes AW. National differences in incidence of acute mastoiditis: relationship to prescribing patterns of antibiotics for acute otitis media. Pediatr Infect Dis J 2001;20:140–4. Luntz M, Brodsky A, Nusem S, Kronenberg J, Keren G, Migirov L, et al. Acute mastoiditis—the antibiotic era: a multicenter study. Int J Pediatr Otorhinolaryngol 20001; 75:1–9. Ongkasuwan J, Valdez TA, Hulten KG, Mason EO Jr, Kaplan SL. Pneumococcal mastoiditis in children and the emergence of multidrug resistant serotype 19A isolates. Pediatrics 2008;122:34–9. Grossman Z, Silverman BG, Proter B, Miron D. Implementing the delayed antibiotic therapy approach significantly reduced antibiotics consumption in Israeli children with first documented acute otitis media. Pediatr Infect Dis J 2010; 29:595–9. Kvaerner KJ, Bentdal Y, Karevold G. Acute mastoiditis in Norway: no evidence for an increase. Int J Pediatr Otorhinolaryngol 2007;71:1579–83. Kaplan SL, Mason EO, Wald ER, Kim KS, Givner LB, Bradley JS, et al. Pneumococcal mastoiditis in children. Pediatrics 2000;106:695–9. Yarden-Bilavsky H, Raveh E, Livni G, Scheuerman O, Amir J Bilavski E. Fusobacterium necrophorum mastoiditis in children—emerging pathogen in an old disease. Int J Pediatr Otorhinolaryngol 2013;77:92–6. Pang LH, Barakate MS, Havas TE. Mastoiditis in a pediatric population: a review of 11 years’ experience in management. Int J Pediatr Otorhinolaryngol 2009;73: 1520–4.
ORIGINAL ARTICLE
Changes in acute mastoiditis in a single pediatric tertiary medical center: Our experience during 2008–2009 compared with data for 1983–2007
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ACHYIA Z. AMIR1,2, RONEN POMP1,2 & JACOB AMIR2,3 From the 1Department of Pediatrics B, Schneider Children’s Medical Center of Israel, Petach Tikva, 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, and 3Department of Pediatrics C, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel
Abstract Objective: The objective of this study was to assess clinical reports and bacteriological changes over a 25-y period in children with acute mastoiditis. Methods: The medical files of all children with a discharge diagnosis of mastoiditis, hospitalized in a tertiary pediatric medical center over a 2-y period (2008–2009), were reviewed and compared to previously published data from the same center for the y 1983–1985, 1993–1995, and 2003–2007. Results: One hundred and thirty-four children (143 episodes) with acute mastoiditis were identified during 2008–2009; 81% had fever, 95% auricular displacement, and 80% post-auricular swelling. Forty-nine children were diagnosed with acute otitis media and had been treated with antibiotics prior to hospitalization. However, 22% showed no clinical symptoms preceding ear protrusion. Cultures grew Streptococcus pneumoniae in 32%, Streptococcus pyogenes in 20%, Pseudomonas aeruginosa in 13%, and Haemophilus influenzae in 10% of cases. From 1990 to 2005, the incidence of S. pyogenes isolation increased from approximately 5% to 20%. During this period, the number of cases increased from 8–20 to 67 per y. Conclusions: S. pyogenes has emerged as a significant pathogen. We found that acute mastoiditis may appear without preceding symptoms in approximately 22% of cases.
Keywords: Acute otitis media, mastoiditis
Introduction Acute mastoiditis, the inflammation of the mastoid process of the temporal bone, is a common and serious complication of acute otitis media. Mastoiditis, if not promptly treated, may cause serious complications such as deep neck infection (Bezold’s abscess), meningitis, abscess formation (sub-periosteal, epidural, or subdural), sigmoid sinus thrombosis, hearing loss, vertigo, and facial nerve palsy [1]. In the pre-antibiotic era, acute mastoiditis was a common disease with complications occurring in 20% of acute otitis media episodes [2]. With the introduction of antibiotics and the use of tympanic ventilation tubes, the rate of acute mastoiditis decreased substantially from 0.4% of acute otitis media cases in a series from 1959 to 0.004% in 1989 [3,4].
Complications have been reported in 4–17.9% of cases [5–13]. However, over the past 20 y, several studies have observed ongoing changes in disease epidemiology and natural history, such as an increasing incidence of the disease [4,10,12,14–17], a rapid progressive course independent of antibiotic treatment [18–20], and changing pathogens [14,21]. The goal of this study was to assess clinical reports and bacteriological changes that have occurred over a 25-y period in a single tertiary medical center.
Methods A retrospective study design was used. All medical files of children (⬍ 18 y) with a discharge diagnosis of mastoiditis, diagnosed and hospitalized in the
Correspondence: J. Amir, Department of Pediatrics C, Schneider Children’s Medical Center of Israel, 14 Kaplan Street, Petach Tikva 49202, Israel. Tel: ⫹ 972 3 925 3775. Fax: ⫹ 972 3 925 3801. E-mail: [email protected] (Received 16 May 2013 ; accepted 17 September 2013) ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2013.849814
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A. Amir et al.
Schneider Children’s Medical Center of Israel, a tertiary pediatric medical center located in central Israel, over a 2-y period (1 January 2008 to 31 December 2009) were reviewed. Acute mastoiditis was diagnosed clinically according to physical and otoscopic findings, i.e. otoscopic evidence of acute otitis media on admission or within 2 weeks prior to admission, and the presence of at least 1 physical finding: auricular displacement or post-auricular swelling. Children not meeting these criteria, those without a clear diagnosis of acute mastoiditis, and children with chronic middle ear disease, foreign bodies, cholesteatomas, or cochlear implants were excluded. Data obtained from the medical files included demographics, relevant medical history, treatment prior to hospitalization, signs and symptoms on presentation, clinical data during hospitalization, and outcomes. Cultures were obtained from all patients by tympanic paracentesis, sub-periosteal abscess aspiration, or an ear canal discharge swab. ‘Reliable’ cultures were defined as those taken from tympanic paracenteses or abscess aspirates. No cultures from the external auditory canal were included in the data analysis. Clinical and microbiological data were compared to past published data from the same medical center relating to cases per year of mastoiditis and cultures since 1983 [5,14]. Similar criteria were used to diagnose acute mastoiditis. All data were retrieved only from previous articles.
recurrent otitis media. Other prior medical conditions included hyper-reactive airway disease in 8, prematurity in 6, tonsillectomy and adenoidectomy in 3, and gastroesophageal reflux disease, Pierre Robin sequence, and Warburg syndrome, each occurring once. Clinical and laboratory data We summarized the clinical manifestations of the study group on admission. The most common symptom preceding diagnosis was the appearance of fever, which occurred in 81% of episodes. Auricular displacement or post-auricular swelling was noted on the day of admission in 95% and 80% of the cases, respectively, prompting the diagnosis. Seven children were hyperpyretic (temperature of ⬎ 41.1°C) at diagnosis. Of the 143 episodes of acute mastoiditis, 31 (22%) cases showed no clinical symptoms preceding ear protrusion. The overall length of hospitalization averaged 7 days (median 6 days, range 2–27 days). Maximal values of laboratory results during hospitalization are illustrated in Table I. Ninetynine children (69%) presented with a white blood cell (WBC) count ⬎ 15,000/ml and 81 (57%) presented with an absolute neutrophil count (ANC) ⬎ 10,000/ml (1 child had neutropenia). One hundred and thirteen (79%) children had a maximal C-reactive protein level of ⬎ 4 (normal ⬍ 0.5 mg/dl). Measured acute phase reactants were unaffected by
Statistical analysis A single-tailed equal variance t-test was used for continuous variables; the Chi-square test and Chi-square test for trend were used for non-continuous variables. A p-value of ⬍ 0.05 was considered significant. The study was approved by the local institutional ethics committee.
Results One hundred and eighty-five children were diagnosed at discharge with acute mastoiditis. After reviewing the medical files, 51 children were eliminated due to chronic middle ear disease, presence of cholesteatoma, cochlear implant, ventilation tubes, or diagnosis uncertainty.The remaining 134, enrolled in the study group, had experienced 143 episodes of mastoiditis; 3 had experienced 2 infection episodes and 1 had experienced 3 episodes. The 143 episodes occurred in 74 (52%) boys and 69 girls (48%); median age was 18 months (mean 30 months). In 44 cases, there was a history of at least 1 prior episode of acute otitis media; 8 cases had a history of
Table I. Correlation between clinical data and antibiotic treatment prior to hospitalization in 143 episodes of mastoiditis in children.
All episodes WBC (⫻ 103/ml) Mean 17.9 Median 17.4 ANC (⫻ 103/ml) Mean 10.8 Median 10.2 CRP (mg/dl) Mean 9.2 Median 8.3 Length of hospitalization (days) Mean 7.0 Median 6 Complications 24 (16%) Mastoidectomy 11 (7%)
No antibiotic treatment (n ⫽ 99)
Antibiotic treatments (n ⫽ 46) p-Value
18.4 18.3
16.7 15.1
0.045
11.0 10.6
10.3 8.8
0.192
9.1 8.3
9.6 8.1
0.316
6.7 6 13 (13%) 3 (3%)
7.8 6 11 (25%) 8 (18%)
0.049 0.05 0.01
WBC, white blood cell count; ANC, absolute neutrophil count; CRP, C-reactive protein.
Changes in mastoiditis in a pediatric center antibiotic treatment for acute otitis media prior to hospital admission.
(amoxicillin in 14, amoxicillin–clavulanate in 12, azithromycin in 7, and ceftriaxone on an ambulatory basis in 4). An additional 9 children received antibiotic treatment for a presumed diagnosis of pneumonia. Overall, 46 children were treated with antibiotics prior to hospitalization. Eleven (25%) of these children developed complications, compared to 13 (13%) patients without prior antibiotic treatment (p ⫽ 0.05, Table I).
Microbiological results
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11
Reliable cultures were obtained in 130 episodes (91%): tympanic membrane paracentesis (n ⫽ 115, 88%) and abscess aspirate (n ⫽ 15, 12%). In 3 cases, more than 1 technique was used; only the abscess aspirate data were used. Sixteen cultures grew 2 bacteria. Only common pathogens were used (contaminants such as Staphylococcus epidermidis were not used). Table II lists the main pathogens identified. Negative cultures were found in 25 episodes (17%); all were taken under antibiotic therapy. Of 105 positive isolates, the most common were Streptococcus pneumoniae (n ⫽ 34, 32% of positive cultures), Streptococcus pyogenes (n ⫽ 21, 20%), Pseudomonas aeruginosa (n ⫽ 14, 13%), and Haemophilus influenzae (n ⫽ 11, 10%). The miscellaneous bacteria were microorganisms that are not known to be a pathogen in otitis and mastoiditis, like S. epidermidis and diphtheroids.
Historical data Acute mastoiditis data from our tertiary medical center have been published in the past and are available for comparison [5,14]. During 1983–1985, 25 cases of mastoiditis were recorded, during 1993–1995 there were 61 cases, during 2003–2007 there were 308, and in the present study covering 2008–2009 there were 134 cases; this reflects yearly cases of 8, 20, 62, and 67 cases per y, respectively. The main clinical differences between the historical and the new data were a decreased mean age of 57 to 30 months at presentation and the complication rate (3.4% in 1993–1995, 17.9% in 2004–2007, and 15.6% in 2008–2009). Figure 1 details the relative incidence of the most prevalent isolated pathogens. The most interesting finding was the increased rate of S. pyogenes as a pathogen in mastoiditis, from about 5% in the early 1990s to 20% 13 y later (Chi-square test for trend p ⫽ 0.016). The incidence of isolation of P. aeruginosa declined dramatically; however we presume that this was related to a better culturing technique. Purulent discharge was used for cultures in previous studies, and all these samples were excluded in the present study [5,14].
Complications During hospitalization, 24 (18%) children underwent head imaging studies (computed tomography scans or magnetic resonance imaging) because of clinically suspected abscesses. Sub-periosteal abscesses were detected in all of these children; in 6 cases, subperiosteal abscesses were accompanied by epidural or deeper abscesses; sinus vein thrombosis appeared in 4 cases, and 1 case of facial nerve palsy was observed. A simple mastoidectomy was performed on 11 (8%) children. Of the 143 episodes, 87 (61%) were examined by a primary pediatrician prior to admission. Forty-nine children had been diagnosed with acute otitis media previously, of whom 37 were prescribed antibiotics
Discussion This retrospective study describes 143 episodes of acute mastoiditis in children requiring hospitalization
Table II. Microbiological data of 143 episodes of mastoiditis in children. Organism
Site cultured Tympanic paracentesis Abscess aspirate Total % of positive cultures aMisc.,
Streptococcus Streptococcus Pseudomonas Haemophilus Moraxella Moraxella Fusobacterium Negative pneumoniae pyogenes aeruginosa influenzae lacunata catarrhalis necrophorum Misc.a culture 29
17
14
9
0
1
0
20
25
5
4
0
2
2
0
2
0
0
34 32
21 20
14 13
11 10
2 2
1 1
2 2
20 19
25
miscellaneous: non-pathogen isolates, i.e. Staphylococcus epidermidis and diphtheroids.
12
A. Amir et al. 60 1983-1995 50
2003-2007 2008-2009
%
40 30 20 10 0 S. pneumoniae
S. pyogenes
P. aeroginosa
H. influenza
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Figure 1. Relative incidence (%) of the primary pathogens isolated from mastoiditis patients from 1983 to 2009.
in a tertiary medical center, over a 2-y period. Cases per y of mastoiditis increased approximately 3-fold from 1983–1995 to 2003–2009. Since the population base referred to our tertiary medical center increased by approximately 40% during the above time period, the increased incidence is partially explained by this. Our tertiary center is the main referral hospital in the region; however more children residing outside of the region may have been hospitalized in our center due to major improvements in transportation facilities. Another explanation may be the increase in antimicrobial resistance rates. Furthermore, delayed antibiotic therapy for acute otitis media by clinicians may also be a possible factor [22]. A significant increasing rate of mastoiditis during 1990–2001 was also reported in southern Israel, with no known cause [10]. However, others have found no trend of increasing numbers of cases per year in spite of restrictive guidelines for antibiotic treatment of acute otitis media, or an increased rate of pneumococcal isolates not susceptible to penicillin [23,24]. The decreasing age of children with mastoiditis over the years can possibly be due to changing day care attendance for young children during the different periods. The cases in this study occurred prior to the introduction of the 13-valent pneumococcal vaccine in Israel. Fever was the most common preceding manifestation, with a median duration of 2 days prior to admission. Diagnosis was made when all children had already experienced a displaced auricle and/or post-auricular swelling. The rate of S. pyogenes isolation increased significantly from 5% in the 1990s to 20% 13 y later. S. pyogenes is not a common cause of acute otitis media and almost all isolates remained susceptible to penicillin. Therefore, it is uncertain why S. pyogenes became a significant pathogen of acute mastoiditis. The higher rate of pre-hospital antibiotic therapy in the historical group compared to the
present study (68% vs 30%) may have affected the isolation rate of S. pyogenes. We may hypothesize that increased virulence of this agent is a possible explanation. A similar observation was reported in southern Israel [10]. Two cases of Fusobacterium necrophorum were recorded in our study (Table II) and 5 more cases were reported 2 y later; 3 of these cases were identified by molecular genetic PCR analysis [25]. We presume that this pathogen is under-diagnosed in cases of acute mastoiditis. P. aeruginosa was isolated in 56% of the positive cultures from 1983 to 1995 and decreased to 13% in the present study (Figure 1). The main reason for this change is the exclusion of ear canal cultures in the present study. In spite of the fact that no anti-Pseudomonas antibiotic regimen was used, all children recovered. We therefore assume that the Pseudomonas cultures that grew from the ear canal in previous studies were not a causative pathogen. In the present study, our cultures probably grew due to contamination of the tympanic membrane cultures. The duration of preceding symptoms prior to diagnosis and hospitalization was relatively short (median 4 days) for non-specific upper respiratory tract infection symptoms, 2 days for fever and earache, and 1 day for spontaneous ear canal discharge, auricular displacement, and post-auricular swelling. These findings imply a rapidly progressive disease of 1–4 days from onset of symptoms to diagnosis and hospitalization, which is in agreement with previously published data [18–20]. The interesting finding that 22% of the children had clinical signs of mastoiditis without other preceding clinical symptoms was unexpected. Given that mastoiditis is a complication of acute otitis media, we assumed that in some of the children a very rapid progression of the infection from the middle ear to the mastoid bone would prevent a clinical diagnosis of otitis media [26]. However, no
Changes in mastoiditis in a pediatric center
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correlation was found between a specific pathogen and this rapid course. The main limitations of this study were the retrospective method and the fact that all the historical data were collected from the published text and not from raw data. In conclusion, our findings of a lack of preceding symptoms in 22% of the cases, and the short duration of symptoms prior to diagnosis, may indicate a rapid course of disease. The main change in the bacteriology profile over the years was an increase in cases of S. pyogenes isolation. Acknowledgement
[11]
[12]
[13]
[14]
[15]
The authors thank Mrs Phyllis Curchack Kornspan for her editorial services. [16]
Declaration of interest: The authors confirm that there was no conflict of interest. None of the authors received financial or material support for this research.
[17]
[18]
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