26
Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country employing conservative management of acute otitis media Anthonsen K, Høstmark K, Hansen S, Andreasen K, Juhlin J, Homøe P and Caye-Thomasen P Department of Oto-Rhino-Laryngology Head & Neck Surgery, Rigshospitalet Faculty of Health Sciences University of Copenhagen DENMARK

Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Embed Size (px)

Citation preview

Page 1: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Acute mastoiditis in Eastern Denmark 1998-2007

- development in a country employing conservative management of acute otitis media

Anthonsen K, Høstmark K, Hansen S, Andreasen K, Juhlin J, Homøe P

and Caye-Thomasen P

Department of Oto-Rhino-Laryngology – Head & Neck Surgery, Rigshospitalet

Faculty of Health Sciences

University of Copenhagen

DENMARK

Page 2: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Acute mastoiditis in children:

- a 10-year retrospective and validated multicenter study

Anthonsen K, Høstmark K, Hansen S, Andreasen K, Juhlin J, Homøe P, Caye-Thomasen P.

Pediatr Infect Dis J. 2013 May;32(5):436-40.

Page 3: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Why this study?

Conservative guidelines for prescription of

antibiotics for acute otitis media in Denmark

– more complications, mastoiditis?

Some studies indicate increasing incidence of acute mastoiditis

Lack of consensus on diagnostic criteria

Page 4: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Objective

Evaluation of:

• Changes in incidence of acute mastoiditis

• Clinical and microbiological findings

• Treatment

• Complications

- and to propose diagnostic criteria

Page 5: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Material and methods

• All children with acute mastoiditis (IDC H 70.0)

1998-2007 in Eastern Denmark (2.2 mio inhabitants)

• Two-way approach:

- data from the National Patient Registry

- data from all local hospital registries

• Patient file retrieval and review

Page 6: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Patients

National Registry + local hospital registries:

333 children aged 0-15 years with acute mastoiditis

Excluded by reviewing patient files: • Not meeting diagnostic criteria: 49

• Double registration: 29

• Cholesteatoma: 9

• Not admitted: 2

• Files not found: 28

216 children included

Page 7: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Criteria for the diagnosis acute mastoiditis

A) Clinical signs of or recent AOM (within two

weeks)

B) At least three of the following four clinical findings

1) Protrusion of the pinna

2) Retroauricular redness

3) Retroauricular pain on palpation

4) Retroauricular swelling with or without

fluctuation / subperiosteal abscess

C) And/or operative findings of acute mastoiditis

D) Exclusion of other conditions e.g. external otitis, perichondritis, retroauricular swelling of lymph nodes,

insect bite, erysipelas, other types of abscesses

Page 8: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Results - epidemiology

• 216 children aged 0-15 years

• Median age 1.3 years

• 62 (29%) >/= 2 years

154 (71%) <2 years.

• Mean incidence of AM: 4.8/100.000 children/year

Page 9: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Incidence

22

26

13

28

26

18

14

25

14

30

5,3 6,1

3

6,3 5,8

3,9 3

5,4

3

7,5

0

5

10

15

20

25

30

35

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Number of children (blue) and incidence pr. 100.00 children aged 0-15 years (red)

Page 10: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Cultures – ear canal/middle ear

63

46

29

15 15

10 10 9

3 1

12

29.6

21.6

13.6

7.0 7.0 4.7 4.7 4.2

1.4 0.5

5.6

0

10

20

30

40

50

60

70

Total 213 cultures. Red = valid %. Blue=N.

Page 11: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Cultures – mastoid

18 18

6 5

3 2 2

1 1 0

4

30 30

10 8,3

5 3,3 3,3

1,6 1,6 0

6,6

0

5

10

15

20

25

30

35

Obtained during surgery or by needle aspiration

N=60. Red = valid %. Blue=N. N

Page 12: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Bacterial resistence

Ear canal/middle ear cultures:

• 77% susceptible to penicillin (N=84)

• 81% susceptible to ampicillin (N=77)

Mastoid cultures:

• 94% susceptible to penicillin (N=33)

• 93% susceptible to ampicillin (N=27)

Page 13: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Antibiotics prior to admittance

• 35% received antibiotics prior to admittance

• In the group aged 2 or older,

44% received antibiotics prior to admittance

• No difference in occurrence of retroauricular

abscess between children receiving or not receiving

antibiotics prior to admittance

Page 14: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Antibiotics during admittance

• 16 different antibiotics used

• Penicillin preferred 46%

• Ampicillin 26%

• Cefuroxime 21%

Page 15: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Surgery performed Total %

Myringotomy 184 85.6

No surgery (ex. simple myringotomy i LA) 122 56.5

Tubulation 68 30.1

Tubulation only 21 9.7

Mastoidectomy 67 31

Mastoidectomy, no tubulation 13 5.6

Simple absces incision 1 0.5

N %

Surgery

Page 16: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Complication N %

None 214 99

Vertigo 1 0.5

Cerebral/cerebellar absces 0 0

Septicaemia 0 0

Spreading of infection to eye and facial region 1 0.5

Meningitis 0 0

Facial paresis 1 0.5

Sinus thrombosis 0 0

Large perforation of tympanic membrane 1 0.5

Complications total 4 1.9

N %

Complications

Page 17: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Conclusions

• No evidence of increasing incidence

• Most common: Streptococcus pneumoniae

• Recommended: Penicillin

• Mastoidectomy: 31%

• Complications are rare (1.9%)

Page 18: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

Thank you for listening!

Page 19: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

”Questionnaire Mastoiditis”

1. Years of experience as oto-surgeon?

2, 4, 5, 6, 11, 12, 15, 23, 24, 28, 33, 40

Page 20: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

”Questionnaire Mastoiditis”

2. What do you believe are needed for the diagnosis of mastoiditis? Please rate the signs by numbers! 112223344x clinical signs of acute otitis media (ongoing or within 14 days 1111112222xx ≥2 retroauricular signs of infection 233333444 sagging of the ear canal 4455555x positive findings at imaging (MRI and/or CT) 1122345x discharge/acute infection in mastoid process at mastoidectomy

36x other? Retroaur swelling, certain or uncertain fluctuation retroaur

Page 21: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

”Questionnaire Mastoiditis”

3. What is the immediate intervention?

111122xxxxx iv antibiotics

12233xxxx paracenthesis

22344xx grommets

11234xx incision/aspiration 46 CT/MRI 3455x(x) mastoidectomi 5 other?

Page 22: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

”Questionnaire Mastoiditis”

4. If mastoidectomi is not performed immediately, what would be the indication for operative intervention?

11111xxxx deteriorating general condition

22222xxxxx no improvement of general condition

2333xxxx fever – rising or persisting

33344x(x) CRP or WBC rising

5xx other (please write)? Recurrent retroaur absces

Page 23: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

”Questionnaire Mastoiditis”

5. For how long would you observe for change of the condition?

123x 12 h

11112xxx 24 h depend individual case

112233 48 h

longer?

Page 24: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

”Questionnaire Mastoiditis”

6. Would you always perform preoperative imaging? No, no, no, no, no, never, no, no CT or MRI?

Page 25: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

”Questionnaire Mastoiditis”

7. What bacteriological studies should be made?

nasopharyngeal culture

11112xxxxxxx middle ear fluid culture (but hardly sufficient) 3xxx anaerobic culture?

122xxx bacterial growth from bone at operation?

Page 26: Acute mastoiditis in Eastern Denmark 1998-2007 - dokse.dkdokse.dk/onewebmedia/Dokumenter/Foredrag DOKS 2013...Acute mastoiditis in Eastern Denmark 1998-2007 - development in a country

”Questionnaire Mastoiditis”

8. What follow-up is recommended?

1111xxxxxxx clinical? daily, 1w, 1w, 1-3w, 1w and 1mo, 10-14d, 2 w, 1mo, 1mo

222xxxxx audiological? 1w and 1mo, <1mo, 1 mo, 1mo, 1mo, 2mo, 2mo

x other? Depend if chol found – uncompl cases in infants 1 w, discharge to private ENT