Mastoiditis

Mastoiditis is inflammation of the temporal bone. It is thought to most often follow acute otitis media.

Before antibiotic treatment, mastoiditis followed as many as 1 in 5 cases of Acute Otitis Media

Harrison W Lin, Josef Shargorodsky, and Quinton Gopen, (2010)

Presentation by Andy Moore

Mastoiditis: EpidemiologyMedian age at diagnosis is 3.3 Years

Almost half have a history of middle ear disease

8% have recurrent Otitis Media

Nearly 70% receive antibiotics pre-admission, and of those the large majority receive antibiotics for Otitis Media (92%)

Pseudomonas and Strep Pneumo are the most commonly isolatedagents

M Nussinovitch et al., (2004)

Mastoiditis: Signs and Symptoms

SIGNS

Complicated Otitis Media

Otorrhea

Postauricular proptosis and redness

Cervical mass

Lymphadenopathy

Facial nerve weakness or paralysis

SYMPTOMS

HeadacheOtalgiaLethargy/MalaiseIrritabilityPoor feedingCervical painRhinorrheaDizzinessHearing lossVertigo

Harrison W Lin, JosefShargorodsky, and Quinton Gopen(2010)

Mastoiditis: Diagnosis

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Images from: Harrison W Lin, Josef Shargorodsky, and Quinton Gopen, (2010)

Controversies in Diagnosis of Acute Mastoiditis

• Some studies advocate imaging for most cases of complicated Acute Otitis Media due to the often subtle presentation of mastoiditis when it is partially treated. JemyJose et al., (2003)

• Other studies have found that clinical diagnosis with empiric treatment and without imaging is sufficient Sharon Tamir et al., (2009)

Complications of Mastoiditis• Acute mastoiditis• Facial palsy• Acute petrosititis• Serous labyrinthitis• Suppurative labyrinthitis• Postauricular abscess• Bezold’s abscess• Zygomatic arch abscess• Meningitis• Epidural abscess• Subdural abscess• Brain abscess• Sigmoid sinus

thrombophlebitis• Otitic hydrocephalus

Harrison W Lin, Josef Shargorodsky, and Quinton Gopen (2010)

Is the Incidence of Mastoiditis Increasing?

• Both the Pneumococcal Vaccine and the use of antibiotics are presumed to have led to some resistant organisms responsible for cases of mastoiditis

• Multidrug resistant pneumococcal serotypes have been identified as the main cause of mastoiditis at some US hospitals.

Julina Ongkasuwan et al (2008)

Is the Incidence of Mastoiditis increasing?

However, evidence for increased incidence of mastoiditis during years of pneumovax and antibiotic treatment are lacking. David Ho, Brian W Rotenberg, and Robert G Berkowitz, (2008)

In a retrospective 15 year UK study antibiotics halve the risk of mastoiditis, but the high number of episodes needing treatment to prevent 1 case precludes the empiric treatment of all otitis media as a strategy for preventingmastoiditis.

General practitioners would need to treat 4831 otitis media episodes with antibiotics to prevent 1 child from developing mastoiditis.

Paula Louise Thompson et al., (2009)

Annual incidence of mastoiditis diagnoses and antibiotic prescribing for otitis media in children 3 months to 15 years of age in UK general practices.

Thompson P L et al. Pediatrics 2009;123:424-430

©2009 by American Academy of Pediatrics

TreatmentMyringotomy and pressure equalization tube

placement

Cortical mastoidectomy

Lumbar puncture

Drainage or thrombectomy.

IV antibiotics

Steroid therapy and anticoagulation are also often used

Treatment• There is no consensus about treatment.

• Treatment varies widely across the US with resource utilization the highest at Children’s and Research hospitals (median cost $9600, mean $28,000)

• In a 2003 population of 1000 mastoiditis pts across the US, 50% underwent tympanostomy tube placement and 22% mastoidectomy

Jason L Acevedo et al (2009)

Bibliography1. Jason L Acevedo et al., “Existence of important variations in the United States in the

treatment of pediatric mastoiditis,”Archives of Otolaryngology--Head & Neck Surgery 135, no. 1 (January 2009): 28-32.

2. F Glynn et al., “Acute mastoiditis in children: presentation and long term consequences,”The Journal of Laryngology and Otology 122, no. 3 (March 2008): 233-237.

3. David Ho, Brian W Rotenberg, and Robert G Berkowitz, “The relationship between acute mastoiditis and antibiotic use for acute otitis media in children,”Archives of Otolaryngology--Head & Neck Surgery 134, no. 1 (January 2008): 45-48.

4. Jemy Jose et al., “Life threatening complications after partially treated mastoiditis,”BMJ 327, no. 7405 (July 3, 2003): 41 -42.

5. Harrison W Lin, Josef Shargorodsky, and Quinton Gopen, “Clinical strategies for the management of acute mastoiditis in the pediatric population,” Clinical Pediatrics 49, no. 2 (March 2010): 110-115.

6. M Nussinovitch et al., “Acute mastoiditis in children: epidemiologic, clinical, microbiologic, and therapeutic aspects over past years,”Clinical Pediatrics 43, no. 3 (April 2004): 261-267.

7. Julina Ongkasuwan et al., “Pneumococcal mastoiditis in children and the emergence of multidrug-resistant serotype 19A isolates,”Pediatrics 122, no. 1 (July 2008): 34-39.

8. Sharon Tamir et al., “Acute mastoiditis in children: is computed tomography always necessary?,”The Annals of Otology, Rhinology, and Laryngology 118, no. 8 (August 2009): 565-569.

9. Paula Louise Thompson et al., “Effect of antibiotics for otitis media on mastoiditis in children: a retrospective cohort study using the United kingdom general practice research database,”Pediatrics 123, no. 2 (February 2009): 424-430.