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Abstract

Background: Mastoid abscess remains a recognised complication of otitis media despite the advent of antibiotics. The objectives of this study were to describe the risk factors in patients with mastoid abscess following acute and chronic otitis media and discuss the management of this infection. Method: A retrospective analysis was done on all patients who underwent mastoidectomy for mastoid abscess from January 2002 to December 2007. Data on the patients’ presentation, associated complications, management, and follow-up were analysed. Results: A total of 12 patients were enrolled in this study population. Group A consisted of patients with mastoid abscess preceded by acute otitis media, while Group B consisted of patients with mastoid abscess and chronic otitis media. In Group A (n = 7), 4 patients had a pre-morbid immunocompromised condition, but they did not have cholesteatoma. None of the patients in Group B (n = 5) had any pre-morbid illnesses. Out of 12 patients, 7 patients had associated extracranial complications, and 1 patient had intracranial complications. Most patients recovered well after mastoidectomy. Recurrence was noted in 1 patient who had acute lymphoblastic leukaemia. Conclusion: Mastoid abscess is still a recognised complication of acute otitis media, especially in patients who are immunocompromised. Immunocompetent patients may also develop mastoid abscess following chronic otitis media associated with cholesteatoma. Thus, early treatment of otitis media and close vigilant follow-up are advocated to ensure prompt detection of mastoid abscess complications.

Keywords: abscess, cholesteatoma, complications, immunocompromised patient, mastoiditis, otitis media, otolyngology; head neck

Introduction In the era of antibiotics, mastoid abscessis an uncommon complication of otitis media.Thishasresultedinadeclineintheincidenceofmastoidectomy performed for mastoid abscess.Nevertheless,therearestillanumberofpatientswho develop mastoid abscess, which requiresprompt diagnosis and management. Recordsof patients who underwent mastoidectomyfor mastoid abscess at Universiti KebangsaanMalaysia Medical Centre (UKMMC) werereviewed. The objective of this review was tostudy the characteristics of patients who mayhaveahigherriskofdevelopingmastoidabscessfollowingacuteorchronicotitismedia(COM).

Original Article Mastoid Abscess in Acute and Chronic Otitis Media

Mazita Ami1, Zahirrudin zakaria2, Goh Bee See1, Asma abdullah1, Lokman SaiM1

1 Department of Otorhinolaryngology–Head and Neck Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, 56000 Cheras, Kuala Lumpur, Malaysia

2 Department of Otorhinolaryngology, Hospital Pulau Pinang, 10990 Pulau Pinang, Malaysia

Submitted: 1Nov2009Accepted: 18Mar2010

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Materials and Methods ThisisaretrospectiveanalysisofpatientswhounderwentmastoidectomyformastoidabscessinUKMMCfrom2002to2007.Theoperativecensuswasreviewedtoidentifypatientswhounderwentmastoidectomyformastoidabscess.Themedicalrecords of these patients were reviewed toconfirm the diagnosis of mastoid abscess intra-operatively.Thediagnosisofmastoidabscesswasdefinedbyfindings of puswithin the coalescentmastoidaircells.ThisstudywasapprovedbytheResearchandEthicsCommitteeofUKMMC(FF-242-2008).

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Results

Atotalof13patientswere identified inthisstudy,andtheiragesranged3–70yearsoldwithameanof30.4yearsold.Furtherdataof1patientcouldnotbetracedandhadtobeomitted,whichleftatotalof12cases.Thepatientswereclassifiedinto2groups:GroupAconsistedofpatientswithmastoid abscess preceded by acute otitis media(AOM), andGroup B consisted of patientswithmastoidabscessandunderlyingCOM.AOMwasdefinedashavingsymptoms fordurationof lessthan12weeks,andcaseswereclassifiedasCOMwhensymptomspersistedfor12weeksorlonger.Allpatientsinthisseriespresentedwithunilateralearinfection.

Group A: Patients diagnosed with AOM with mastoid abscess Therewere7patientscategorisedintoGroupA(Table1).Allpaediatricpatients(n=3,agelessthan12yearsold)inthisstudywereinthisgroup.These patients had aural symptoms between 3and28dayspriortopresentation.Post-auricularswellingwaspresent in3patients,mastoidpainwas present in 4 patients, and otorrhoea waspresent in 2 patients. Otoscopic examinationrevealed perforated tympanic membrane in 2patients. There were 5 out of 7 patients who hadother associated complications. There werealso 4 out of 7 patients in this group who hadpre-morbid conditions leading to a relativelyimmunocompromised state compared to theothersubjects.Cholesteatoma,however,wasnotnotedinanyofthesepatients.

Group B: Patients diagnosed with mastoid abscess and underlying COM There were 5 patients categorised intoGroup B (Table 2). In this group, the patientshadchronicaural symptoms for3 to 12monthsandacute(new)symptomsfor2to6weekspriorto presentation. Post-auricular swelling waspresent in 3 patients,mastoid painwas presentin 4 patients, and otorrhoea was present in 3patients.Otoscopicexaminationrevealedthatallpatients had a perforated tympanic membrane.Itwasnotedthatonly3outofthe5patientshadother associated complications. All 3 patientshadunderlyingcholesteatoma,butnoneofthesepatientshadanypre-morbidillnesses.

Associated complications of otitis media Out of 12 patients, 8 (66.7%) hadcomplicationsofmastoiditis.Theseweremainly

extracranialcomplications,in7outof8patients:facialnervepalsy,in3patients,Bezold’sabscess,in3patients(Figure1),andzygomaticrootabscessin1patient(Figure2).Inthisseries,only1patienthad an associated intracranial complication ofmeningitis.

Management and follow-up All patients were admitted and startedon broad-spectrum intravenous antibiotics.Intravenousceftriaxonewaschosenbecauseofitsgoodblood-brainbarrierpenetration.Ceftriaxonewas administered at a dose of 1 g daily, unlesspatients had intracranial complications, whichrequired a dose of 2 g twice daily. The type ofantibioticswasmodifiedaccordingtothecultureresults.Thedurationofantibiotictreatmentwas2weeksinallpatients. The bacteria isolated from patients’ pusculturewereStaphylococcusaureusin3patients,Klebsiella pneumoniae in 2 patients, coagulase-negative Staphylococcus spp in 1 patient andPseudomonasaeruginosain1patient.Therewere2 patients with mixed growth, but the culturescontained predominantly Enterococcus spp.Theother5patientshadnogrowthonoperativespecimenorswabculture. Allofthepatientsinthisserieshadmastoidexplorationforabscessdrainageanderadicationof diseased mastoid air cells. Modified radicalmastoidectomy was performed in almost halfof the patients (5 out of 12 patients). Corticalmastoidectomywithmyringotomyandventilationtubeinsertionwasperformedin4patients,and3ofthosepatientshadAOM.Radicalmastoidectomywas only performed in 2 patients (1 from eachgroup). Post-operatively, all patients had a goodrecovery. The average follow-up period was 24months (range 8–58 months), and 2 out of 12patients were lost during the post-operativefollow-up.Only1patientwithacutelymphoblasticleukaemia(ALL)inGroupAhadarecurrenceofmastoidabscess,whichoccurred1monthlater. ThepatientwithALLdevelopedAOMwhileundergoingchemotherapy;thepatientwastreatedwith amoxicillin. Despite treatment compliance,thepatientdeveloped lowermotorneuronfacialnervepalsy5days later.Radicalmastoidectomywasperformed,which showed a bonydehiscentover the horizontal segment of the facial nervewhich was covered by granulation tissue. Thestapes suprastructure was also absent. Post-operatively,thefacialnervepalsyimprovedfromHouse–BrackmanngradeIVtogradeII.However,hehadanotherepisodeofAOMwithfacialnerve

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palsygradeVamonth later.Unfortunately,duetopancytopeniaandapoorgeneralcondition,hewasdeemedunfitforanothermastoidexploration.This patient later succumbed to the underlyinghaematologicalmalignancy.

Discussion

Thecomplicationsofotitismediaarebroadlycategorised into extracranial and intracranialcomplications. Extracranial complications (suchas mastoiditis, subperiosteal abscess, facialparalysis, and labyrinthitis) and intracranialcomplications (such as cerebral or extraduralabscess, meningitis, focal encephalitis, lateralsinus thrombosis, and otic hydrocephalus) aremorelikelytobeassociatedwithAOMthanCOM(1–3). Since the introduction of antibiotics inthe 1940s, the incidence of acute mastoiditisand surgical intervention has declined. Recent

publications, however, have noted an increasein the incidence of acute mastoiditis followingAOM in children (4,5). Conversely, there hasbeenareducedincidenceofCOMsincethe1990s.However,therateofextracranialandintracranialcomplicationshasremainedstable(6).Therehavebeensignificantsocioeconomicimprovementsinmanycountriesduringthistime.Thisisimportantbecause the established risk factors associatedwith COM include low socioeconomic class,malnutrition, and congested living conditions(7). Therefore, these studies seem to suggest anincreasedincidenceofmastoiditisfollowingAOMcomparedwithCOM. Mastoiditishasoftenbeenrecognisedasanextracranial complication of otitis media whenpatients develop tender post-auricular swelling.The current treatment of mastoiditis is mainlyantibioticswithsurgeryreservedtomyringotomy(5,8). Mastoid abscess may develop as acomplicationofmastoiditis followingbothAOMandCOM(9–11).Itoccurswhenpurulentmaterial

Table 1:Demographicsofpatientsdiagnosedwithacuteotitismediawithmastoidabscess(GroupA)Patient Age

(years)Pre-

morbidcondition

Duration of

symptoms (days)

Other complications

Type of mastoid surgery

Duration of follow-up (months)

NA 3 Nil 3 None Cortical losttofollow-upLMK 48 DM,HT 7 Meningitis MRM 58MS 6 ALL 5 Facialnervepalsy Radical losttofollow-upWQE 7 BTM 14 Zygomaticroot

abscessCortical 14

CKC 46 Nil 30 Facialnervepalsy Cortical 10CCW 70 DM 21 Bezold’sabscess MRM 8

Abbreviation:ALL=acutelymphoblasticleukaemia,BTM=betathalassaemiamajor,DM=diabetesmellitus,HT=hypertension,MRM=modifiedradicalmastoidectomy

Table 2:Demographicsofpatientsdiagnosedwithacuteotitismediawithmastoidabscess(GroupB)Patient Age

(years)Duration of acute

symptoms (days)

Choles-teatoma

Other complications

Type of mastoid surgery

Duration of follow-up (months)

NH 37 4 Yes None MRM 50SN 29 4 Yes None MRM 24AU 22 6 Yes Facialnerve Radical 10AH 43 2 No Bezold’sabscess MRM 18WJ 14 4 No Bezold’sabscess Cortical 8

Noneofthepatientshadpre-morbidcondition.Abbreviation:MRM=modifiedradicalmastoidectomy

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collectionaccumulateswithinthemiddleearandmastoidaircells,anditisoftenaccompaniedbygranulation tissue. Surgical intervention is stillthemostcommontreatmentformastoidabscess.Therefore, it is importanttodistinguishmastoidabscess from uncomplicated mastoiditis andmanagepatientsaccordingly. The most common clinical presentationof mastoid abscess in this series was a tender,fluctuant post-auricular swelling, which wassimilar to other cases in the literature (11,12).Otorrhoeawaslesscommon,andfacialasymmetry,neckswelling,andmeningismwereevenrarer.Allof thepatientswithcholesteatomahadahistoryofchronicotorrhoeasincechildhood. Complications following COM were moreprevalent in subjects with cholesteatoma (13).Mustafa et al. showed that 15%of patientswithCOMhadassociatedcholesteatoma,andone-thirdof them presented with complications. In COMwithoutcholesteatoma,only6.7%presentedwithcomplications.Inthecurrentseries,thenumbersweretoosmalltomakeanysignificantcomparison;however,3outof5patientswithmastoidabscessfollowingCOMhadcholesteatoma.Interestingly,theincidenceofmultiplecomplicationscanoccurbetween 11% and 58% of cases and appears tobe more prevalent in patients with intracranialcomplications(13–15). Not surprisingly, the complication ratefollowing COM has been reported to be higherthan that following AOM (14,15), but cautionshouldbeexercisedinyoungchildrenwithAOMbecause intracranial complications may occurrelatively rapidly in the course of the disease(16).Inthisseries,therewasonly1patientwithmeningitisasacomplicationofmastoidabscess.However, patients with mastoiditis or mastoidabscess who did not undergo mastoid surgerywasexcluded;therefore,theseriesmaynothavecapturedthesecases. In our centre, patients with suspectedmastoid abscess following mastoiditis werepromptly admitted and commenced on broad-spectrum intravenous antibiotics. A high-resolutionCTofthetemporalboneandcontrast-enhancedCTofthebrainwerealsoperformedinallpatients.Mastoidectomywithabscessdrainagewasindicatedwhentherewaspurulentcollectionclinically,evidenceontheCTscanorinpatientswithcholesteatoma. ThepredominantorganismsculturedinthisserieswereStaphylococcusaureusandKlebsiellapneumoniae; however, there was no singlepredominant organism in AOM or COM. Therewere5(42%)patients’samplesthatexhibitedno

Figure 1: CoronalCTscanofapatientdiagnosedwithleftmastoidabscessandBezold’sabscess(arrow)

Figure 2: Axial CT scan of temporal boneshowing right mastoid abscess andzygomaticrootabscess(arrows)

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growth on routine cultures. Previous antibiotictreatment may have resulted in the absenceof bacterial growth (4). In addition, tests foranaerobiccultureswerenotroutinelyperformedin our institution when anaerobes are expectedto be prevalent in COM. Previous studies haveshown that commonorganisms inAOM includeStreptococcus pneumoniae and Haemophilusspp. whereas common organisms in COMincludeProteusmirabilis,Enterococcusspp.,andPseudomonasaeruginosa(5,13–15,17). Mastoidectomy was performed expedientlyoncethepatient’smedicalconditionwasstabilised,and the decision to bring down the posteriorcanal wall or to perform radicalmastoidectomywas depended on the intra-operative findings.Generally, intra-operative findings of intactossicleswithnocholesteatomaindicatedcorticalmastoidectomy with myringotomy (if thetympanic membrane was intact). In this series,intra-operative findings of ossicular erosion,includingerosionofthestapessuprastructure,ledtoradicalmastoidectomyintwopatients. Interestingly, serious co-morbidities werenoted to be present in patients who developedmastoid abscess following AOM. The only 4(25%) patients with pre-morbid illness werethose who developedmastoid abscess followingAOM. These pre-morbid conditions includedALLin1patient,BTMin1patient,anddiabetesmellitus in 2 patients. It is postulated that animmunocompromised state due to illness maymakeapatientsusceptibletodevelopingmastoidabscessfollowingAOM. Factors that have been shown to influencethe spread of infection include the type andvirulence of the infecting organism, hostresistance, and the adequacy of treatment (15).Patientswithhaematologicalmalignancy,suchasALL,may presentwith leukaemic infiltration ofthe temporalbone;however, this isuncommon.Moreover, surgical findings often revealedgreenish soft tissue mass with gelatinous fluidwithinthemiddleear(18),whichwasnotevidentin our patient. In this case, it is postulated thatenhanced organism virulencemight explain theextensiveossiculardestructiondespite theacutepresentation. Interestingly, a study showed thatpatients with BTMwere prone to infection dueto impairedphagocyticactionandanaemia(19).Theyarealsopronetorecurrentupperrespiratorytract infectionsbecauseofgeneralised lymphoidhyperplasia and expanding marrow of facialbones,whichresultsinnasalobstruction.Patientswithdiabetesmellitusmaypresentwithmaskedsymptomsduetoneuropathy.Bothpatientswith

diabetesmellitusdevelopedmastoidabscesswithassociatedcomplicationsofmeningitisorBezold’sabscess in the absence of otorrhoea symptoms.The immunocompromised condition of these 4patientscouldhaveresultedinthedisseminationofinfectionbeforeanyapparentearsymptoms. Therefore, early adequate treatment ofAOMandclosevigilantfollow-upareimportant,especially in immunocompromised patients.Antibiotic treatment, however, does not provideabsolute protection against the developmentof complications and, at worst, may mask thesymptoms and signs of complications (4,16).Increasing antibiotic resistance behavioursby organisms in biofilms (demonstrated inStreptococcus pneumonia and Haemophilusinfluenza)may explainwhyantibiotic treatmentdoesnotprovideabsoluteprotection(17). Facial nerve palsy occurred in 4 out of 12patientsinthisseries;3werepatientswithAOMhad facial nerve palsy grade IV to VI (House–Brackmann), which improved after surgery (tograde II at best). The other patient had COMandgradeIIfacialpalsy,whichhadimprovedtograde Ion thesecondpost-operativeday.Theseobservationswereincontrasttopreviousstudies,whichreportedtotalrecoveryinallAOMpatientswith facial paralysis (20,21). They were also incontrast to another study, which suggested thatfacialparalysisinCOMhadapoorprognosis(22). A literature review by White and McCans(23) suggested that several potential processeswere involved in facial palsy secondary to otitismedia:1)directinvolvementofthefacialnervebybacterialinvasion,2)mechanicalcompressiononthevascularsupplyof thenerveby thepurulentexudates or granulation tissue, 3) acute toxicneuritis with venous thrombosis resulting inischaemia, and 4) bacterial toxins that lead tofacialnervedemyelination.Morethanoneoftheseprocessesmaybeinvolvedinthepathophysiologyoffacialpalsy. Therefore, it ispostulated that the recoveryof facial nerve function may depend on theunderlying pathophysiological processes thatresultedinthefacialnervepalsy.RecentstudiesusingtheresultsofelectrophysiologicaltestshaveshownthatfacialnervepalsysecondarytoAOMmaybetreatedclinically(24,25).Anotherstudyonfacialnervepalsydue tonon-cholesteatomatousotitismedia also showed good recoverywithoutsurgical decompression of the nerve (25,26).However, facial nerve palsy associated withcholesteatoma tends to have a poor prognosis,andmastoid surgery is required to create a safeanddryear.

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Conclusion Despite the advancements in the treatmentof otitis media, mastoid abscess is still arecognised complication in both acute andCOM. Although mastoid abscess can occurover a wide age spectrum (3–70 years old), itpredominantly occurs in adults. Patients whoare immunocompromised have a greater risk ofdevelopingmastoidabscessessecondarytoAOM.They may also present with vague symptoms,severediseaseorotherassociatedcomplicationsthat require vigilance on the part of thephysician.MastoidabscessesmayalsodevelopinimmunocompetentpatientswithCOM,especiallyinassociationwithcholesteatoma.Incontrasttopreviouslypublisheddata,facialpalsysecondarytoAOMmaynotrecovercompletely.

Authors’ Contributions

Conceptionanddesign:MAProvisionofstudymaterialsorpatients:GBS,AACollectionandassemblyofdata:ZZAnalysisandinterpretationofthedata:ZZDraftingofthearticle:MA,ZZCriticalrevisionofthearticle:MA,GBS,AAFinalapprovalofthearticle:LS

Correspondence

DrMazitaAmiMS(ORL–HNS)DepartmentofOtorhinolaryngology–HeadandNeckSurgeryFacultyofMedicineUniversitiKebangsaanMalaysiaJalanYaacobLatif,BandarTunRazak56000KualaLumpurMalaysiaFax:+603-91737840E-mail:mazitaami@yahoo.com

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