Acute mastoiditis — the antibiotic era: a multicenter study

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Abstract

Objectives: To evaluate the clinical course and identify the causative organisms of acute mastoiditis in a community where most of the patients who develop acute otitis media are treated with antibiotics. Methods: A multicenter retrospective review of a series of 223 consecutive cases of acute mastoiditis. Setting: Nine secondary or tertiary academic or non-academic referral centers. Results: Prior to the diagnosis of acute mastoiditis, 121 of the patients (54.3%) had been receiving oral antibiotic treatment for acute otitis media for periods ranging from 1 to 21 days (mean 5.3 days). Samples for bacterial culture were obtained from 152 patients. Cultures were negative in 60 patients. The organisms isolated in the 92 positive cultures were: Streptococcus pneumoniae (15 patients), Streptococcus pyogenes (14 patients), Staphylococcus aureus (13 patients), Staphylococcus coagulase negative (three patients), Pseudomonas aeruginosa (eight patients), Haemophilus influenzae (four patients), Proteus mirabilis (two patients), Escherichia coli (two patients), Klebsiella pneumoniae (one patient), Enterobacter (one patient), Acinetobacter (one patient), anaerobic gram-negative bacilli (one patient), and fungi (two patients). Ten patients had mixed flora. Sixteen patients presented with complications (cerebellar abscess, perisinus empyema, subdural abscess or empyema, extradural abscess, cavernous sinus thrombosis, lateral sinus thrombosis, bacterial meningitis, labyrinthitis, petrositis, or facial nerve palsy). Conclusions: Antibiotic treatment cannot be considered an absolute safeguard against the development of acute mastoiditis. Early myringotomy for acute otitis media seems to decrease the incidence of complications. The distribution of causative organisms in acute mastoiditis differs from that in acute otitis media. Intracranial complications in acute mastoiditis are not rare. Because of the diversity of causative organisms in acute mastoiditis and the growing resistance of bacteria to the various antibiotics, all means to obtain a sample for culture prior to antibiotic treatment, including general anesthesia.

Introduction

Acute mastoiditis is an acute inflammatory disease of the mastoid process [1], [2]. Its incidence has declined since the introduction of antibiotics [3], [4]. In 1959 Palva et al. reported that 0.4% of acute episodes of otitis media (AOM) developed into acute mastoiditis [5], whereas the reported incidence during the 1980s was 0.004% [6]. In recent years, however, the number of children admitted to some hospitals with acute mastoiditis has risen [7], [8], [9].

The purpose of this study was to re-evaluate the clinical course and identify the causative organisms of acute mastoiditis in a community where most of the patients with AOM are treated with antibiotics.

Section snippets

Patients and methods

The clinical records of all patients treated for acute mastoiditis at nine secondary or tertiary referral centers in Israel between 1984 and 1998 were reviewed. The diagnosis of acute mastoiditis was made using the following clinical criteria: signs of AOM on otoscopy and local inflammatory findings over the mastoid process (i.e. pain, redness, local sensitivity and/or protrusion of the auricle), or local inflammatory findings over the mastoid process and roentgenographic or surgical findings

Results

Patients’ ages ranged from 3 months to 79 years (mean 5.3 years). Sixty three patients (28.3%) were aged 1 year or younger, and 196 patients (87.9%) were younger than 8 years (Table 1). One hundred and seventeen patients (52.5%) were male and 106 (47.5%) were female.

A history of AOM was recorded in 75 patients (33.6%), of whom 67 (30% of the whole group) had a history of recurrent AOM. Eleven patients (4.9%) had experienced a previous episode of acute mastoiditis (all 11 had experienced

Comments

In line with previous reports [7], [8] most of the patients in the present series were children younger than 8 years of age. One-third of them had a history of recurrent AOM. A second episode of acute mastoiditis was documented in 11 children, all of whom had been characterized as otitis-prone prior to the first episode of acute mastoiditis. A history of recurrent AOM therefore increases the risk of recurrence of acute mastoiditis.

Despite the generally accepted notion that acute mastoiditis is

Conclusions

A history of recurrent AOM increases the risk of recurrent acute mastoiditis.

Antibiotic treatment for AOM is not a safeguard against acute mastoiditis, and may be associated with a latent (masked) course of acute mastoiditis with a normal-looking tympanic membrane.

Early myringotomy for acute otitis media seems to be associated with a less complicated course of acute mastoiditis.

The distribution of organisms in acute mastoiditis differs from that in AOM, with significantly higher rates of S.

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