Eur Arch Otorhinolaryngol (2010) 267:1855–1861 DOI 10.1007/s00405-010-1325-9
OTOLOGY
Acute mastoiditis in southern Sweden: a study of occurrence and clinical course of acute mastoiditis before and after introduction of new treatment recommendations for AOM Karin Stenfeldt • Ann Hermansson
Received: 4 November 2009 / Accepted: 23 June 2010 / Published online: 8 July 2010 Ó Springer-Verlag 2010
Abstract Watchful waiting was recommended as an option for uncomplicated episodes of acute otitis media in Sweden in the year 2000. Concern was raised that these recommendations would lead to a higher incidence of acute mastoiditis. The aim of this study was to map the occurrence, treatment policy and the clinical course of mastoiditis before and after the new treatment recommendations were introduced. Included in the study were all patients (adults and children) who were admitted to two ENT departments in southern Sweden for acute mastoiditis from 1996 to 2005. A total of 42 cases of mastoiditis were identified: 23 during the first period of 1996–2000 and 19 during 2001– 2005. Mastoidectomy was performed in 14 patients during the first period and in 8 during the second period. As much as 39% of mastoiditis patients received antibiotics before hospital care, but had no improvement. There was no indication that the number of patients with acute mastoiditis was increasing after new treatment recommendation of AOM. There was no increase in the occurrence of mastoidectomy. Severe complications of mastoiditis were rare. Although there were potentially threatening complications of mastoiditis in the study, these did not lead to sequelae. It
The first author has previously published under the name Karin Magnuson. K. Stenfeldt (&) Department of Otorhinolaryngology, Malmo¨, Ska˚ne University Hospital, 20502 Malmo¨, Sweden e-mail:
[email protected] A. Hermansson Department of Otorhinolaryngology, Lund, Ska˚ne University Hospital, 22185 Lund, Sweden e-mail:
[email protected]
is important to follow up the consequences when treatment recommendations of AOM are changed. Keywords Mastoiditis Acute otitis media Streptococcus pneumoniae Mastoidectomy Antibiotic treatment Watchful waiting
Introduction Acute mastoiditis is an uncommon but serious complication of acute otitis media (AOM). The signs of acute mastoiditis are AOM accompanied by pain, redness and swelling over the mastoid process and a protruding ear. An ear infection primarily of the middle ear mucosa expands through the antrum to the mastoid cells and involves the mastoid bone, leading to osteitis. In principle, surgery of the mastoid is needed to ensure the diagnosis, but in reality, the diagnosis of acute mastoiditis is often based on clinical findings. The incidence of acute mastoiditis has declined when compared with the first half of the twentieth century, which has been attributed to routine use of antibiotics in the treatment of AOM. AOM is the most common cause of antibiotic treatment in small children. It is agreed that a restricted use of antibiotics is mandatory in trying to counteract the development of bacteria with reduced sensitivity to antibiotics. In Sweden, national guidelines were established in the year 2000, in which the general recommendations for treatment of AOM were changed. Instead of routinely prescribing antibiotics for all episodes of AOM, watchful waiting was introduced as an alternative for children 2–16 years. Concern has been raised that these recommendations would lead to a higher rate of complication following AOM, such as acute mastoiditis.
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Aim of the study
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The aim of the study was to describe the occurrence of mastoiditis, the treatment policy and the clinical course in patients before and after the new treatment recommendations for AOM.
6 5 4 3 2 1
Materials and methods
0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
This study is retrospective and covers the years from 1996 to 2005. It was performed at the Departments of ENT at the ¨ ngelholm, University Hospital in Lund and the hospital in A both situated in the southern part of Sweden. The study was approved by the Ethical Committee of Lund University (Regionala Etikpro¨vningsna¨mnden i Lund H4 143/2007). All patients (adults and children) admitted with mastoiditis were included according to the diagnosis criteria in Table 1. Patients with drainage from an ear tube with local erythema and swelling were excluded. Patients with chronic ear infections were included only if the patient was treated for an acute infection in the mastoid. A protocol with various variables was used for systematic analysis of the medical charts. These variables included age, sex, medical history, previous ear diseases with special focus on history of AOM, age at first AOM, number of AOM episodes, ventilation tube treatment, previous ear surgery, time from first symptom to admittance to hospital, development of symptoms, duration of ear symptoms, symptoms at admittance, clinical findings at admittance, duration of hospital stay, antibiotic treatment before admittance as well as during hospital stay and after release from hospital, laboratory findings, bacteriology, computer tomography findings, type of surgical intervention, findings at surgery, tone audiogram, complications and sequelae. Patients subjected to mastoidectomy were defined as severe cases and patients who were only treated with antibiotics and myringotomy in combination were referred to as milder form of mastoiditis in this study. Statistics was performed by a professional statistician. Student’s t test, chi-square test and binomial tests were performed with a significant level of 95%.
Fig. 1 The number of mastoiditis patients and patients undergoing mastoidectomy over time. All mastoiditis cases are shown in black and mastoidectomy in gray
Results A total of 42 cases of mastoiditis were included. During the first period from 1996 to 2000, 23 cases of acute mastoiditis were diagnosed compared to 19 cases during the second period from 2001 to 2005 (Fig. 1). This is not a statistically significant difference. Distribution of sex and age Of the 42 patients, 12 were female and 30 male (Fig. 2) (statistically significant difference, p = 0.01, binomial test). The mean age was 6 years, and the median age was 2 years and 6 months; 22 mastoiditis patients were under the age of 3 years and 19 were under 2 years of age. Six were infants under 1 year of age. When excluding adult patients and focusing on children under the age of 18 years only, acute mastoiditis patients had a mean age of 3 years 5 months (median 2 years 1 month).
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Table 1 Diagnostic criteria of acute mastoiditis in the present study Mastoidectomy was performed with findings of pus in the mastoid
6
Or
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Ongoing AOM and two or more of the following signs: Redness behind the ear
2
Protruding ear Lowering of the ear canal
18
Pain or tenderness over the mastoid process Swelling over the mastoid process
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Fig. 2 Age of patients with acute mastoiditis in 1996–2005. Male patients are shown in black and female in gray
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Mastoidectomy All patients underwent surgery, i.e., myringotomy or mastoidectomy or both. Myringotomy was performed soon after admittance. Mastoidectomy was performed on severely ill patients and on patients who did not get better after myringotomy and antibiotics in combination. Mastoidectomy was performed in 14 patients during the first period (1996–2000) and in 8 patients during the second period (2001–2005) (Fig. 1). This is not a statistically significant difference. The age of patients subjected to mastoidectomy ranged from 5 months to 54 years, with a mean of 5 years 10 months, median 1 year 11 months (Fig. 3). Surgical findings
was mean 6 days and median 3 days. In comparison, the mild form of mastoiditis had a duration of ear symptoms of 2 days mean and 1 day median (Table 2). This is statistically significant (p = 0.05, Student’s t test). Antibiotics Patients were given antibiotics prior to hospital care in 16 of the acute mastoiditis patients (39%). As much as 41% of patients with the severe form of mastoiditis received antibiotics before hospital care and 35% in the case of the mild form (Table 2). In one patient, no information about antibiotic treatment was found. The number of patients receiving antibiotics before hospital care did not decline after the new treatment recommendations (Fig. 4) (no statistical difference).
In 12 cases, a sub-periosteal abscess was present. One patient had granulomatous tissue covering the sigmoid sinus with bone erosion. One had bone erosion with a dura defect and cerebrospinal fluid leakage. One patient had an infected surgical cavity post-neurinoma surgery. During the first period, one additional case of mastoidectomy was performed in 1996 on the suspicion of mastoiditis with a finding of normal mucosa and the subject was excluded from this study.
For all cases in the total mastoiditis group, the mean and median in-hospital stay was 7 days. The mean time spent in hospital was 8 days (median 6 days) for the severe cases, while the mild form of mastoiditis cases stayed in hospital for a mean of 6 days (median 5 days) (Table 2). There was statistical difference between the groups (p = 0.02, Student’s t test).
First symptom to hospital admittance
Bacterial cultures
The day of first ear symptom was reported by the patients or parents at admittance. The mean time from the first ear symptom to in-hospital care for the mastoiditis patients was 4 days (median 2 days). When analyzing the patients who were subjected to mastoidectomy, defined as the group with a severe form of mastoiditis, the duration of symptoms
Data from bacteriological cultures were found in all except one patient. Results from bacterial cultures taken from the nasopharynx, ear canal drainage and pus collected at myringotomy or the mastoid in operated patients are presented in Fig. 5a–d. None of the cultured pneumococci showed reduced sensitivity to penicillin, nor did any of the Haemophilus influenzae show beta-lactam resistance. Comparison of bacteriology findings between the severe and mild form of mastoiditis are shown in Fig. 6.
14 12
In-hospital care
Imaging
10
One patient was subjected to CT. This was done in a primary setting before sending the patient to the university hospital. This child had neutropenia because of chemotherapy. The imaging showed fluid and swelling of the mucosa of the mastoid, but no destruction or abscess formation.
8 6 4
CRP: C-reactive protein
2
18
Fig. 3 The age of patients subjected to mastoidectomy. Male patients are shown in black and female in gray
Mean CRP was 91 (median 78) at admittance. The more severe mastoiditis cases had a mean CRP 99 (median 84), and the milder form CRP 85 (median 67) (Table 2). There was no statistical difference between the groups.
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1858 Table 2 Differences in disease course of severe cases of mastoiditis (subjected to mastoidectomy) and the milder form (not subjected to mastoidectomy)
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Severe mastoiditis
Milder form of mastoiditis
Mean
Mean
Duration of ear symptoms prior to hospital stay
6
Antibiotics prior to hospital care
41%
Duration of hospital stay CRP at admittance
8 99
6
Median 3
2
Median 1
35% 6 84
6 85
5 67
but the time span varied greatly. Patients subjected to mastoidectomy were followed for up to 5 years.
5 4
Hearing
3 2 1 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Fig. 4 Number of mastoiditis patients who received oral antibiotics before admittance to hospital. Use of antibiotics is shown in black and no antibiotics in gray
After the mastoiditis episode, 28 patients had normal audiograms. In ten patients, there was no information on hearing in the charts, and the hearing had thus not been measured. The number of patients in whom hearing testing was performed at follow-up decreased during the study period. Three patients had documented periods of secretory otitis media after the mastoiditis episode. One patient was deaf after neurinoma surgery before the mastoiditis episode on the same ear.
Previous disease In the 42 patients diagnosed with acute mastoiditis, 14 had no history of previous ear disease. Eleven patients had previous episodes of otitis media and two had been treated with ventilation tubes during an earlier period of time. One patient, 44 years of age, had previously been subjected to myringo-ossiculoplasty (in 1975), followed by mastoidectomy and myringoplasty many years later (in 1991), and the present mastoiditis was concurrent with an infected cholesteatoma located in the same ear. One patient of age 55 years had surgery for vestibular schwannoma 2 years earlier, and the mastoiditis occurred in the same ear. One child of 6 years had had a previous episode of acute mastoiditis treated by mastoidectomy 6 months before the present admission (both occasions included in the present study). One child had Down’s syndrome where a cholesteatoma was found during mastoidectomy. Finally, one child had leucopenia secondary to chemotherapy of a neuroblastoma. Sequelae All cases in the group had no documented sequelae after the mastoiditis episodes, excluding periods of secretory otitis media. One child, 1.5 years of age, developed neutropenia during the acute mastoiditis episode, but had normal bone marrow function after treatment. All patients had follow-ups,
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Discussion Watchful waiting as an alternative for AOM has gained international interest because of the rising threat of drugresistant bacteria [1]. After the introduction in the year 2000 of new treatment recommendations for AOM in Sweden, a possible increase of severe complications of AOM, such as acute mastoiditis, has been of concern. However, results of the present study indicate that the number of patients with mastoiditis did not increase in the area of southern Sweden that was studied. Recent studies support that the trend toward less liberal use of antibiotics against AOM does not seem to increase the number of cases of mastoiditis [2–4]. However, other authors have reported an increase in the number of mastoiditis patients in recent years [5–9]. In the present study, patients were given antibiotics prior to hospital care in 39% of the acute mastoiditis patients. About the same rate of pre-hospital use of antibiotics were found in other studies [6, 10], but a higher rate of antibiotic use prior to the mastoiditis episode was more commonly found [3, 5, 9, 11–13]. There is disagreement on whether routine antibiotic use in AOM protects against mastoiditis [6] or is no safeguard against the development of mastoiditis [5, 11]. Also, not only just being treated with antibiotics or not could possibly influence the development
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gr ow th
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0 SP
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HI
GAS
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ot he
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Fig. 5 Cultures from patients with acute mastoiditis. Number of patients with positive cultures of Streptococcus pneumoniae (SP), Moraxella catarrhalis (MC), Haemophilus influenzae (HI), Group A Streptococci (GAS), Staphylococcus aureus (SA) and Pseudomonas 14 12 10 8 6 4 2 0 SP
MC
HI
GAS
SA
PA
Fig. 6 Comparison of bacteriology findings between severe and mild form of mastoiditis. Cultures are from several locations (middle ear, ear drainage, nasopharynx). Severe mastoiditis is defined as that subjected to mastoidectomy (black), and mild form as that treated with antibiotics and myringotomy (gray). Abbreviations are explaned in Fig. 5
of acute mastoiditis, but also the time span between onset of symptoms of AOM and treatment with antibiotics. Receiving antibiotics early could be the difference between
SP
MC
HI
GAS
SA
PA
other
aerodinosa (PA). a Cultures from the nasopharynx. b Cultures from ear canal drainage. c Cultures from middle ear pus on paracentesis. d Cultures from the mastoid on mastoidectomy
developing a milder form of mastoiditis as opposed to a severe form. In the present study, patients who developed a milder form of mastoiditis, where mastoidectomy was not necessary, had a shorter time span from onset of ear symptoms to hospital care. It is possible that early treatment with intravenous antibiotics had this positive effect. In the present study, none of the mastoiditis patients were under watchful waiting for AOM at admittance. Patients who did not receive antibiotics had either not been diagnosed with AOM or had not been to a doctor before admittance. One reason for this is that acute mastoiditis often has a fast onset [13] and patients soon get severely ill, so that hospitalization is necessary. Ho et al. [3] saw a clear trend in that mastoiditis patients less often received antibiotics because of AOM prior to hospital care in recent years. In contrast, the proportion of mastoiditis patients in the present series who received antibiotics prior to hospital care did not decline after the new national guidelines of the year 2000, and the number of mastoiditis patients who were not given antibiotics did not increase (Fig. 4). A preliminary interpretation could be that the new guidelines were not generally followed. However, mastoiditis patients constitute a very small proportion of the huge number of
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AOM patients and it is possible that these patients were sicker and were therefore given antibiotics, quite according to the guidelines. The bacteriological findings are in concordance with other studies [6, 8, 10]. Streptococcus pneumoniae was the most common cause of mastoiditis in the present study and was the overwhelming finding in cultures from the mastoid. Bacterial cultures were lacking in only one patient. Cultures from ear drainage and nasopharynx can be misleading because of contamination with coexisting bacteria that are not the cause of the current mastoiditis episode. We would like to stress the importance of culturing middle ear fluid at myringotomy as well as performing a culture from the mastoid during surgery. A large proportion of the mastoiditis patients in the present study were small children: 19 patients out of 42 were younger than 2 years of age. On checking the protocols, it was seen that small children younger than 2 years of age had a fast onset of disease, with signs as fever, protruding ear and redness over the mastoid, and the diagnosis was thus evident at an early stage. Some authors [6, 9, 13] have reported that younger children had more severe episodes of mastoiditis than older children. In a recent study from Norway, Kvaerner et al. [4] could not find evidence of a more severe disease for children less than 2 years of age. Many patients with mastoiditis were healthy prior to the mastoiditis incident, and a majority had no history of AOM. This is in accordance with other studies [5, 6, 9, 14] where a common finding was that patients had mastoiditis in connection with the first episode of AOM. The treatment of choice for acute mastoiditis has traditionally been a combination of antibiotics and surgical intervention (myringotomy and in severe cases mastoidectomy) [12], but in some centers surgery is used much more sparingly [15]. In a retrospective study from Spain [7] of children with acute mastoiditis ranging over the same time span as in the present study (1996–2005), the number of patients who underwent mastoidectomy increased. In our study, the number of patients subjected to mastoidectomy did not increase. Centers included in the study do not have the habit of using CT in the diagnosis of mastoiditis. CT is widely used in other centers in Sweden and worldwide in the diagnosis of mastoiditis, and to support the decision for mastoidectomy [16, 17]. No severe sequelae were found in the present study, and the role of CT in mastoiditis diagnosis is an interesting matter for discussion. One patient was excluded from the present study because of normal mucosa found at mastoidectomy. Surgery could possibly have been avoided if a CT scan had been performed. The CT of the only patient in the study who was subjected to imaging supported the decision not to perform surgery. This was a patient whose disease was difficult to assess because of
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leucopenia and the result showed that it was not as severe as feared. Some authors [6, 10, 15] suggest that CT can be valuable in the diagnosis of complications in cases where there is no clinical improvement, or prior to surgical intervention, but when there is no clinical suspicion of complications, most cases can be managed without CT. Others propose more widely used indications for CT, as images can differentiate between periostitis and subperiosteal abscess formation, indicate infectious complication and reveal silent complications of clinical importance (e.g., sinus thrombosis and epidural abscess) in need of surgical intervention or medical treatment (anticoagulation, antibiotic choice) [12, 14, 16]. In an ongoing prospective study in Sweden, the occurrence and treatment of mastoiditis is closely followed and one of the key questions is the use of imaging techniques in diagnosis and treatment. There were potentially threatening complications of mastoiditis in the study, although they did not lead to sequelae. Subperiosteal abscess [17] was present in 12 (28%) of the patients. This could be considered as a feature of the mastoiditis disease and not a complication. For comparison, 23% of the patients developed subperiosteal abscess in the Spratley study [5]. In the present study, one patient had an intracranial complication in the form of a dura defect with cerebrospinal fluid leak caused by the disease. In addition, one patient had granulomatous tissue covering the sigmoid sinus with bone erosion. None of the patients had meningitis or sinus thrombosis, which are feared complications of mastoiditis [5, 7, 11–13]. In the present study of 42 patients, only sporadic cases of severe complications could be expected. After recovery, hearing was tested in only 28 of the patients and there was a trend of fewer hearing tests done throughout the present study. Even though deafness is an extremely uncommon sequelae of mastoiditis, it is our opinion that a hearing test should always be done after the sense organ has undergone such a serious disease, especially since most patients affected by mastoiditis are small children. Considering the results from the present study, we recommend prompt management when there is suspicion of mastoiditis as the disease develops quickly, especially in small children. Cultures from the nasopharynx, ear drainage, as well as during surgery are important both to decide the therapy in the actual case and to follow the development of bacterial resistance in the region. The patient must receive intravenous antibiotics without delay and paracentesis should be performed preferably under general anesthesia in children. If no improvement is seen, mastoidectomy must be considered. This study compares the occurrence, treatment policy and clinical course of patients with mastoiditis before and after the new national guidelines for the treatment of AOM
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were introduced. This is of importance as consequences must be followed up when treatment recommendations of AOM are changed. The results from the present study indicate that a restricted use of antibiotics during AOM in Sweden have not caused more cases of mastoiditis or resulted in more complications in the region studied. Conclusions There is no indication that the number of patients with acute mastoiditis has been increasing after the new treatment recommendations of AOM. The proportion of patients with mastoiditis who received antibiotics before hospital admittance had not decreased since the new treatment recommendations of AOM were introduced. Mastoiditis is more often manifested in boys than in girls. Common characteristics of mastoiditis patients are previously healthy patients of low age, rapid onset of infection and elevated CRP. Streptococcus pneumoniae was the most common cause of mastoiditis and was predominant in severe cases. The number of mastoidectomies performed did not increase during the study period. Early treatment of mastoiditis symptoms is important and could possibly avoid severe disease and major surgery Even though mastoiditis is a serious and invasive infection, threatening complications seldom develop sequelae. The study can serve as a basis for a discussion and consensus on the diagnosis criteria, investigation and treatment policy of mastoiditis patients. A further study of mastoiditis throughout Sweden has been initiated. Acknowledgments The Research and Development Fund of ¨ ngelholm Hospital provided financial support. Bengt Magnuson has A skillfully checked the English language. Conflict of interest statement no conflict of interest.
The authors declare that they have
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