Mastoiditis

Acute Mastoiditis – Conservative Management

2 Morsels ago (Yes you can mark the passage of time in “Morsels”) [HSP and Testicular Pain] we addressed some common themes of the Ped EM Morsels.  This week will highlight one of these themes again – Clinical Examination is more important in determining patient management than a collection of test results.

We all very comfortable with diagnosing and managing Acute Otitis Media (AOM). We are also aware of potential complications of AOM and the need to vigilantly search for patients at risk for complications (Cochlear Implants) and signs of complications (Gradeningo’s Syndrome).  But once you discover a complication what needs to be done?  Acute Mastoiditis is the most common complication of AOM – how do you diagnose it and how does the ENT physician manage it?

Incidence of Mastoiditis

  • Interestingly, there are numerous papers that have been published over the past decade looking at whether the incidence of Mastoiditis has been altered with the increased use of Watchful Waiting / Delayed Antibiotic Strategies.  There is conflicting data, but recently a true population study demonstrated that there has “not been a significant change in the incidence of acute mastoiditis in the pediatric population of the United States” (Pritchett, May 2012)
  • Internationally, this fact appears to be true also (Groth, 2011)
  • Kids 1 – 4 years of age have highest number of cases.

Diagnose Mastoiditis

It is a Clinical Diagnosis!

  •  AOM on otoscopy with
    • Inflammatory changes over the Mastoid Area (tenderness, erythema, edema, abscess)
    • Protruded Auricle

“But it means that there is extension of the infection and, therefore, we should get a CT to ensure that it is not extending into the brain! Plus the ENT doctor is going to ask what the CT shows before saying “hello”… so I might as well get the test.”

What does the ENT literature say?

  • Is CT necessary to diagnosis Acute Mastoiditis when it is clinically suspected?
    • Simple answer = NO
    • In rare cases of “masked mastoiditis,” where there is no evidence of AOM, a CT would be needed.
    • If you have AOM and postauricular edema or erythema than you have just made the diagnosis.
  • Is CT necessary to routinely rule out further complications of Mastoiditis?
    • Simple answer = NO
    • But your exam needs to be thorough.
  • When is a CT scan indicated?
    • When the patient has clinical signs of CNS involvement (ex. stupor, altered mental status).
    • When there is evidence of cranial nerve involvement (ie. Gradeningo’s Syndrome).
    • When there is a history of cholesteatoma.
  • Why does this limited approach to CT make sense?
    • There has been a change in practice making the management of Mastoiditis more conservative and less aggressive.
      • Parental Antibiotics combined with myringotomy and incision and drainage of subperiosteal abscess has proven to be as efficacious as traditional mastoidectomy.
      • The Conservative approach leads to no greater complication rates and yields earlier hospital discharge.
    • These kids are not going home… they will be in the hospital and observed. CT scans can be done later if:
      • Condition deteriorates.
      • Persistent high fevers after 48-72 hours of therapy.
      • Local progression of disease.

 

So, if you think that the child clinically has Mastoiditis and has an otherwise normal neurologic exam, give the kid IV antbioitcs, pain medications, and call the ENT physician.  Discuss how you are aware that their own literature would be against the unnecessary irradiation of the patient and… await collegial conversation that will ensue.

 

 
Pritchett CV, Thorne MC. Incidence of Pediatric Acute Mastoiditis. Arch Otolaryngol Head Neck Surg. May 2012; 138(5): pp. 451-455.
 
Bakhos D, Trijolet JP, Morieniere S, Pondaven S, Al zahrani M, Lescanne E. Conservative Management of Acute Mastoiditis in Children. Arch Otolaryngol Head Neck Surg. Apr 2011; 137(4): pp. 346-350.
 
Groth A, Enoksson F, Hermansson A, Hultcrantz M, Stalfors J, Stenfeldt. Acute Mastoiditis in children in Sweden 1993-2007 – No increase after new guidelines. International Journal of Pediatric Otorhinolaryngology. Dec 2011; 75(12): pp. 1496-1501
 
Tamir S, Schwartz Y, Peleg U, Perez R, Sichel JY. Acute Mastoiditis in Children: Is Computer Tomography Always Necessary? Annals of Otology, Rhinology, and Laryngology. 2009; 118(8): pp. 565-569.
 

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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4 Responses

  1. Vivek Tayal says:

    Sean,
    How does MRI compare to CT for complicated mastoiditis?
    VST

    • Sean Fox says:

      Dr. Tayal,
      Excellent question. MRI is certainly gaining more favor. MRI has a higher sensitivity for detecting extra-axial fluid collections and associated vascular complications (ex, sinus venous thrombosis). For conditions involving cranial nerve involvement, like Gradeningo’s, MRI is certainly superior to CT. Additionally, MRI does not require contrast administration.

      Unfortunately, MRI is more costly and often requires patient sedation. Certainly it also takes a long time to obtain, perform, and get the results of.

      So, I would say that MRI is a better way to see complications; however, if the child has altered mental status, then CT is the way to go, naturally.

      Interestingly, the French article listed in the references of the Morsel (Bakhos) mentions a case of facial nerve palsy that would have qualified for MRI, but did not require it, because the child improved by the time the MRI was available.

      Thank you,
      sean

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