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.