Otogenic brain abscess in childhood

Identification of Risk Factors for Mortality and Prolonged Hospitalization in Patients Treated With Surgical Drainage for Otogenic Intracranial Complications: A Nationwide Study Using a Japanese Inpatient Database

OBJECTIVE

Data on risk factors for otogenic intracranial complications including cerebral abscess have been limited. Using a nationwide database, the aim was to identify the factors related to mortality and delayed discharge.

STUDY DESIGN

Retrospective.

SETTING

Nationwide database using the Diagnostic Procedure Combination database.

MAIN OUTCOME MEASURES

Data of 145 patients were extracted from a Japanese inpatient database between 2012 and 2020. The main outcome was survival at discharge. In a subgroup analysis of the 137 surviving patients, the second outcome was delayed discharge.

RESULTS

The mortality rate was 5.5% (8 of 145). Logistic regression analyses identified intracerebral complications (adjusted odds ratio [OR], 3.09) and more than 2-day delay of the first surgery after admission (adjusted OR, 4.68) as risk factors for mortality. Specifically, consciousness level evaluated by the Japan Coma Scale (JCS) was significantly related to prolonged hospitalization or mortality: JCS I (adjusted OR, 3.40) and JCS ≥II (adjusted OR, 25.1).

CONCLUSIONS

Although otogenic intracranial complications are rare, and their mortality is decreasing because of the progress in imaging and clinical strategies, they remain the most severe complications of suppurative otitis media and/or cholesteatoma. Consciousness level at admission, comorbid diabetes mellitus, and a greater than 2-day delay of surgical intervention were related to prolonged hospitalization or mortality.

Surgical management of mastoiditis with intratemporal and intracranial complications in children. Outcome, complications, and predictive factors

INTRODUCTION

Intratemporal or intracranial complications of acute mastoiditis are often of significant severity, can be life-threatening, and require prompt and usually aggressive treatment. This study focused on analyzing the outcomes and complications of different surgical techniques used in intracranial and intratemporal complications of acute mastoiditis, the most common complication of acute otitis media.

METHODS

A retrospective study of pediatric patients with mastoiditis with intratemporal and intracranial complications was designed at the Niño Jesús University Children's Hospital in Madrid, Spain, from 2005 to 2021.

RESULTS

Of 417 patients with mastoiditis, 112 patients developed intratemporal and intracranial complications, with subperiosteal abscess being the most frequent complication. The most frequently isolated pathogens were Streptococcus pneumoniae, Streptococcus pyogenes, and Fusobacterium necrophorum. The most used surgical technique was myringotomy with placement of transtympanic drainage, in 86.6% of all cases. In patients with intracranial complications, neurosurgical procedures were necessary for 19.2%, with craniotomy with mastoidectomy being the most frequent. Most of the cases evolved favorably, and only 5.4% of the patients required surgical reintervention, being more frequent in intratemporal complications. In terms of complications, we found cases of neutropenia in 3.6%, neurological sequelae in 5.4%, and permanent hearing loss in 2.7%.

CONCLUSIONS

There was a favorable evolution with a low incidence of reoperation and sequelae within our series. The surgical technique of choice correlated with the severity of the complication. If the mean size of the abscess exceeds 20 mm, incision and drainage, along with myringotomy and tube placement, should be considered as the initial treatment. Closed mastoidectomy should be reserved for deteriorating of clinical evolution or acute mastoiditis with intracranial complications. Intracranial and multiple concomitant complications were associated with a more extended hospital stay, ICU occupancy, neurosurgical intervention, and risk of neurological sequelae and neutropenia. Conversely, intratemporal complications may result in permanent hearing loss.

Surgical corridors for congenital aural atresia with otogenic cerebellar abscess and lateral sinus thrombosis

The following is a case report of an adolescent with mental retardation who had congenital aural atresia with contralateral congenital facial palsy. She developed multiple intracranial complications (cerebellar abscess and lateral sinus thrombosis) due to cholesteatoma. We managed her in a multidisciplinary approach. This report discusses case management, emphasising the meticulous intraoperative steps taken in identifying the landmarks and precautions adopted to avoid postoperative facial palsy and other complications.

Clinical outcomes of intracranial complications secondary to acute mastoiditis: The Alder Hey experience

OBJECTIVE

Acute mastoiditis is the most common intra-temporal complication of acute otitis media. Its management remains a challenge due to potential extracranial and intracranial complications. This study was designed to evaluate the recent experience with acute mastoiditis and its associated intracranial complications at a tertiary paediatric centre.

METHODS

A retrospective case note review was carried out for patients admitted to Alder Hey Children's Hospital between January 2006 and December 2016 with a diagnosis of acute mastoiditis. Patients were identified using ICD-10 codes H700, H701, H702, H708 and H709. A case note review was performed to identify patients with intracranial complications and data collected.

RESULTS

30 patients were identified with intracranial complications of acute mastoiditis, with 18 males and 12 females. The average age was 4 years and 2 months (range 2 months-15 years). The most common presenting complaint was otalgia and vomiting (63%), with only 27% patients presenting with mastoid swelling. 83% of patients were investigated with a combination of CT and MRI scans, 6.7% with CT scans only and 6.7% with MRI scans only. 73% were diagnosed with sinus thrombosis, 40% cerebral abscess and 33% postauricular subperiosteal abscess. 78% of the patients required surgical intervention. 27 of the 30 patients recovered fully with no significant long term sequalae following an average of 50 months follow-up.

CONCLUSION

Intracranial complications of acute mastoiditis remain a significant challenge. Most patients tend to present without mastoid swelling, necessitating a high index of suspicion in patients with picket fence fever, vomiting, drowsiness, headaches, seizures or cranial nerve involvement. Most cases treated at our institution required acute surgical intervention in addition to adjuvant medical treatment with majority patients recovering fully.

Otogenic brain abscesses: A systematic review

Objective

Otogenic brain abscesses are one of the most significant life-threatening complications of otologic infections. Given their low prevalence, otogenic brain abscesses require a high index of suspicion for diagnosis. In this systematic review, we aim to provide an analysis of otogenic brain abscesses and describe common clinical signs and symptoms, bacteriology, location, treatment options, morbidity, and mortality.

Data Sources

PubMed, Cochrane CENTRAL database, Google Scholar, and Scopus.

Methods

A systematic review of literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses recommendations. Variables assessed included clinical signs and symptoms, bacteriology, location, treatment, morbidity, and mortality.

Results

Twenty-nine studies met inclusion and exclusion criteria, corresponding to a total of 1307 otogenic abscess cases for review. Fifty-five percent of abscesses were found in the temporal lobe and 28% in the cerebellum. Most patients (88.3%) had a history of suppurative chronic otitis media. The most common symptoms were headache, altered mental status, papilledema, and meningeal irritation. Fever, nausea, and vomiting affected about 40% of patients. The most commonly cultured bacterial species was Proteus mirabilis. In addition to antibiotics, most otogenic brain abscesses were treated by burr hole aspiration. Average mortality following advent of computed tomography was 8.11%.

Conclusion

Although rare, otogenic brain abscesses may occur as a complication of suppurative otitis media and require a high index of suspicion. Appropriate imaging studies and multidisciplinary expertise are crucial in the diagnosis and management.

Level of Evidence

4.

A Rare Complication of Chronic Otitis Media: Cerebellar Abscess

Chronic otitis media (COM) and its associated complications are currently less common because of the popularity of imaging modalities such as computed tomography and magnetic resonance imaging and the increased use of antibiotics. Patients can be treated without any complications owing to early diagnosis. Despite all these new developments and opportunities, complications of autogenous cerebellar abscess may develop and be fatal. In this case report, we present our own clinical experience regarding a patient with cerebellar abscess as a complication of COM.

Intracranial complications of CSOM in pediatric patients: A persisting problem in developing countries

BACKGROUND

Intracranial complications (ICC) of chronic suppurative otitis media (CSOM) occur even in the antibiotic area. These complications are commonly seen in pediatric patients due to poor hygiene and low immunity. They are more prevalent in developing countries due to illiteracy, low socioeconomic status and lack of access to health care facilities.

OBJECTIVE

To study the incidence, clinical profile, treatment and outcome of pediatric patients presenting with intracranial complications of chronic suppurative otitis media.

METHODS

A retrospective analysis of intracranial complications of CSOM in pediatric patients was conducted over a period of 15 years at a tertiary level institute. Data regarding age, sex, clinical presentation, laboratory and radiological investigations, management, duration of hospitalization, and outcomes were recorded.

RESULTS

There were 142 patients, in the pediatric age group, diagnosed as having intracranial complications due to chronic otitis media during the study period. There was a decline in the incidence of ICC of CSOM. The most frequent intracranial complication seen was brain abscess (58.5%). All patients were administered intravenous antibiotics for 4-6 weeks and underwent canal wall down mastoidectomy. Neurosurgical intervention was considered in the required patients. The case fatality rate in our study was 2.8% (4 patients).

CONCLUSION

Otogenic intracranial complications can be fatal if not managed appropriately and timely. Broad spectrum intravenous antibiotics are usually required for 4-6 weeks with or without neurosurgical intervention and mastoid exploration. A high index of suspicion is required in all patients presenting with danger symptoms.

A case of otogenic brain abscess causing loss of consciousness

Acute or chronic otitis media can cause intracranial complications, one of the most serious being brain abscess. Empirical antibiotic treatment and proper surgical management should be considered to avoid fatal consequences. However, proper extent and optimal timing of surgical intervention are still matters of debate. We present a case of a 31-year-old man who presented with acutely altered mental status, caused by otogenic brain abscess who we treated successfully with antibiotics and otologic surgery and no neurosurgical treatment.

Conservative management of otogenic brain abscess with surgical management of attico antral ear disease: a review

Otological intra cranial complications are still a major problem in developing countries. Otogenic brain abscess is a serious, life-threatening complication of otitis media and it usually occurs due to attico antral ear disease. Treatment of otogenic brain abscess is immediate surgical drainage, and mastoidectomy is done to remove the source of infection. This article describes three cases of otogenic brain abscess secondary to attico antral ear disease, which were less than 1.6 cm in size and were treated conservatively with antibiotic therapy. All the patients were started on intravenous antibiotic therapy and serial CT scan was done to monitor the progression of the brain abscess. Canal wall down mastoidectomy was done for the removal of otogenic source of infection. Antibiotic therapy was continued for 6 weeks. Post operative CT scan was done after 8 weeks and it showed complete resolution of the abscess. This study showed that small otogenic brain abscess, which are less than 1.6 cm in size responded to treatment with antibiotics, could be managed by medical therapy. Surgery was required only for the management of attico antral ear disease. To best of our knowledge this is the first review on conservative management of small otogenic brain abscess secondary to attico antral ear disease.

Unilateral attico antral ear disease with bilateral intracranial complications

A 12 year old female patient, who had attico antral type of ear disease on right side, was brought to tertiary care centre for the management of fever, vomiting and headache. Patient had unilateral attico antral type of ear disease with bilateral intracranial complication. Along with the right attico antral type of ear disease and right lateral sinus thrombosis, patient had brain abscess in the left occipital lobe. Brain abscess was drained first and later mastoidectomy was done to eradicate the source of infection and to prevent further complications due to ear disease. Patient recovered well and patient was free from any problem during follow up period of 6 months. Bilateral intra cranial complications occurring simultaneously in a patient with a unilateral attico antral type of ear disease is not reported in the literature.

Otogenic cerebellar abscess due to purulent labyrinthitis and defect of the superior semicircular canal and its propagation through the endolymphatic sac

The otogenic cerebellar abscess still is one of the most dangerous complications of otitis media and implicates a high risk of mortality. Early diagnosis and therapy are decisive factors for the chances of rehabilitation. Radiologic imaging (CT/MRI) plays an important role. A broad-spectrum antibiotic according to antibiogram is indispensable. The type of surgical intervention depends on the cause and localization of the abscess. In this case the cerebellar abscess was a complication resulting from labyrinthitis, which was propagated through the endolymphatic duct and sac to the posterior fossa dura. Consequently, it could be cured ultimately only after petrosectomy and abscess drainage toward the mastoid cavity. It is mandatory to completely sanitize the infection surgically in order to avoid lethal complication especially in case of a delayed clinical course or recurrent symptoms of labyrinth involvement. Close interdisciplinary collaboration between ORL, neurosurgery and neuroradiology is desirable for successful therapy.

Combined Approach for Otogenic Brain Abscess

Otogenic intracranial infections usually require both neurosurgical and otolaryngological surgery. This prospective, non-randomized study investigated the value of combining both surgical procedures. Thirteen patients with otogenic intracranial abscess were treated by mastoidectomy and abscess removal through the same incision between 1993 and 2002. Another 12 patients underwent abscess removal or mastoidectomy followed by the other procedure within 7 days. The clinical features of the patients were compared. Four patients died in our series. All four patients had Glasgow Coma Scale (GCS) scores of 7 or less. The preoperative GCS score was the main factor in mortality. One patient had recurrence after the combined approach compared to nine patients with recurrence after separate procedures. The surgical procedure was the main factor affecting the recurrence rate. The combined approach and total capsule excision of the abscess may reduce the risk of recurrence of otogenic intracranial abscess.

Petrositis and cerebellar abscess complicating chronic otitis media

A 12-year-old girl with chronic otitis media complicated by petrositis and cerebellar abscess is presented. Early surgical intervention, in combination with broad-spectrum antibiotics, provided a good outcome. Life-threatening complications of otitis media, although rare, still occur in developed countries.

Otogenic brain abscess: review of 41 cases

Forty-one patients in whom otogenic brain abscess was diagnosed and has been treated since 1968 are presented. Sixty-five percent of the patients were between 5 and 15 years of age. All patients had chronic otitis media, and 95% had cholesteatoma. Abscess was located in the temporal lobe in 54%, in the cerebellum in 44%, and in both locations in 2% of the cases. Most patients had radical mastoidectomy and evacuation of the abscess through the mastoidectomy (61%). In addition to mastoidectomy, burr hole drainage was used in 20% and craniotomy in 15%. The most common micro-organism involved was Proteus. Overall mortality in this series is 29%, but after 1976, when CT became available for the diagnosis and follow-up, the mortality rate was reduced to 10%.