Acute mastoiditis in children

Risk factors for recurrent acute mastoiditis in pediatric patients: a registry-based cohort study

OBJECTIVE

To describe characteristics of pediatric patients with recurrent acute mastoiditis, and to identify risk factors for this condition.

STUDY DESIGN

A retrospective cohort study.

SETTING

Data based on electronic medical records of the largest Health Maintenance Organization in Israel.

METHODS

Children hospitalized due to acute mastoiditis during the years 2008-2018 were identified, and their diagnosis was verified. Patients with recurrent acute mastoiditis were identified and grouped, and their characteristics were outlined and compared to those of the original group to identify risk factors for recurrence.

RESULTS

During the 11-year period, a total of 1115 cases of children hospitalized due to acute mastoiditis were identified with a weighted incidence rate of 7.8/100,000. Of this group, 57 patients were diagnosed with recurrence following a full clinical recovery. The incidence proportion of recurrent acute mastoiditis was 5.1% (57/1115), male-to-female ratio was 27:30, 73.4% were younger than 24 months, the median period from the first episode was 3.4 months (IQR 2.0;10.0), and 82.5% of the patients (n = 47) had a single recurrence, whereas 18.5% (n = 10) had two recurrences or more. Mastoidectomy and swelling over the mastoid area during the first episode were identified as the main risk factors for recurrent mastoiditis HR = 4.7 [(2.7-8.2), p < 0.001] and HR = 2.55 [(1.4-4.8), p = 0.003], respectively. Mastoidectomy was the only independent significant risk factor for recurrence in a multivariate analysis.

CONCLUSIONS

Mastoidectomy and swelling over the mastoid area during the first episode of acute mastoiditis were found strongly related independent risk factor for future recurrent episodes of acute mastoiditis.

[Increasing incidence of mastoidectomies in children : Result of reduced antibiotic therapy or late COVID-19 sequela?]

BACKGROUND

An increasing number of pediatric patients with mastoiditis and a consequent increase in mastoidectomy rates was noted in 2022 and 2023.

OBJECTIVE

This study aimed to analyze the increase in the number of children presenting with mastoiditis and subsequent mastoidectomy, to assess correlations with prior antibiotic treatment or COVID-19 infection, and to provide an overview of involved pathogens, treatment, and disease course.

MATERIALS AND METHODS

A retrospective analysis of all patients with mastoidectomy since 2012 was conducted. Data collected comprised type and duration symptoms, prior antibiotic therapy, diagnostic tests and disease course, causal pathogens, length of hospitalization, and complications.

RESULTS

A highly significant increase in mastoidectomies in children could be demonstrated from 2022. Neither the pathogens involved nor the course of disease or complications showed differences. An increase in the number of patients with prior outpatient antibiotic therapy could be shown. About a half of the patients becoming ill after fall 2022 had a positive history of COVID. Hyperplasia of adenoid tissue was a far less frequent causal mechanism than in the years before COVID.

CONCLUSION

No clear correlation with reduced outpatient antibiotic therapy could be found. Whether there exists an association with prior COVID infection cannot be judged at this time, due to the high number of asymptomatic and therefore unknown COVID infections.

Mastoiditis Now Affects Adults: A Case Report of an Occurrence of the Disease in an 82-Year-Old Male

Mastoiditis is typically considered a suppurative complication of otitis media seen in children. Vaccines and therapeutics can change the demographics of diseases. Childhood vaccination against Haemophilus influenza, for example, has shifted the mean age for ear, nose, and throat infections caused by this bug to age 25, whereas this used to be most prevalent in the pediatric age group previously. The authors present the case of an 82-year-old man who had mastoiditis. This case serves as a reminder to avoid anchoring bias when seeing an undifferentiated patient in the emergency department.

A Child With Retroauricular Tenderness: Is It Really Mastoiditis?

The presence of retroauricular tenderness and erythema has always been closely linked to a diagnosis of acute mastoiditis (AM), a condition that has become less common over the years given the advent of antibiotics and pneumococcal vaccination. However, other etiologies such as retroauricular cellulitis can also present similarly. We present the case of a 10-year-old patient who presented with outward and downward protrusion of the left ear with retroauricular tenderness and erythema and was initially presumed to have a diagnosis of AM and admitted for intravenous antibiotic management. Imaging was negative for any evidence of AM, and in retrospect, the patient was diagnosed with retroauricular cellulitis secondary to acute otitis externa. Being familiar with this differential of retroauricular pain and tenderness can lead to more cost-effective patient care and a different approach with antibiotic management.

The Development of Bilateral Mastoiditis Following Acute Otitis Media in a Pediatric Patient with Limited Access to Health Care

Infection of the mastoid cells, known as mastoiditis, can develop due to untreated otitis media, in which bacteria colonize the mastoid air cells that line the inner and middle ear. Antibiotic therapy for otitis media has made the development of mastoiditis a very rare occurrence. However, despite its low prevalence, it is important to keep this complication in mind when treating otitis media in the pediatric population due to the increased susceptibility of mastoiditis in this demographic. Furthermore, pediatric patients of lower socioeconomic status who have limited access to health care may be at an even greater risk for the development of mastoiditis. We report a case of a pediatric patient with significant barriers to health care who developed bilateral mastoiditis as a complication of otitis media, requiring hospitalization and intravenous antibiotic therapy. The patient also experienced hearing loss as a sequela of the infection. Improved access to medical care, parent or guardian education on how to recognize primary otitis media infections, and the use of adequate antibiotic therapy when indicated can effectively prevent the development of mastoiditis following otitis media infections among patients.

Acute otitis media-related facial nerve palsy in a child: a case report and a literary review

BACKGROUND

Acute otitis media has become a rare cause of facial palsy in children. A high index of suspicion is essential to achieve the diagnosis and to properly treat this condition to avoid permanent neurological sequelae.

CASE PRESENTATION

A case of acute otitis media-related facial nerve palsy in an 18 months-old child is described and a review of the recent literature about the clinical presentation, diagnosis, and management of this condition is performed.

CONCLUSIONS

Facial paralysis is an uncommon complication of acute otitis media that requires appropriate care. As highlighted in our report, the treatment of facial nerve palsy secondary to otitis media should be conservative, using antibiotics and corticosteroids. The role of antiviral is still a matter of debate. Myringotomy and a ventilation tube should be added when spontaneous perforation of the tympanic membrane is not present. More aggressive surgical approach should be considered only when there is no significant improvement.

Murine models of orthopedic infection featuring Staphylococcus aureus biofilm

Introduction: Osteomyelitis remains a major clinical challenge. Many published rodent fracture infection models are costly compared with murine models for rapid screening and proof-of-concept studies. We aimed to develop a dependable and cost-effective murine bone infection model that mimics bacterial bone infections associated with biofilm and metal implants. Methods: Tibial drilled hole (TDH) and needle insertion surgery (NIS) infection models were compared in C57BL/6 mice (female, N = 150 ). Metal pins were inserted selectively into the medullary canal adjacent to the defect sites on the metaphysis. Free Staphylococcus aureus (ATCC 12600) or biofilm suspension (ATCC 25923) was locally inoculated. Animals were monitored for physiological or radiographic evidence of infection without prophylactic antibiotics for up to 14 d. At the end point, bone swabs, soft-tissue biopsies, and metal pins were taken for cultures. X-ray and micro-CT scans were performed along with histology analysis. Results: TDH and NIS both achieved a 100 % infection rate in tibiae when a metal implant was present with injection of free bacteria. In the absence of an implant, inoculation with a bacterial biofilm still induced a 40 %-50 % infection rate. In contrast, freely suspended bacteria and no implant consistently showed lower or negligible infection rates. Micro-CT analysis confirmed that biofilm infection caused local bone loss even without a metal implant as a nidus. Although a metal surface permissive for biofilm formation is impermeable to create progressive bone infections in animal models, the metal implant can be dismissed if a bacterial biofilm is used. Conclusion: These models have a high potential utility for modeling surgery-related osteomyelitis, with NIS being simpler to perform than TDH.

Actinomyces and Shewanella algae complicated paediatric mastoiditis: a case report of a multidisciplinary approach

Cerebral venous sinus thrombosis in children is a rare complication of acute mastoiditis that can potentially be fatal. Clinical expertise is essential for early diagnosis and management due to its subtle course. We present the first known case of paediatric acute mastoiditis with venous sinus thrombosis caused by Shewanella algae and Actinomyces europaeus . A 17-year-old male presented clinical signs of right acute otitis media and mastoiditis. Brain computed tomography showed mastoid opacification, cerebral sinus thrombosis and an extradural collection. Microbiology revealed the presence of S. algae and A. europaeus . A multidisciplinary approach combining medical and surgical treatment allowed the patient to make a full recovery.

Intracranial Complication as a Manifestation of Clinical Onset in a Child With Insidious Ear Infection

Acute mastoiditis is a common consequence of acute otitis media and may lead to intracranial complications. Common clinical presentations include otological complaints (i.e., otorrhea, otalgia, fever). Intracranial complication remains a rare manifestation of middle ear infection. We present the case of a child who presented with non-specific symptoms without any otological complaints. Prompt clinical assessment and imaging revealed an otogenic brain abscess with concurrent mastoiditis. Management of this child required both medical and surgical treatment by a multidisciplinary team.

Incidence of acute otitis media in children < 16 years old in Germany during 2014-2019

BACKGROUND

Acute otitis media (AOM) remains a common infection in children despite the introduction of pneumococcal conjugate vaccines. This study estimated AOM incidence rates (IRs) over time in children < 16 years old in Germany following PCV13 introduction.

METHODS

AOM episodes were identified in the InGef healthcare claims database from 2014-2019 in children aged < 16 years. Each AOM episode was classified as either simple or recurrent. Recurrent AOM was defined as 3 or more episodes identified within a 6-month period; or 4 or more episodes within a 12-month period with at least one episode in the prior 6 months. AOM-related surgical procedures within 12 months and complications within 21 days of an AOM episode were also identified. Annual IRs were calculated as number of episodes/child-years (CY) at risk. 95% Confidence intervals (95%CI) were calculated using the Wilson method. The Mann-Kendall test was used to assess trends over time.

RESULTS

Between 2014 and 2019, the study population comprised 916,805 children with 327,726 AOM episodes, of which 15% (49,011) of all episodes were identified as recurrent AOM and 85% (278,715) as simple AOM. There were significant declines in AOM (p = 0.003) in the study population overall and in all age groups over the study period; from 101 (95%CI 101-102)/1000 CY to 79 (95%CI 78-80)/1000 CY in the total study population, from 209 (95%CI 206-212)/1000 CY to 147 (95%CI 145-150)/1000 CY in < 2-year-olds, from 239 (95%CI 237-242) to 179 (95%CI 177-182)/1000 CY in 2-4-year-olds, and from 50 (95%CI 49-50) to 38 (95%CI 37-39)/1000 CY in 5-15-year-olds. No significant trends were identified for AOM-related surgical procedures over the study period; however, AOM-related complications overall increased (p = 0.003).

CONCLUSION

Between 2014 and 2019, AOM incidence overall declined in children aged 0-15 years in Germany. Over the study period, the incidence of complicated AOM cases increased, however the incidence of AOM-related surgical procedures remained constant. Despite the impact of PCV13, the burden associated with AOM in Germany remains substantial.

Complicated Trichosporon asahii mastoiditis in immunocompetent child

Background

Trichosporon asahii is an opportunistic fungus that causes infections in immunosuppressed patients. It is rarely seen in children and immunocompetent hosts. The mortality rates are still high despite early treatment with proper antifungal drugs. Trichosporon asahii mastoiditis in an immunocompetent child makes this case challenging.

Case presentation

This report presents a case of Trichosporon asahii mastoiditis which was complicated by transverse sinus thrombosis, in an otherwise healthy 21-month-old girl, and successfully treated with voriconazole. Trichosporon asahii was isolated, in three different occasions, from ear discharge of an immunocompetent healthy child, who presented with prolonged history of fever and received appropriate dosages of multiple types of antimicrobials as an outpatient but without improvement. After 48 h of starting the Voriconzole; post auricular swelling and ear discharge improved significantly.

Conclusion

A high index of clinical and microbiological suspicion is needed for optimal diagnosis of Trichosporon infection. Trichosporon asahii can also cause infection in immunocompetent individual even without previous history of hospitalization or intervention. We emphasize the importance of early pediatric infectious evaluation and intervention.

Role of Surfactant Protein D in Experimental Otitis Media

Surfactant protein D (SP-D) is a C-type collectin and plays an important role in innate immunity and homeostasis in the lung. This study studied SP-D role in the nontypeable Haemophilus influenzae (NTHi)-induced otitis media (OM) mouse model. Wild-type C57BL/6 (WT) and SP-D knockout (KO) mice were used in this study. Mice were injected in the middle ear (ME) with 5 μL of NTHi bacterial solution (3.5 × 105 CFU/ear) or with the same volume of sterile saline (control). Mice were sacrificed at 3 time points, days 1, 3, and 7, after treatment. We found SP-D expression in the Eustachian tube (ET) and ME mucosa of WT mice but not in SP-D KO mice. After infection, SP-D KO mice showed more intense inflammatory changes evidenced by the increased mucosal thickness and inflammatory cell infiltration in the ME and ET compared to WT mice (p < 0.05). Increased bacterial colony-forming units and cytokine (IL-6 and IL-1β) levels in the ear washing fluid of infected SP-D KO mice were compared to infected WT mice. Molecular analysis revealed higher levels of NF-κB and NLRP3 activation in infected SP-D KO compared to WT mice (p < 0.05). In vitro studies demonstrated that SP-D significantly induced NTHi bacterial aggregation and enhanced bacterial phagocytosis by macrophages (p < 0.05). Furthermore, human ME epithelial cells showed a dose-dependent increased expression of NLRP3 and SP-D proteins after LPS treatment. We conclude that SP-D plays a critical role in innate immunity and disease resolution through enhancing host defense and regulating inflammatory NF-κB and NLRP3 activation in experimental OM mice.