MastoiditisGeneral Medicine Pediatric Mastoiditis Updated: Feb 25, Author: In most cases, symptoms involving the middle ear eg, fever, pain, conductive hearing loss predominate, and the disease in the mastoid is not considered a separate entity. In some patients, the infection spreads beyond the mucosa of the middle ear cleft, and osteitis in the mastoid air-cell system or periosteitis of the mastoid process develops, either directly mastoiditis diagnosis emedicine means of bone erosion through the cortex or indirectly sustanon 250 mg kaufen the diagnisis vein of the mastoid. These mastoiditis diagnosis emedicine are considered to have acute mastoiditis also called acute surgical mastoiditis [ASM]which is an intratemporal complication of otitis media.
Pediatric Mastoiditis: Background, Anatomy, Pathophysiology
General Medicine Pediatric Mastoiditis Updated: Feb 25, Author: In most cases, symptoms involving the middle ear eg, fever, pain, conductive hearing loss predominate, and the disease in the mastoid is not considered a separate entity. In some patients, the infection spreads beyond the mucosa of the middle ear cleft, and osteitis in the mastoid air-cell system or periosteitis of the mastoid process develops, either directly by means of bone erosion through the cortex or indirectly via the emissary vein of the mastoid.
These patients are considered to have acute mastoiditis also called acute surgical mastoiditis [ASM] , which is an intratemporal complication of otitis media. Acute mastoiditis is divided into acute mastoiditis with periosteitis incipient mastoiditis , characterized by purulence in the mastoid cavities; and coalescent mastoiditis acute mastoid osteitis , characterized by effacement of the bony septae between the mastoid air cells.
This can lead to abscess formation cavity and the dissection of pus into surrounding areas. Subacute mastoiditis masked mastoiditis is persistent and low-grade ear and mastoid infection that causes bony septae destruction. Chronic mastoiditis is a prolonged mastoid air cell suppurative infection lasting months to years. Chronic mastoiditis most commonly is associated with chronic suppurative otitis media CSOM and, in particular, with cholesteatoma formation.
The mastoid is a division of the temporal bone. It surrounded by the posterior cranial fossa, the middle cranial fossa, the canal of the facial nerve, the sigmoid and lateral sinuses, and the petrous tip of the temporal bone. It develops from a narrow outpouching of the posterior epitympanum named the aditus ad antrum.
The mastoid initially consists of a single cell, the antrum, that is linked to the middle ear by a narrow channel. Pneumatization takes place shortly after birth, after the middle ear becomes aerated. This process is complete by the age of 10 years.
Mastoid air cells are created by the invasion of epithelial lined sacs between spicules of new bone and by the degeneration and redifferentiation of existing bone marrow spaces.
Other areas of the temporal bone, including the petrous apex and zygomatic root, pneumatize similarly. The antrum, similar to the mastoid air cells, is lined with respiratory epithelium that swells in the presence of infection.
Because of their adjacency to the mastoid, infection can lead to complications involving the semicircular canals, sternocleidomastoid muscle, seventh nerve, internal carotid artery, jugular vein, meninges, sigmoid sinus, and brain. Acute mastoiditis generally complicates acute otitis media AOM. Because the middle ear and mastoid air cells are connected, [ 2 ] the middle ear mucosal inflammations can also ivolve the mastoid.
Generally, the mastoid infection subsides as the middle ear infection resolves. However, when middle ear infection persists, purulence accumulates in the mastoids. Blockage of the antrum by inflamed mucosa entraps infection in the air cells by inhibiting drainage and by precluding re-aeration from the middle-ear side. Mastoiditis can erode through the antrum and extend to any of the surrounding structures mentioned above see Anatomy , causing clinically significant morbidity and life-threatening disease.
Persistent acute infection in the mastoid cavity can lead to a rarifying osteitis, which destroys the bony trabeculae that form the mastoid cells; hence, the term coalescent mastoiditis is used for this condition.
Coalescent mastoiditis is essentially an empyema of the temporal bone that, unless its progress is arrested, either drains through the natural antrum to cause spontaneous resolution or unnaturally drains to the mastoid surface, petrous apex, or intracranial spaces to create a further complication. Other temporal bone or nearby structures, such as the facial nerve, labyrinth, or venous sinuses, may become involved.
As with most infectious processes, both host and microbial factors are involved in the development of acute mastoiditis. Host factors include mucosal immunology, temporal bone anatomy, and systemic immunity, whereas microbial factors include the protective coating, antimicrobial resistance, and ability of the pathogen to penetrate local tissue or vessels ie, invasive strains. More than half of the S pneumoniae organisms recovered are of serotype 19, with serotypes 23 and 3 being the next most common.
Pseudomonas aeruginosa and other gram-negative aerobic bacilli and anaerobes are infrequently recovered in acute infection. However, recent studies suggest an increase in the incidence of Fusobacterium necrophorum acute mastoiditis 8. Mycobacterium tuberculosis is rarely the cause of mastoiditis in developed countries.
However, resistance may vary according to local resistance rate. A study by Koutouzis et al looked to determine whether serotype distribution and antibiotic resistance of Streptococcus pneumoniae acute mastoiditis in children have changed in the post pneumococcal conjugate vaccines PCVs era. The study found that after the introduction of PCV7, a significant increase of serotype 19A and replacement of PCVs serotypes was identified.
After PCV13, the overall proportion of pneumococcal mastoiditis and the incidence of serotype 19A were not significantly declined. A significant proportion of resistant isolates to penicillin and erythromycin is attributed to serotype 19A. Multicenter surveillance of S. Recent treatment with antimicrobials, attendance at a daycare center, and the winter season are associated with an increased incidence of MDRSP.
After the introduction of vaccination with the 7- and later 13 valent pneumococcal vaccines, a reduction of MDRSP occurred. Staphylococcus aureus, especially methicillin-resistant S aureus MRSA , has emerged as an important pathogen.
Although P aeruginosa has been recovered in some series, [ 14 ] higher rates of recovery may happen when samples are obtained from the external canal in patients with otorrhea. Chronic mastoiditis is generally a result of CSOM; it is rarely a result of failure of treatment of acute mastoiditis.
The most frequently recovered isolates from chronically inflamed mastoids are similar to the one isolated from CSOM and include P aeruginosa, Enterobacteriaceae, S aureus including MRSA , [ 11 ] and anaerobic bacteria. The infection may be polymicrobial aerobic and anaerobic in over one half of patients.
The predominant anaerobic bacteria are Peptostreptococcus species, anaerobic gram-negative bacilli eg, pigmented Prevotella, Porphyromonas, and Bacteroides species and Fusobacterium species. Epub May 1. Over one half of anaerobic gram-negative bacilli and Fusobacterium species can produce the enzyme beta-lactamase. S pneumoniae and H influenzae are rarely isolated.
The pathogenic role of P aeruginosa in many of these patients is often questionable because it colonizes the ear canal and can contaminate specimens obtained through the nonsterile canal.
Blastomycosis, [ 19 ] M tuberculosis , nontuberculous mycobacteria, and Mycobacterium bovis are infrequent causes of mastoiditis. The epidemiology of acute mastoiditis is similar to that of AOM, with the highest incidence in children younger than 2 years. Since the advent of antimicrobial agents, the incidence of mastoiditis has decreased. Although the incidence of the disease has substantially declined in the United States, it is still a clinically significant infection with the potential of life-threatening complications.
Of great concern was the sharp increase in the incidence of acute mastoiditis reported in several locations in the turn of the century. This increase may be due to a rising rate of infections caused by antibiotic-resistant organisms, [ 22 , 23 ] increased virulence of the pathogens, and decreased use of antibiotics to treat AOM.
However, the incidence significanly declined as the conjugated pneumococcal vaccine, which was licensed for clinical use in the United States in 7 valent and 13 valent , became more widely available and more frequently administered. A recent study [ 25 ] illustrated a downward trend in otitis media-related healthcare use in the United States from to The significant reduction in otitis media visit rates in in children younger than 2 years coincided with the advent of pneumococcal conjugate vaccine A study by Raveh et al that assessed the characteristics, treatment, and outcome of acute mastoiditis in children with a cochlear implant reported that of the children who underwent cochlear implantation, 13 3.
In all of the 9 children who had unilateral cochlear implant, the acute mastoiditis episode occurred in the implanted ear. Developing countries and countries where uncomplicated AOM is not managed with antibiotics have an increased incidence of mastoiditis, presumably resulting from untreated otitis media.
For example, the incidence of acute mastoiditis in the Netherlands, which has a low antibiotic prescription rate for AOM, is reported as 3. In all other countries with high antibiotic prescription rates, the incidence is considerably lower than this, at 1. Acute mastoiditis is a disease of the young. Most children with acute mastoiditis are younger than 2 years median age, 12 months and have little history of antecedent otitis media. At this age, the immune system is relatively immature, particularly with regard to its ability to respond to challenges from polysaccharide antigens.
No sex predilection is known. However, for all forms of mastoiditis, race affects the incidence of otitis media. Some populations, such as the Inuit, almost universally have middle-ear disease and, invariably, have chronic mastoiditis. Expect patients with acute mastoiditis to recover completely if the facial nerve, vestibule, or intracranial structures are not involved. In most cases, cosmetic deformity of the surgically treated ear can be prevented with judicious placement of the incision and the development of flaps to pull the ears posteriorly when replaced.
Conductive hearing loss should resolve, provided the ossicular chain remains intact. Conduct testing after otorrhea ceases and the ear has healed. Mastoiditis, when it progresses beyond the first 2 stages see Pathophysiology , is considered a complication of otitis media. Complications of mastoiditis result from further extensions of the process in or beyond the mastoid itself.
Such extensions include the following:. Acute mastoiditis in children: Complicated otitis media and its implications. Otolaryngol Head Neck Surg. Pneumococcal mastoiditis in children. Fusobacterial infections in children. Curr Infect Dis Rep. Pediatr Infect Dis J. Pneumococcal mastoiditis in children and the emergence of multidrug-resistant serotype 19A isolates. Microbiology of acute mastoiditis and complicated or refractory acute otitis media among hospitalized children in the postvaccination era.
Role of methicillin-resistant Staphylococcus aureus in head and neck infections. Changes in acute mastoiditis in a single pediatric tertiary medical center: Our experience during compared with data for Scand J Infect Dis. Acute mastoiditis in children aged years--a national study of cases in Sweden comparing different age groups.
Int J Pediatr Otorhinolaryngol. The role of anaerobic bacteria in acute and chronic mastoiditis. Fusobacterium necrophorum mastoiditis in children - emerging pathogen in an old disease. The role of beta-lactamase-producing-bacteria in mixed infections.
Blastomycosis presenting as isolated otitis and otomastoiditis.