1. <2 years (N=46) 2-8 years (N=42) P-value
Boys, n (%) 25 (54) 30 (71)
History of recurrent AOM1
10 (22) 9 (21) 0.97
AM diagnosis day, median2
4 5
Previous antibiotic therapy, n (%) 13 (28) 19 (45) 0.16
Fever, n (%) 28 (61) 28 (67) 0.57
Laboratory tests at admission3
Leukocytosis
ANC, average (range)
High CRP level
29 (63)
10.9 (1.5-26.5)
44 (98)
31 (74)
11.9 (1.2-27.8)
40 (95)
0.28
0.37
0.92
PCV status4
Unimmunized, n (%)
PCV7/PCV13 immunized, n (%)
27 (59)
19 (41)
35 (83)
7 (17)
0.01
0.01
INTRODUCTION
• Acute mastoiditis (AM) is the most common
suppurative complication of acute otitis media
(AOM), which mainly effects the pediatric
population.
• AM it diagnosed in children with a recent history
of AOM, who present with otalgia, fever,
posterior auricular swelling, erythema and
mastoid tenderness sometimes accompanied by
a protruded auricle or otorrhea.
• AM should be treated with parenteral antibiotics
for 7-10 days, accompanied or not by
myringotomy. In more advanced cases surgery
may be necessary.
• Computed tomography (CT) scans and magnetic
resonance imaging (MRI) studies are the
preferred imaging modalities for AM; each is
used in order to evaluate different structures.
• This study evaluated the necessity and timing of
these imaging modalities.
PATIENTS AND METHODS
• Children <8 years of age who presented between
2005-2014 with AM were identified.
• AM diagnosis was based on clinical findings (post-
auricular tenderness, erythema or swelling,
protruding auricle, palpable/fluctuating mass,
bulging and hyperemic tympanic membrane) and
systemic signs (fever with or without lethargy,
irritability, poor feeding, diarrhea).
• Data analyzed included demographics, past
medical history including recurrent AOM as defined
in the guidelines, past surgical history, AM signs and
symptoms, pneumococcal conjugate vaccine (PCV)
immunization status, laboratory data, decisions as
well as timing of imaging studies, AM-related
sequelae as well as AM-related surgical
interventions.
DISCUSSION
• Our study showed that the majority of
children presenting with clinically
diagnosed AM that were adequately
treated with intra-venous antibiotic
therapy, with or without myringotomy,
presented with a benign course of disease.
• Even though the majority of children in
our study did not undergo imaging
studies, there were no eventful sequelae.
• The relatively low numbers of imaging
studies performed (CT, 23%; MRI, 3%) are
in line with the recent Triological Society
Best Practice 2014 paper on AM, which
recommends imaging "if the patient fails
to improve after 48 hours, or if there is
deterioration in their clinical status" .
• The advent of PCVs in immunization
programs worldwide may result in a more
complex presentation of AM, presenting
with atypical bacteria. In parallel, more
sophisticated imaging techniques will be
introduced. We anticipate that special MRI
techniques may replace in the future CTs
for the assessment of AM.
• In the future, we believe that we will
witness a change in the indications for
performing imaging studies as well as a
change in the choice of imaging modalities
and the time of their acquisition.
Contact: Sharon Ovnat Tamir, MD
E-mail: sharontamir@gmail.com
REFERENCES
1. Ovnat Tamir S, Roth Y, Dalal I, Goldfarb A, Marom T.
Acute mastoiditis in the pneumococcal conjugate
vaccine era. CVI. 2014;21(8):1189-91.
2. Tamir S, Schwartz Y, Peleg U, Perez R, Sichel JY. Acute
mastoiditis in children: is computed tomography
always necessary? Ann Otol Rhinol Laryngol. 2009;
118(8):565-9.
3. Tamir S, Shwartz Y, Peleg U, Shaul C, Perez R, Sichel
JY. Shifting trends: Mastoiditis from a surgical to a
medical disease. Am J Otolaryngol. 2010;31(6):467-71.
Acute Mastoiditis in Children: Necessity and Timing of Imaging
Tal Marom, MD, Sharon Ovnat Tamir, MD
Department of Otolaryngology - Head and Neck Surgery,
Edith Wolfson Medical Center, Holon, Israel
Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel
Table 1. Acute mastoiditis episodes, younger children
(<2 years) vs. older children (2-8 years).
Figure 1. Timing of imaging studies, complications and
surgery during acute mastoiditis course: (A) children <2
years of age, (B) children 2-8 years of age.
RESULTS
• 86 children contributed 88 AM episodes. 63%
were in boys and 52% in children <2 years of age.
• Table I shows the demographics and the clinical
data. The annual incidence of AM was
5.8/100,000 children.
• In 20 (23%) episodes CT scans were performed,
and in 3(3%), additional MR studies were done.
• For children who underwent imaging studies, the
decision was based on the evolvement of
subperiosteal abscess (45%), clinical worsening
despite adequate antibiotic therapy (35%), and
new-onset of focal neurological signs (20%).
FIGURE 2.
(A) Axial brain CT. Subperiosteal abscess overlying the
destructed right temporal bone (white arrow), with an
underlying epidural abscess (black arrowhead).
(B) Axial brain CT. Filling defect in the right sigmoid sinus,
suggesting a thrombus (white arrow). The mastoid
cavity is completely opacified.
(C) Coronal brain CT showing an epidural abscess (white
arrow).
(D) Coronal brain MRI, demonstrating thickening of the
cranial dura mater, from the right sigmoid sinus level
towards the spinal canal (black arrow). In the right
suboccipital soft tissue, a lesion compatible with a deep
subperiosteal abscess is shown (white arrow).
A