M.D., Raul Rudoy, M.D., John D. Nelson, M.D

Transcription

1 INFECTIUS DISEASE Charles M. Ginsburg, M.D., Raul Rudoy, M.D., John D. Nelson, M.D During a -year period, 7 cases of acute mastoiditis occurred in infants and young children who ranged in age from months to years of age. All patients had abnormalities of the tympanic membrane and most had fever and localized edema and redness of the overlying skin. Fifty per cent of the infants who were less than one year of age had swelling primarily above the involved ear pushing the pinna out and down. By contrast, older children had swelling of the skin overlying the mastoid process which produced the classical finding of an elevated earlobe. Mastoid roentgenograms were a useful adjunct to diagnosis, revealing concurrent osteomyelitis in 9 patients. A diagnosis of specific bacterial etiology was made in 0 per cent of the patients in whom cultures were performed. Streptococcus pneumoniae, StaPhylococcus aureus and Streptococcus pyogenes were the bacteria most frequently isolated. Unusual manifestations or serious complications occurred in per cent of the patients, including one death (due to meningitis). These data indicate that the frequency of serious complications from acute mastoiditis has not declined over the past decades. T HE INCIDENCE of acute mastoiditis has declined precipitously since the introduction of effective antimicrobial agents for the treatment of acute otitis media.it is not surprising, therefore, that the disease has received little attention in the medical literature during recent decades.- Whether the decline in the incidence of the disease has been accompanied by changes in the clinical characteristics, etiologic agents, and morbidity and mortality is not known. The purpose of this communication is to review our experience with acute mastoiditis during the past 4 years. From the Department of Pediatrics, University of Texas Southwestern Medical School, Dallas, Texas. Correspondence to: Charles M. Ginsburg, M.D., Department of Pediatrics, University of Texas Southwestern Medical School, Harry Hines Boulevard, Dallas, TX 7. Received for publication March, 90; revised April, 90 and accepted April, 90. Materials and Methods The clinical records of children with acute mastoiditis at Children's Medical Center and Parkland Memorial Hospital, Dallas, Texas, during a -year period from 9 through 979 were reviewed. nly patients with acute middle ear disease accompanied by local swelling over the mastoid area were included. Mastoid disease was confirmed by surgery or roentgenograms in the majority of patients. Patients with chronic middle ear and mastoid disease, defined as over one month's duration, were not included. Results During the -year period, there were 7 patients with acute mastoiditis. The frequency remained similar throughout the -year period with two or three cases annually. The age range was from two months to twelve J. B. Lippincott Co. 49

2 GINSBURG ET AL. TABLE I. Physical Findings at the Time of Diagnosis Feature Age of Patients <I Year ( patients) : Year ( patients) Abnormal tympanic membrane (00%)* (00%) Temperature > C (6%) (9%) Erythema of overlying skin (%) 4 (69%) Swelling above ear only II (0%) 0 behind ear only 7 (%) 6 (74%) both above and behind ear 4 (%) 9(6%) * No. (%) of patients with sign. years with a mean of.6 years. There were 7 males and 0 females. Twenty-two children were less than one year of age and of these were male. Sixty per cent of the patients were Caucasian, per cent black and per cent had Latin-American surnames. This approximates the racial distribution in Dallas. The abnormalities present on physical examinations are shown in Table I. All pa- tients had abnormalities of the tympanic membrane consisting of opacity, immobility or either bulging or perforation. Fever was generally moderate with only per cent of patients having a temperature greater than 40 C. Localized edema with or without erythema of the overlying skin was present in all patients; however, its location varied according to the age of the patient. Eleven of twenty-two patients (0%) who were less than one year of age had swelling primarily above the involved ear which pushed the pinna out and down (Fig. I). By contrast, older children had swelling of the skin overlying the mastoid process which produced the classical finding of an elevated earlobe. All but one patient had unilateral involvement, with the right side affected in 9 patients and the left in 7. The patient with bilateral disease was a two-monthold male who died of associated meningitis due to Pseudomonas aeruginosa. Roentgenograms of the mastoid area were abnormal in all 4 patients on whom the FiG. I. Eleven-month-old child with acute mastoiditis caused by Streptococcus pneumoniae. The primary area of swelling is above the ear, displacing the pinna outward and downward. 0 Vol. 9 No. CLINICAL PEDIATRICS

3 ~ ACUTE MASTIDITIS T ABLt:. Results of Mastoid Roentgenograms Radiologist's Interpretation < Year ( Patients) Ages of Patients ;=: Year ( Patients) -ABLE. Results of Cultures from Middle Ear Fluid, Mastoid Cavity, Blood or Cerebrospinal Fluid Unilateral cloudiness {7%) 4 (7%) Bacteria Bilateral cloudiness 4 (9%) (6%) steomyel iris * (0%) 7*(%) Sterile cultures Streptococcus pneumoniae * In patients, the roentgenograms were reported as Streptococcus pyogenes cloudiness plus osteomyelitis. ne patient (~ year) had Staphylococcus llureus osteomyelitis alone. Pseudomonas aeruginosa H emophilus influenzae B study was done. (Table ). Three patients with surgical confir~ation of mastoiditis did not have roentgenographic studies. Although 6 patients had bilateral roentgenographic evidence of mastoid infection, only previously mentioned patient had bilateral swelling and erythema. pacification of the mastoid air cells was the most frequent finding, being present in all but one patient who had only a destructive lesion of the bone. Ten other patients had roentgenographic t:vidence of temporal bone destruction. A diagnosis of specific bacterial cause was made in 0 patients (6%) based on cultures obtained from blood, cerebrospinal fluid, mastoid pus or middle ear fluid (Table ). Cultures were not obtained from patients, and in ten patients cultures were sterile. Streptococcus pneumoniae, Streptococcus pyogenes and Staphylococcus aureus were the agents most frequently isolated. Eikenella corrodens, Staphylococcus epidermidis and microaerophilic streptococci were isolated from the middle ear fluid and abscess cavity of a patient with a cerebellar abscess. The 9-month-old infant with tuberculous mastoiditis had had symptoms for three weeks when hospitalized and therefore was classified as acute by our definition. The same bacterial species was isolated from the middle ear and mastoid in each of the.6 patients in whom both cultures were obtained. Surgical procedures were performed on 4 patients (7%). These consisted of simple mastoidectomy and myringotomy in, myringotomy alone in 4, radical mastoidectomy in and simple mastoidec~omy in 7 Citrobacter Streptococcus Mycobacterium sp. viridans tuberculosil' Non-enterococcal group D streptocqccus Group D strept<>coccus Mixed culture (Eickenella cottodens,staphylococcus epidermidil' and MicroaeroPhilic streptococcus) Ages of Patients <I Year ~I Year Total (9 (0 (49 Patients) Patients) Patients) patients. Needle aspiration alone of the abscess cavity was performed in 4 of the 0 patients with subperiosteal abscess. All patients received antibiotics. Penicillin G or penicillin derivatives were given to all except patients with gram negative bacillary infection or tuberculosis who were treated with appropriate drugs. U ncommon local manifestations and complications occurred in % of the patients (Table 4). The single death occurred in a two month old infant with bilateral mastoid disease and associated meningitis caus~d by Pseudomonas aeruginosa. Four additional pa TABLE 4. Complications of Acute Mastoiditil" Condition steitis Subperiosteal Meningitis, abscess Facial palsy Cerebellar abscess Death l l4 () (%) 0(%) (9%) (4%) (%) (~%) (0%) ( %) 9 (%) CLINICAL PEDIATRICS August 90

4 GINSBURG ET AL. T ABLE. Reported Complications of Acute Mastoiditis Zoller (%) (4%) (%) (%) 7 (6%) Ronis et at.' Present series I (%) (%) tients had meningitis. Streptococcus pneumoniae was recovered from the middle eat and/or mastoid pus and cerebrospinal fluid in. ne patient with sterile cerebrospinal fluid cultures had CSF pleocytosis and Streptococcus pyogenes was isolated from cultures of the middle ear fluid and mastoid pus. Discussion Although infrequent, acute mastoiditis occurs at all ages, including very young infants. In the younger age group, the diagnosis may be overlooked if it is not realized that the swelling may occur above the ear and not over the mastoid process. This is because the mastoid process of the temporal bone is not fully developed in infants. When the partially pneumatized mastoid becomes infected, purulent secretions find egress through the tympanomastoid fissure. When this occurs, the swelling pushes the superior aspect of the pinna out and down. Differentiation from cellulitis or lymphadenitis may at times be difficult, However, patients with lymphadenitis wi~l, in most instances, have infected lesions of the skin or scalp above the involved area, and will have a normal tympanic membrane and normal roentgenograms. Mastoid roentgenograms were a useful adjunct to diagnosis. They were diagnostic in 0 infants and suggestive in others who had clouding of the mastoid air cells on the affected side only, nly one of the six patients who had bilateral clouding of the mastoid air cells without evidence ofbony destruction had clinical evidence of bilateral mastoid involvement. Three of the latter group had bilateral otitis media. By contrast, 7 of the patients (4%) who had unilateral clouding of the mastoid had bilateral otitis media. A bacteriologic diagnosis was made in 0 per c~nt of patients in whom cultures were obtained. Pneumococci, staphylococci and strep~ococci were the most frequently isolated organisms. In previous reports, Group A streptococcus has been the organism most frequently isolated.l.4 nly one patient had infection caused by HemoPhilus influenzae. The infrequency of this agent as a pathogen in mastoiditis and its frequency in uncomplicated otitis media seems paradoxical. The explanation may be that Hemophilus causes disease of mucous and serous membranes but is less likely to attack bone. Gram-stain of pus from the middle ear fluid obtained by tympanocentesis, or by myringotomy, is a rapid and reliable guide for the initial selection of antibiotic therapy. In most instances, a p~nicillase-resistant penicillin or a cephalosporin provides adequate coverage until the results of the cultures ate available. The ultimate antibiotic regimen should be di(::tated by the results of cultures and susceptibility testing of organisms obtained from the mastoid or middle ear cavities. Because no single treatment regimen was employed during the time of the study, it is not possible to evaluate either the necessity for surgical intervention or the efficacy of the various surgic;ll procedures. The indications for surgical treatment should be evaluated on an individual basis. Prompt ev~cuation of pus would appear to be indicated in toxic patients and in those with signs of meningeal irritation. Complications or the unusual manifestations of osteitis, abscess and facial palsy, occurred in half the patients. Ronis and Vol. 9 No. CLINICAL PEDIATRICS

5 ACUTE MASTIDITIS associatesl reported complications in 9 per cent of patients of approximately the same age, but did not include osteitis of the temporal bone as a complication. In a larger series covering the years , Zollers found complications in (6%) of 679 patients with acute mastoiditis and deaths (.6%). He concluded that the incidence of complications from acute mastoiditis diminished greatly after the years However, his data do pot support his conclusion; the relative frequency of serious complications and mortality more than doubled between 949 and 970 as compared with the period between 97 and 94 (Table ). The disease, though less frequent, continues to have a substantial complication rate. References. Ronis B, Ronis M, Liebman E: Acute mastoiditis as seen today. Eye Ear Nose Throat Month 47:4, 96. Palva T, Pulkinen K: Mastoiditis. J Laryngol tol 7:7, lq9. Palva T: Mastoiditis in children. Laryngoscope 7:, Boies LR: Acute mastoiditis: Ann tol Rhinol Laryngol :60, 94. Zoller H: Acute mastoiditis and its complica;tions: a changing trend. South Med J 6:477, 97 BKSHELF: Psychiatric Emergencies in Pediatrics. Aman U Khan. Chicago, Year Book Publishers, pp. no price listed This book addresses not only psychiatric emergencies in pediatrics, but also many ongoing psychological issues faced by pediatricians. The chapter headings suggest the broad scope of the book and include: crisis theory and intervention; acute anxiety and fear, acute psychophysiological symptoms; agression and violence in children; grief, depression and suicide, childhood psychoses; drug treatment of acute psychiatric conditions; drug abuse and drug dependence; child abuse; management of rape victims; and management of irate patients. In addition, topics less tied to psychiatric emergencies include: reactions to hospitalization; coping with chronic illness; facing a dying child and his family; psychiatric interviews with parents and children; and basic issues in malpractice. The author is careful to include the developmental perspective in his discussion of various clinical problems so that the differential effects of a problems on children of different ages can be appreciated. The physiological aspects of various topics are also included. Much of the relevant literature is summarized, and specific guidelines for management of each problem are provided. It is a noteworthy achievement for a single author to address himself to all of the above topics, and most have been handled well. The chapter on managing irate parents has good clinical examples and is particularly well done, as is the chapter on crisis intervention. Some specific limitations of the book include the chapter on psychotropic medication, which often lacks specific guidelines on usage in emergency contexts. In addition, ~he poten~ial cardiotoxic effects of tricyclic antidepressants if taken in acute overdosage is not mentioned in either the discussion on antidepressants or the chapter on suicide. Another concern is the discussion of anorexia nervosa, which disappointingly focuses on hospitalizing these patients and setting criteria for tube feeding rather than describing the primarily outpatient family-oi-iented approach of Minuchin that should by now be incorporated into pediatric training. Also disappointing is the brief attention given to school avoidance, a particularly important topic for a book dealing with psychiatric emergencies in pediatrics precisely because it usually is m~sked by somatic or other symptoms and is not detected unless specifically thought of and askt:d ~bout. Finally, the book would be strengthened by a discussion of how the pediatrician and psychiatrist collaborate in addressing various clinical problems. verall,.! consider this book to be a meaningful contribution to behavioral pediatrics in that it summarizes broad ~opics succinctly and provides specific guidelines for their management. Pediatric trainees will find this a useful starting point in learning about various clinical issues at the interface of pediatrics and psychiatry. GRDN HDAS, MD, Philadelphia CLINICAL PEDIATRICS August 90