Acute mastoiditis and osteomyelitis of the temporal bone

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Summary

Objective:

Acute mastoiditis becomes clinically significant when infection spreads through the periosteum and induces periosteitis. This study describes an atypical complication of acute mastoiditis: osteomyelitis of the temporal bone.

Patients and methods:

The study sample included all patients admitted for acute mastoiditis between September 2001 and December 2003 who had symptoms, signs and imaging findings of osteomyelitis of the temporal bone beyond the mastoid area. The files were reviewed for diagnosis, work-up, radiographic findings and treatment.

Results:

The study group included 6 of the 120 patients treated for acute mastoiditis. In four children (66%), the diagnoses of acute otitis media and acute mastoiditis were made simultaneously at admission. Ear cultures yielded coagulase-positive Staphylococcus in three patients, Bacteroides in two, multiple organisms in two, S. pneumoniae in one, and no growth in two. Complications were suspected if there was a lack of improvement in symptoms and signs, or in cases of skin involvement over the temporal bone beyond the area of the mastoid in accordance with imaging findings. Computerized tomography demonstrated temporal bone absorption beyond the mastoid area (squama and/or petrous bones) in all children, suspected sinus vein thrombosis in two, and suspected epidural abscess in one. All children were treated with at least cortical mastoidectomy and insertion of ventilation tubes. Revision mastoidectomy was performed in three children in whom no improvement was noted and imaging suggested other complications.

Conclusion:

The present study describes an unusual complication of acute mastoiditis—osteomyelitis of the temporal bone beyond the mastoid framework. The disorder is characterized by a failure to respond both locally and systemically to accepted medical and surgical therapy, persistent fever and high levels of inflammatory markers, and computerized tomography findings of temporal bone destruction. Treatment includes broad-spectrum antibiotics and at least cortical mastoidectomy. Prognosis is good.

Introduction

Acute otitis media (AOM) is an inflammatory process involving the mucoperiosteum of the middle ear cleft [1]. It is among the most common conditions treated by pediatricians and otolaryngologists [2]. The clinical spectrum extends from a self-limiting benign condition to a complicated disease with intracranial involvement [3].

As mastoid air cells form part of the middle ear cleft, some level of mastoid involvement is expected in any inflammation of the middle ear. Acute mastoiditis (AM) becomes clinically significant if it spreads through the periosteum and induces periosteitis, which may cause bone destruction (acute coalescence mastoiditis). The infection may progress through adjacent bones or through emissary veins beyond the mastoid air cells and may present as a subperiosteal abscess or an intracranial complication [4]. AM may also result from an infectious process that simultaneously attacks the middle ear mucosa and the osseous tissue [5]. In these cases, the bony framework of the middle ear cleft can be involved primarily, from an early stage [3].

The incidence of AM in patients with AOM dropped from 50% at the turn of the 20th century to 6% in 1955, and to 0.4% in 1959. By 1993, only 0.24% of patients with AOM developed AM [2]. At the same time, however, the rate of subperiosteal or other extra/intracranial complications increased from 20% to nearly 50% of patients with AM in some centers [2]. In our experience, however, the incidence was only 15% [6].

AM was initially considered an unusual occurrence in infancy because of the yet undeveloped mastoid. However, several recent articles have reported AM already in the first year of life, and even in infants as young as 2 months [7], in accordance with the prevalence findings for AOM [8].

AM may be the first apparent clinical sign of AOM [9], especially in neonates, in whom the physical examination is often difficult [9].

Although bone destruction of the mastoid partitions and of the cortical bone over the mastoid is typical of AM, bone destruction beyond the mastoid area has not been previously described. In this study, we present six children with AM and osteomyelitis of the temporal bone, with emphasis on the work-up, radiologic appearance, and treatment options.

Section snippets

Patients and methods

From September 2001 to December 2003, 120 children with AM were treated at the Schneider Children's Medical Center of Israel, a tertiary referral center. The diagnosis of AM was based on standard clinical criteria, namely, symptoms and signs of AOM, retroauricular erythema, swelling and tenderness, and protrusion of the auricle. Six of the children had symptoms, signs and imaging findings of osteomyelitis of the temporal bone beyond the mastoid area, and they formed our study group. Their

Results

The study sample comprised five boys and one girl aged 11–65 months (mean 26 months). Two children (33%) had a positive history of recurrent otitis media. In two children, the diagnosis of AOM was suggested prior to referral, and in four (66%), the diagnosis of AOM and acute mastoiditis were made simultaneously at admission. None had been treated with antibiotics prior to hospital admission.

The duration of symptoms prior to admission ranged from 1 to 7 days (mean 4 days). The presenting

Discussion

We describe six children treated at Schneider Children's Medical Center of Israel for AM with osteomyelitis of the temporal bone.

Their mean age was 16 months, which is consistent with the increased incidence of AM in children younger than 2 years [3], [10], [11]. Two had a history of recurrent otitis media (33%). Earlier studies reported no correlation between a history of recurrent ear infections and development of complications of AM [3]. The short duration of symptoms prior to admission

Conclusion

This study describes an aggressive form of AM with osteomyelitis of the temporal bone, beyond the mastoid framework. The hallmarks of this entity are failure to respond to accepted medical and surgical therapy, signs of cellulitis of the skin over the involved bone beyond the mastoid area, persistent elevation of CRP levels, and CT findings of bone destruction beyond the mastoid area. In most of our children, AOM was not diagnosed prior to admission. The short period of symptoms before

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