Acute Mastoiditis with and without Intracranial Complications. 20 Years of Experience Using Uniform Medical Protocol

Background: Since July 1997 a mandatory management protocol for acute mastoiditis (AM) has been used in Bnai Zion MC. Initial management includes myringotomy, culture & VT insertion followed by initiating of a broad-spectrum antibiotics and imaging in search of an intracranial complication (ICC).

Objective: The study aim was to characterize the presenting features in children with AM who also have ICC as compared to those who do not have an ICC on presentation.

Methods: All AM patients (n=160) treated between 1997 and 2017 during the study period.

Results: 24 children (15%) had an ICC. Information regarding bacterial culture was available in all patients. In 99 (62%) culture was positive. The most commonly isolated organisms were group A Streptococcus (n=38) and Streptococcus pneumoniae (n=21). The mean duration of hospitalization was 18.7 and 8 days in patients with and without ICCs, respectively. Patients who presented with fluctuation over the mastoid area or spontaneous perforation had 4 and 3 time higher chances respectively to have an ICC as compared to patients who presented without these features (p<0.01). All patients in whom Fusobacterium was isolated developed ICC.

Conclusions: AM patients who present with spontaneous perforation or fluctuation over the mastoid have a higher risk for ICCs. Fluctuation and spontaneous perforation can be used as measures for severity of AM and risk for ICC, also in the absence of any other alarming clinical feature. Yet, one should keep in mind that by basing the decision to perform imaging in AM on these risk measures, ICCs are missed.