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Acute mastoiditis is a serious condition that carries with it a high rate of morbidity and mortality. This review highlights the pearls and pitfalls of mastoiditis, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence. Acute mastoiditis most commonly affects pediatric patients and is a suppurative infection of the mastoid air cells. It is often associated with otitis media, and common bacteria include Streptococcus and Staphylococcus. History and examination may reveal tympanic membrane erythema, pinna protrusion, postauricular erythema, mastoid tenderness with palpation, external canal swelling, otorrhea, fever, and malaise. The disease should be suspected in those who fail treatment for otitis media and those who demonstrate the aforementioned abnormalities on examination and systemic symptoms. Laboratory analysis may reveal evidence of systemic inflammation, but a normal white blood cell count and other inflammatory markers should not be used to exclude the diagnosis. Computed tomography (CT) of the temporal bones with intravenous contrast is the recommended imaging modality if the clinician is unsure of the diagnosis. CT may also demonstrate complications. Treatment includes antibiotics such as ampicillin-sulbactam or ceftriaxone as well as otolaryngology consultation. Complications may include subperiosteal and intracranial abscess, deep neck abscess, facial nerve palsy, meningitis/encephalitis, venous sinus thrombosis, and seizures. An understanding of acute mastoiditis can assist emergency clinicians in diagnosing and managing this potentially deadly disease. [ABSTRACT FROM AUTHOR]

The universal use of computed tomography (CT) has opened up new possibilities in the noninvasive examination of human mummies, and particularly the detailed study of the fine structures of the temporal bone. The aim of this study was to describe the morphological changes, as seen on CT, found in the right temporal bone of Djed-Hor, an around 2300 year old Heidelberg's Egyptian mummy, and to discuss their possible causal relation to his death. Here we showed the presence of a compress on the auricle, and of probable pus in the mastoid, middle ear, and external ear with erosion of the tegmen tympani probably related to a fatal acute mastoiditis. These typical morphological changes of such a disease were demonstrated in the same way as in living patients of today. This would be the first depiction of a compress on an auricle associated with pus in the ear of an Egyptian mummy. [ABSTRACT FROM AUTHOR]

Herein, we report a case of otitis externa caused by Malassezia slooffiae complicated with mastoiditis. A 70-year-old male complained of fever and severe otorrhea from left external auditory canal 2 months after undergoing a craniotomy to remove a hematoma. He had right-sided paralysis and undertook bed rest. Brain computed tomography revealed continuous fluid accumulation in the left mastoid air cells and middle ear from left external auditory canal in addition to leukocytosis and increased C-reactive protein level. The tympanic membrane was severely swelling. These results indicated the presence of otitis media and mastoiditis. Otorrhea culture showed large amounts of M. slooffiae. The administration of liposomal amphotericin B (L-AMB), the irrigation of external auditory canal with normal saline, and the application of topical ketoconazole ointment were started. The administration of L-AMB for 8 weeks and voriconazole, which was switched from L-AMB, for 4 weeks ameliorated his infection and he was transferred to another hospital to receive rehabilitation. From these results and his clinical course, the diagnosis of otitis externa caused by Malassezia slooffiae complicated with mastoiditis was made. And the possibility of the contamination by M. slooffiae was very low. Clinicians should be aware that M. slooffiae can provoke otological infections since M. slooffiae is the most common Malassezia sp. in external auditory canal. [ABSTRACT FROM AUTHOR]

Review of the scientific literature dedicated to clinical data and diagnosis modalities for aural tuberculosis published since the start of the 21st century. Search of the Medline, Cochrane and Embase databases for the period 2000–2020. Selection of articles in English, French and Spanish devoted to clinical cases and series documenting clinical data and diagnosis for aural tuberculosis of articles by two authors. Analysis performed according to SWiM guidelines. Extraction of data on pre-established files documenting clinical and diagnostic data. In total, 173 articles: 163 case reports (228 patients) and 10 cohorts (177 patients) from 49 countries were analyzed. Female/male sex ratio was 1.05, with ages ranging from less than 1 month to 87 years. Tuberculosis involved another site in 35.1% of cases. Aural involvement was bilateral in 19.7% of cases. Clinical presentation corresponded to otitis media (prior antibiotic treatment and auricular surgery in 41.4% and 10.1% of cases, respectively) without any pathognomonic symptoms or signs. Associated severe locoregional complications were seen in 32% of cases, with 23.2% and 13% incidence of peripheral facial palsy and severe intracranial complications, respectively. Time to diagnosis ranged from less than 1 month to 384 months, and was longer than 12 months in 26.5% of case reports, without significant correlation (P = 0.29) with severe revelatory locoregional complications. Incidence of Mycobacterium tuberculosis detection ranged from 33.4% of documented cases in auricular secretions to 64.6% in polyps, granulomas, and/or biopsies. In the case reports, diagnosis with certainty was done in 58.3% of cases, while it was based on involvement of another site and on indirect criteria or positive clinical progression after treatment in the other 10.1% and 31.6%, respectively. Aural tuberculous must always be considered in case of unfavorable progression of otitis. Definitive diagnosis is based on multiple auricular sample sites, polymerase chain reaction, and γ interferon blood assay. [ABSTRACT FROM AUTHOR]

Objective: Hypertrophic pachymeningitis (HP) is a rare disorder that causes localized or diffuse inflammatory fibrosis and thickening of the dura mater. Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV)-related HP is the most frequent form of HP. Otitis media with AAV (OMAAV) patients with HP are associated with higher rates of both ANCA-negative phenotypes and disease-related mortality. However, few studies have reported the imaging characteristics of HP due to AAV/OMAAV. Therefore, we investigated this issue in the present study.Methods: This retrospective study included patients diagnosed with HP between 2011 and 2020 at our hospital. Age, sex, causative disease, serum C-reactive protein (CRP) level, and MRI data were collected from medical records. We compared the locations of MRI enhancement depending on the causative diseases.Results: Of the 18 included patients with HP (mean age, 64.1 ± 2.6 years; range, 33-77 years), 10 (55.6%) were female, 12 (66.7%) were diagnosed with AAV/OMAAV, four (22.2%) were diagnosed as idiopathic, two (11.1%) were diagnosed with invasive Aspergillus mastoiditis. Eleven (61.1%) had cranial neuropathies. Facial nerve paralysis was common in AAV/OMAAV, while abducent nerve paralysis was common in idiopathic HP. Cranial fossa enhancement was most common presentation in patients with HP, whereas inner acoustic canal (IAC) enhancement was seen only in patients with AAV/OMAAV, while HP involving the cavernous sinus was seen only in patients with idiopathic and mastoiditis.Conclusion: HP involving the IAC may be a key factor in diagnosing AAV/OMAAV. [ABSTRACT FROM AUTHOR]

Objective: Although cochlear implantation (CI) is a relatively safe operation, postoperative complications sometimes occur. We reviewed the frequency and severity of complications of CI at our hospital. We compared our results with previously reported complications and considered measures to improve patient outcomes.Methods: This retrospective study examined the medical records of 70 patients who received CI between March 2005 and December 2018. We collected the following data: age at the time of the first surgery, etiology of hearing impairment, date of implantation, type of implanted devices, and complications. Surgical complications were divided by time into perioperative, early, and late, and by severity into major or minor.Results: Records of 38 adults and 32 children were analyzed. Bilateral CI was performed in 16 patients, 8 of whom were sequential, and unilateral CI was performed in 54 patients. The total number of operations was 78 for 86 CI. Complications were observed in 15 of 78 operations (19%), and the rates of minor and major complications were 15% and 4%, respectively. Complication rates were 21% (8/39) for children and 10% (4/39) for adults. All of the perioperative and early complications were minor. There were three major complications, all of which were infections presenting with mastoiditis and subcutaneous or subperiosteal abscesses. One case required reimplantation twice because of recurrent mastoiditis and temporal abscess.Conclusions: There was no significant difference in the incidence of complications between children and adults, but all major complications were infection in pediatric cases. Careful attention is needed to prevent postoperative infection. [ABSTRACT FROM AUTHOR]

Auritidibacter ignavus is an emerging diagnosed microorganism associated with fulminant otitis, mastoiditis and recurrent otitis. Here we describe a clinical case in a little girl in La Gomera Island together with images of the bacteriological culture and whole genome sequencing. [ABSTRACT FROM AUTHOR]

In modern clinical medical practice, middle-ear infection is a frequently reported condition. If untreated, persistent inflammation caused by infection may lead to perforation of the mastoid process or other portions of the temporal bone. When the middle-ear abscess penetrates the surrounding bone and invades the mastoid process, it causes mastoiditis. Abnormal osseous fistulae were observed on the temporal bones of individuals M137 and M199, which were unearthed in Qufu Olympic Sports Center Cemetery in Qufu City, Shandong Province, and date to the Warring States to the Han Dynasty (475 BCE–220 CE). Microscopic observation and CBCT were used to examine the lesions. A differential diagnosis suggests that the lesions were related to mastoiditis, and based on reference studies, burial information, and paleopathological observation, pollution in the living environment and poor living conditions may be potential factors that caused individuals M137 and M199 to suffer from mastoiditis. The two examples from Qufu are the earliest reported cases of mastoiditis from China; however, infections in the middle ear often go unnoticed in archaeological samples. [ABSTRACT FROM AUTHOR]

Objectives: Luc's abscess is a rare complication of acute otitis media, with a challenging diagnosis and a controversial surgical treatment. The aim of the present study was to review the published literature in order to clarify the clinical features and the surgical management of those patients.Methods: A systematic review of the literature was carried out for published reports or case series in English language, describing a temporo-zygomatic (or Luc's) abscess which complicated an acute or chronic otitis media and/or mastoiditis, confirmed through CT scan or MRI of the petrous bone. The collected clinical and radiological data were merged and critically appraised.Results: Eighteen reports of Luc's abscess were included. Adding our case report, a total of 21 cases were included in the analysis. Abscess drainage plus myringotomy alone vs. abscess drainage plus myringotomy and mastoidectomy were the two surgical management approaches described in the literature. Patients undergoing first line mastoidectomy were successfully treated in all cases, while among those undergoing a more conservative approach, one failure required subsequent mastoidectomy.Conclusions: The clinical features of Luc's abscess are rather constant and help in rising the suspicion before the radiological diagnosis. Although cases with associated intra-cranic complications have been reported, the limited existing data do not permit to advocate the mastoidectomy over a more conservative surgical approach. However, the decision to avoid mastoidectomy as the first line surgical treatment should be based on the clinical and radiologic assessment, after an accurate counseling, particularly in the case of a pediatric patient. [ABSTRACT FROM AUTHOR]

To characterize the clinical presentation of pediatric patients who, upon AM diagnosis, also had imaging-diagnosed ICCs (ID-ICCs); to define the group of AM patients at risk of developing ID-ICCs; and to update knowledge about organisms causing AM. Analysis of all AM patients admitted between 1997 and 2018 and treated according to an obligatory protocol including both brain imaging and sampling for bacterial culture upon clinical diagnosis of AM. Of 166 admitted patients (0.5–19 years old) 22 (13%) already had ID-ICCs. In patients who, on admission, had already received antibiotics for acute otitis media (AOM) and also had CRP (C-reactive protein) levels above 93.5 mg/L, the risk of ID-CC was increased by 22.5-fold (P < 0.0001). Bacterial culture results were available for all patients and were positive in 115 (69%). Organisms most commonly found in patients without prior antibiotic treatment were group A Streptococcus pyogenes (53%), Streptococcus pneumoniae (23%), and Haemophylus influenzae (11%), while with prior antibiotic treatment they were Fusobacterium necrophorum (21%), Streptococcus pyogenes (18%) and Pseudomonas aeruginosa (18%). Since the risk of ID-ICC in patients with the abovementioned CRP and prior antibiotic treatment was significantly higher than in the others, these high-risk patients should undergo diagnostic imaging on admission. Antibiotic treatment prior to AM development may promote growth of non-AOM pathogen. [ABSTRACT FROM AUTHOR]

Mastoiditis is a complication of the medium otitis characterized by suppuration and destruction of the mastoid cells and the pyramid petrosa; its tuberculous etiology has decreased in the last 40 years. Paralysis resulting from mastoiditis is more common in children. The incidence of mastoiditis has risen, although there are no reports in the literature associated with renal transplants. A 37-year-old man developed paralysis of the seventh cranial nerve associated with tuberculous mastoiditis 71 days after living donor–related renal transplant while on immunosuppressive therapy. The mastoiditis diagnosis was clinical and radiologic, the axial tomography being the election examination. The paralysis of the facial nerve happens for the easy destruction of the bony capsule that involves it. When treated early with tuberculostatic drugs, surgical procedures can be avoided in patients with tuberculous etiology in a mastoiditis, especially in an immunocompromised patient. [ABSTRACT FROM AUTHOR]

Objectives Recurrent acute mastoiditis is repeatedly reported in the literature, but data to understand the pathogenesis, update treatment recommendations and inform future trials are sparse due to the infrequency of the disease. Methods A retrospective chart review from 2001 to 2016 was conducted including 73 children treated for acute mastoiditis. A follow-up survey was attempted for each patient. Bacteriology, method of treatment, hospital course, complications, and otologic history were analyzed. A chi-squared test, Fisher's exact test and Mann - Whitney U test compared recurrent acute mastoiditis to single acute mastoiditis cases. Additionally, a comprehensive PubMed search and review of world literature addressing recurrent pediatric acute mastoiditis was performed for comparative purposes. Results Among 73 children with acute mastoiditis, six (8%) experienced recurrent acute mastoiditis. Streptococcus pneumoniae was the only bacteria isolated in this group. History of recurrent acute otitis media (>4 per year) prior to the first episode of acute mastoiditis was identified in 24% with single episode of acute mastoiditis and 83% with recurrent mastoiditis (p < 0.05). Fewer intracranial/intratemporal complications were identified among recurrent mastoiditis patients (p < 0.05). In a group of patients treated with more extensive surgical communication during mastoidectomy for primary acute mastoiditis (wide mastoidectomy with broad attic exposure and posterior tympanotomy) no recurrence was observed. Conclusion We identify multiple risk factors associated with recurrence and provide early data supporting anatomic predisposition to the development of recurrent acute mastoiditis. More aggressive opening between the mastoid cavity and middle ear may prevent recurrent acute mastoiditis episodes. [ABSTRACT FROM AUTHOR]

Objective To examine preoperative risk factors, postoperative 30-day outcomes and adverse events of acute mastoiditis using a national pediatric surgical database. Methods We explored our objectives using a cross-sectional analysis of a hospital-based reporting system database. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) pediatric database was used to identify surgical encounters for the treatment of acute mastoiditis from 2012 to 2015. Patient demographics, co-morbidities, laboratory values, surgical details, complications, and outcomes were tabulated. Linear regression was used to determine predictors of prolonged hospital stay based on pre-operative, surgical and outcome variables. Results 113 patients with acute mastoiditis were identified from with mean age of 7.8 years. Mastoidectomy was the most common index procedure performed (44; 34%). Average hospital stay length was 5.2 days. No patients died within 30 days. 4 (3.1%) patients required readmission, and 9 (6.9%) required unplanned subsequent operative procedures. Pre-operative presence of sepsis or systemic inflammatory response syndrome (SIRS; p = 0.03), and unplanned additional procedures were associated with a prolonged hospital stay (p = 0.03), but age, gender, race, and pre-operative morbidities were not (p > 0.05). Conclusions Contemporary surgical management of acute mastoiditis in children appears to be safe. Mortality is rare and has been potentially eliminated as a complication. Rates of pre-operative systemic infection were very high, despite current antibiotic utilization trends. Opportunities for quality improvement exist to investigate how to decrease rates of preoperative sepsis, limit readmissions, and unplanned re-operations. The role of mastoidectomy appears prominent, as it was used in about two-thirds of cases. Level of evidence 4. [ABSTRACT FROM AUTHOR]

To investigate the microbial patterns and clinical outcomes of pediatric patients undergoing mastoidectomy for acute coalescent mastoiditis and to identify factors associated with poor outcomes and/or prolonged treatment. Monocentric retrospective cohort study. Tertiary referral pediatric hospital in Indiana. By cross-referencing database data from the Pediatric Health Information System (PHIS) querying for all inpatient stays (patients younger than eighteen) with a diagnostic code of mastoiditis between January 1st, 2010 and August 31, 2019, and the electronic health record (Cerner) for Riley Hospital for Children, 46 patients with mastoidectomy were included. A two-tailed T-test was used to evaluate continuous parametric data. Statistical significance was determined as P < 0.05. For continuous variables, data was analyzed using continuous logistic regression. A criteria of p > 0.1 was used for inclusion in the multivariate regression. Inclusion criteria was met by 46 patients. From 2010 to 2019, S. pyogenes and S. pneumoniae were the most common bacteria, each isolated in 11 of 42 bacterial isolates (26.2%). There was no growth in 35.4% (17/48) of intra-operative wound cultures. On univariate analysis, patients with negative cultures had longer length of hospital stay (LOS) (7.7 days [6.5] vs. 4.3 [2.8]; p = 0.018) as well as higher rates of PICC (peripherally inserted central catheter) placement (53.3% vs. 19.4%; p = 0.021). There was a statistically significant difference in terms of gender (p = 0.021), with 15 males and 16 females in the positive culture cohort and 13 males and 2 females in the negative culture cohort. On multivariate analysis, which included gender, PICC placement, both intracranial and extracranial complications, duration of antibiotics, and LOS, female gender was the only significant predictor of positive culture status (p = 0.039). S. pyogenes and S. pneumoniae were the predominant etiologic agents in acute coalescent mastoiditis between 2010 and 2019, and negative wound cultures were associated with worse clinical outcomes. [ABSTRACT FROM AUTHOR]

Pediatric emergency admissions fell significantly during the COVID-19 pandemic. This study investigated the changes in severe infectious complications managed by otolaryngology between the pre-pandemic period and the first year of the pandemic to determine if COVID-19 or related public health measures influenced the rate or severity of presentations managed in otolaryngology. A retrospective chart review was conducted on pediatric patients who presented with severe infectious otolaryngology presentations (acute mastoiditis, deep neck space abscesses, and orbital complications of sinusitis) over the pre-pandemic (March 2018–February 2020) and early pandemic (March 2020–February 2021) periods. Patient characteristics, details of presentation, treatment, and outcomes were extracted from patients' charts. Independent samples t-tests/Mann-Whitney U-tests for continuous variables and Pearson chi-squared tests/Fisher's exact test for categorical variables were conducted to compare the pre vs early pandemic groups. There were 93 pre-pandemic and 28 early pandemic presentations. The monthly case average was significantly lower during the early pandemic period than the 2 years prior [3.58 (2.80) vs 2.00 (2.00), P =.045]. The average monthly frequency of presentations for deep neck space abscess and mastoiditis were significantly higher in the pre-pandemic group when compared to the early pandemic group [1.96 (±0.33) vs 1.33 (±0.48), P =.049;.71 (±0.26) vs 0.17 (±0.41), P =.01, respectively]. The early pandemic group was significantly younger (3.81 vs 6.04 years, P =.005), however there were no differences in gender, length of admission, and days from symptom onset to presentation between the two groups (P >.05). The early pandemic group had significantly elevated inflammatory markers on presentation [CRP, WBC, neutrophils (P =.02, P =.02, P =.04, respectively)] compared to the pre-pandemic group. The COVID-19 pandemic has had an effect on severe infectious complications of ENT pathologies, including decreased average monthly cases during the early pandemic, younger age at presentation, and elevated inflammatory markers. • Retrospective chart review of operative pediatric infections across the pandemic. • Monthly-case volume of selected infections decreased during the pandemic. • Surrogates for disease severity were not different across the pandemic. • Conditions displayed higher inflammatory markers during than prior to the pandemic. • COVID-19 and/or its mitigation efforts has impacted infectious otolaryngology conditions. [ABSTRACT FROM AUTHOR]

Intratemporal or intracranial complications of acute mastoiditis are often of significant severity, can be life-threatening, and require prompt and usually aggressive treatment. This study focused on analyzing the outcomes and complications of different surgical techniques used in intracranial and intratemporal complications of acute mastoiditis, the most common complication of acute otitis media. A retrospective study of pediatric patients with mastoiditis with intratemporal and intracranial complications was designed at the Niño Jesús University Children's Hospital in Madrid, Spain, from 2005 to 2021. Of 417 patients with mastoiditis, 112 patients developed intratemporal and intracranial complications, with subperiosteal abscess being the most frequent complication. The most frequently isolated pathogens were Streptococcus pneumoniae , Streptococcus pyogenes , and Fusobacterium necrophorum. The most used surgical technique was myringotomy with placement of transtympanic drainage, in 86.6% of all cases. In patients with intracranial complications, neurosurgical procedures were necessary for 19.2%, with craniotomy with mastoidectomy being the most frequent. Most of the cases evolved favorably, and only 5.4% of the patients required surgical reintervention, being more frequent in intratemporal complications. In terms of complications, we found cases of neutropenia in 3.6%, neurological sequelae in 5.4%, and permanent hearing loss in 2.7%. There was a favorable evolution with a low incidence of reoperation and sequelae within our series. The surgical technique of choice correlated with the severity of the complication. If the mean size of the abscess exceeds 20 mm, incision and drainage, along with myringotomy and tube placement, should be considered as the initial treatment. Closed mastoidectomy should be reserved for deteriorating of clinical evolution or acute mastoiditis with intracranial complications. Intracranial and multiple concomitant complications were associated with a more extended hospital stay, ICU occupancy, neurosurgical intervention, and risk of neurological sequelae and neutropenia. Conversely, intratemporal complications may result in permanent hearing loss. [ABSTRACT FROM AUTHOR]

Objectives Seven years after the introduction of the pneumococcal conjugate vaccines (PCV) in Israel, its effect on the incidence and severity of episodes of acute mastoiditis (AM) remains unclear. The primary objective of this study was to determine the incidence of AM and describe its clinical features in children during the years that followed the introduction of the PCV13 in comparison with the pre-PCV period. Methods Included in this retrospective comparative case series were all pediatric patients diagnosed with AM between Jan. 2007 and Dec. 2015 in one tertiary medical center. The patients were divided into 3 groups: pre-PCV, post-PCV7 (July 2009 through Dec. 2010) and post-PCV13 (Jan. 2011 through Dec. 2015). The patients' medical records were reviewed, and data on age at presentation, gender, presenting signs, bacterial ear cultures, hospitalization course, complications, surgical interventions, inflammatory response and outcome were retrieved and compared between the groups. Comparison was made between the pre-PCV and the post-PCV13 groups. Results 216 children were identified for analysis, 80 children in the pre-PCV period, 31 in the post-PCV7 period and 105 in the post-PCV13 period. Their mean age was 2.6 years. The number of AM cases per 1000 visits at the emergency room decreased by 46% in the post-PCV13 period compared to the pre-PCV period. There was no difference in the rate of AM between the post-PCV7 and post-PCV13 periods. No differences were found in age, gender, hospitalization length, C-reactive protein level, white blood cell count, rate of surgical interventions (mastoidectomy and incision and drainage) and rate of complications between the 3 groups. Conclusion The incidence of AM was lower in the post-PCV13 period compared to the pre-PCV period. The rate of AM complications, however, has not changed, nor has the number of mastoidectomies. [ABSTRACT FROM AUTHOR]

Nasopharyngeal cancer (NPC) with mastoid recurrence is extraordinarily rare, and its development is thought to involve the Eustachian tube. We herein report a case of NPC with mastoid recurrence masquerading as acute otomastoiditis with facial paralysis in a 60-year-old man 44 months after concurrent chemoradiotherapy. The diagnosis was confirmed by exploratory tympanomastoidectomy with biopsy and Epstein-Barr-encoding region (EBER) in situ hybridization. Distant liver metastasis was detected simultaneously, and the patient underwent salvage treatment. He died 15 months later. Despite the rarity of mastoid recurrence, clinicians should be vigilant in the differential diagnosis of mastoiditis in patients with NPC after radiotherapy. Tumor biopsy and EBER in situ hybridization can aid in the accurate diagnosis of this uncommon condition. [ABSTRACT FROM AUTHOR]

Objective Evaluate the Montreal Children's Hospital experience with outpatient management of uncomplicated acute mastoiditis with parenteral antibiotic therapy alone and determine if it is a safe alternative to inpatient management. Subjects and method A retrospective review of pediatric patients diagnosed with acute mastoiditis at a tertiary care pediatric hospital between 2013 and 2015 was performed. Patients with syndromes, immunodeficiency, cholesteatoma, chronic otitis media, cochlear implant in the affected ear, or incidental mastoid opacity were excluded. Results 56 children age 6 months to 15 years old were treated for acute mastoiditis, including 29 hospitalizations and 27 outpatients. Patients managed as outpatient with daily intravenous ceftriaxone had a 93% cure rate. Eighteen hospitalized and one outpatient had complications of acute mastoiditis. Children with complications were more likely to be febrile (p = 0.045). Two patients failed outpatient therapy and were admitted; one for myringotomy and piperacillin-tazobactam treatment and one required a mastoidectomy. 4/27 children treated as outpatient underwent myringotomy and tube insertion, 2 underwent myringotomy and tube along with admission and 21 did not require tube insertion. The average total duration of intravenous antibiotic therapy was respectively 4.9 and 18.9 days in the outpatient and hospitalized group. The average duration of admission was 5.9 days. Conclusion Outpatient medical therapy of uncomplicated pediatric mastoiditis is safe, successful, and efficient. Benefits include efficient use of surgical beds, cost savings and patient and family convenience. Careful patient selection and close monitoring are keys for successful outcome. [ABSTRACT FROM AUTHOR]

Objectives The objectives of this study were to investigate the incidence of complicated acute otitis media (cAOM) as well as the associated microbiology before and after introduction of the 7- and 13-valent pneumococcal conjugate vaccines (PCV-7 and -13), respectively. CAOM comprises “heavy” AOM (AOM demanding hospitalization), mastodismus (M) and acute mastoiditis (AM). Methods A retrospective cohort study of the incidence and microbiology associated with cAOM during the non-PCV era, the PCV-7 and 13 eras, respectively. Clinical and microbiological data were prospectively registered in a local database. The incidences of cAOM as well as the distribution of various bacterial strains in the three eras were compared. Results A total of 246 cases of cAOM (125 in the pre-vaccine period (2001–2006), 50 in the PCV-7 period (2007–2010) and 71 in the PCV-13 period (2011–2015)) were identified. The incidence of hAOM decreased by 62% in the PCV7-era but increased to almost pre-vaccine levels in the PCV-13 era. In the M + AM group, a decrease by almost 21% in the PCV7-era was found compared to the pre vaccine era, whereas the decrease was only 12% in the PCV13-era. The three most common findings in both hAOM and M + AM were Streptococcus pneumonia (SP), group A streptococcus (GAS) and “no growth”. In the hAOM group, SP decreased from 38% in the pre-vaccine era to 31% in the PCV7-era and further to 16% in the PCV13-era. GAS decreased from 17% in the pre-vaccine era to 0% in the PCV7-era and 16% in the PCV13-era. The percentage of “no growth” increased from 12% to 38% and 44%, respectively. In the M + AM group, SP decreased to 10% in the PCV13-era compared with 44% in the pre-vaccine era and 41% in the PCV7-era. An increase in GAS from 15% in the pre-vaccine era and PCV7-era to 30% in the PCV13-era was observed. The “no growth” percentage increased from 13% in the pre-vaccine era to 26% in the PCV7-era and 33% in the PCV13-era. Conclusion Introduction of PCV7 and PCV13 has been associated with an overall reduction of cAOM in Central Region Denmark. Pneumococci were still one of the two most common bacteria species related to cAOM though a decrease in pneumococci positive cases was observed. We found an increase in M + AM induced by GAS and a relatively large increase in “no growth”, which might be caused by a more aggressive pre-hospital approach to treatment with antibiotics. Consequently, it is not evident whether the reduction of incidences is caused by the vaccines or a more aggressive antimicrobial attitude to manage AOM. The shift to GAS from SP is worrisome, and therefore continuous surveillance of the microbiology associated with AOM is warranted. [ABSTRACT FROM AUTHOR]

IgG4-related disease (IgG4-RD) is a chronic inflammatory disorder, characterized by elevated serum IgG4 levels as well as abundant infiltration of IgG4-positive plasmacytes and fibrosis in various organs, including the head and neck region. In particular, the salivary glands, orbit, and thyroid are common sites of disease involvement. IgG4-RD is diagnosed based on various clinical, serological, and histopathological findings, none of which are pathognomonic. Hence, various differential diagnoses, which exhibit elevated serum IgG4 levels and infiltration of IgG4-postive cells into tissues, need to be excluded, especially malignant diseases and mimicking disorders. Systemic corticosteroids are generally effective in inducing IgG4-RD remission; however, recurrent or refractory cases are common. In addition, although the pathogenic mechanisms of IgG4-RD remain unclear, an antigen-driven inflammatory condition is believed to be involved. Recent studies have indicated the important pathogenic role of B cell/T cell collaboration and innate immunity in this disease. Nevertheless, additional research and discussions are needed to resolve many remaining questions. In this review, we provide an overview of the recent insights on the history, clinical features, diagnosis, and treatment of IgG4-RD in the head and neck region. Furthermore, we have also addressed the pathogenesis of this disease. [ABSTRACT FROM AUTHOR]

Lemierre syndrome, also known as Lemierre's disease is a rare condition that was first described by Andre Lemierre in 1936. We present a case of a 3-year-old boy who presented with ankylosis of the right temporomandibular joint (TMJ) secondary to a mastoid infection as part of Lemierre syndrome. His ankylosis resulted in restricted mouth opening, which had a considerable impact on his speech and ability to eat. Surgical treatment comprising right coronoidectomy, gap arthroplasty of the TMJ, and interpositional fat grafting, enabled him to move his jaw and function has returned. This case report highlights the consequences of Lemierre syndrome and the need for clinicians to be aware of its features and the impact it may have on patients. [ABSTRACT FROM AUTHOR]

Background Acute mastoiditis (AM) is a suppurative infection of the mastoid air cells, representing the most frequent complication of acute otitis media. AM remains an important entity in children due to its potential complications and sequelae. We aim to describe the cases of AM admitted at our department, identify risk factors potentially associated with complications and analyse the changes in clinical approach of AM over time. Methods Case review of clinical files of children admitted with acute mastoiditis from June 1996 to May 2013 at a Lisbon metropolitan area hospital. Data was divided into two groups (prior and after May 2005) in order to evaluate changes in AM approach over the years. Results 135 AM episodes were included. The median age was 3.8 years and 42% children were less than 24 months of age. Symptoms at presentation included fever (69%), ear pain (56%) and otorrhea (40%). Complications occurred in 22% patients and were more common in children under 24 months (33% vs 15%, p ≤ 0.01). Leukocyte count was significantly higher in children with complications (16.7 vs 14.5 × 10 9 /μL, p ≤ 0.05) as was C-Reactive Protein value (13 vs 6.3 mg/dL, p ≤ 0.001). There was a significant association between the development of complications and C-Reactive Protein value at admission (OR 1.892; IC95%: 1.018–2.493, p ≤ 0.01). The optimal cut-off value was 7.21 mg/dL. Over time there was a significant increase in middle ear cultures obtained by tympanocentesis during surgery (2% vs 16%, p ≤ 0,01) and also a decrease in the use of broad spectrum antibiotherapy as initial treatment (52% vs 25%,p ≤ 0,001). Conclusions Children under 24 months, with high leukocyte count or with high C-Reactive Protein value should be monitored closely since complications tend to be more frequent. A CRP value of 7.21 mg/dL at admission seems to be a good cut-off to monitor children for potential complications. Throughout the period analysed more cultures were performed allowing identification of the pathogens and implementation of appropriate antibiotic therapy. [ABSTRACT FROM AUTHOR]

We describe the youngest case to date of a 2 year old child who developed central skull base osteomyelitis (SBO) initially presenting with a fever, vomiting and sore throat. An extremely rare complication of mastoiditis following otitis media in children is SBO which can present with non-specific symptoms. This report describes the first case of symptomatic ischaemic stroke secondary to SBO in an immunocompetent child. We review the literature of the management and the potential cerebrovascular complications of central SBO in children secondary to otolaryngological infection. [ABSTRACT FROM AUTHOR]

Lemierre's syndrome is a complex infection involving oropharyngeal sources leading to septic jugular thrombophlebitis. Otogenic variants may arise from complicated ear disease and involve cranial venous sinuses. We describe a case of a 9 year boy with chronic suppurative otitis media leading to mastoiditis, cranial venous sinus and jugular vein thrombophlebitis, and Bacteroides bacteremia. Both the pathogen and the extent of venous involvement were unusual in this case. Otogenic Lemierre's syndrome is a serious infection associated with significant morbidity which should be considered in any child with otogenic findings and septic thrombophlebitis. [ABSTRACT FROM AUTHOR]

Objectives Cochlear implantation is performed at a young age, when children are prone to acute otitis media. Acute mastoiditis is the most common complication of otitis media, but data on its management in the presence of a cochlear implant are sparse. The objective of this study was to assess the characteristics, treatment, and outcome of acute mastoiditis in children with a cochlear implant. Methods The medical files of all children who underwent cochlear implantation at a pediatric tertiary medical center in 2000–2014 were retrospectively reviewed. Those diagnosed with acute mastoiditis after implantation were identified, and data were collected on demographics, history, presentation, method of treatment, complications, association with untreated otitis media with effusion, and long-term middle-ear sequelae. Results Of the 370 children (490 ears) who underwent cochlear implantation, 13 (3.5%) were treated for acute mastoiditis (median age at acute mastoiditis, 32 months). Nine had a pre-implantation history of chronic secretory or acute recurrent otitis media, and 5 had been previously treated with ventilation tubes. In all 9 children who had unilateral cochlear implant, the acute mastoiditis episode occurred in the implanted ear. The time from implantation to mastoiditis was 5–61 months. The same treatment protocol as for normal-hearing children was followed, with special attention to the risk of central nervous system complications. Primary treatment consisted of myringotomy with intravenous administration of wide-spectrum antibiotics. Surgical drainage was performed in 8 out of 13 patients, with ( n = 7) or without ( n = 1) ventilation-tube insertion, to treat subperiosteal abscess or because of lack of symptomatic improvement. There were no cases of intracranial complications or implant involvement or need for a wider surgical approach. No middle-ear pathology was documented during the average 3.8-year follow-up. Conclusions The relatively high rate of acute mastoiditis and subperiosteal abscess in children with a cochlear implant, predominantly involving the implanted ear, supports the suggestion that recent mastoidectomy may be a risk factor for these complications. Despite the frequent need for drainage, more extensive surgery is usually unnecessary, and recovery is complete and rapid. As infections can occur even years after cochlear implantation, children with otitis media should be closely followed, with possible re-introduction of ventilation tubes. [ABSTRACT FROM AUTHOR]

Infections play a major role in the practice of ENT. Microbial penetration into tissues of the head and neck can initiate a focal reaction causing superficial self-resolving infections. However, some of these have the potential to develop into life-threatening disease. We provide an overview of the most common ENT infections with focus on the presentation, diagnosis and management. Foreign bodies of the ear, nose and throat are a common presentation to primary and emergency care. Most commonly these are seen in children and include plastic toys, beads and foodstuffs inserted into the ears and nose. Diagnosis is often delayed as insertion is usually not witnessed. In exceptional cases airway foreign bodies can present as a life-threatening emergency. Removal of foreign bodies can usually be achieved by a skilled practitioner with minimal complications. Methods of removal include suction catheters, syringing, and use of instrumentation. In adults, the treatment of oesophageal food bolus obstruction may require a combination of medical and surgical intervention. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the clinical picture and microbiological findings of children hospitalized due to acute otitis media and to analyze how it differs from acute mastoiditis. Methods A retrospective review of the medical records of all children (0–16 years) hospitalized due to acute otitis media in the Department of Otorhinolaryngology at the Helsinki University Hospital, between 2003 and 2012. Comparison with previously published data of children with acute mastoiditis ( n = 56) from the same institute and period of time. Results The most common pathogens in the children hospitalized due to acute otitis media ( n = 44) were Streptococcus pneumoniae (18%), Pseudomonas aeruginosa (16%), Streptococcus pyogenes (14%), and Staphylococcus aureus (14%). One of the most common pathogens of out-patient acute otitis media, Haemophilus influenzae , was absent. Otorrhea was common in infections caused by S. pyogenes and otorrhea via tympanostomy tube in infections caused by P. aeruginosa . In children under 2 years-of-age, the most common pathogens were S. pneumoniae (43%), Moraxella catarrhalis (14%), and S. aureus (7%). S. pyogenes and P. aeruginosa were only found in children over 2 years-of-age. Previous health problems, bilateral infections, and facial nerve paresis were more common in children hospitalized due to acute otitis media, compared with acute mastoiditis, but they also demonstrated lower CRP values and shorter duration of hospital stay. The number of performed tympanostomies and mastoidectomies was also comparatively smaller in the children hospitalized due to acute otitis media. S. aureus was more common and S. pneumoniae , especially its resistant strains, was less common in the children hospitalized due to acute otitis media than acute mastoiditis. Conclusions Acute otitis media requiring hospitalization and acute mastoiditis compose a continuum of complicated acute otitis media that differs from common out-patient acute otitis media. The bacteriology of children hospitalized due to acute otitis media resembled more the bacteriology of acute mastoiditis than that of out-patient acute otitis media. The children hospitalized due to acute otitis media needed less surgical treatment and a shorter hospitalization than those hospitalized due to acute mastoiditis. [ABSTRACT FROM AUTHOR]

Objectives To study the outcome of different surgical methods of treating subperiosteal abscesses resulting from acute mastoiditis. Methods Medical records for all children from a Swedish retrospective multicentre study, conducted between 1993 and 2007, with acute mastoiditis and subperiosteal abscess, but without predisposing diseases or other complications, were studied. A total of 115 children aged 0–16 years were identified. All patients had received intravenous antibiotics and most had undergone myringotomy. Results Thirty-three children had been treated with only minor interventions such as retroauricular needle aspiration and/or incision, while 67 had undergone mastoidectomy. Fifteen had undergone both needle aspiration and mastoidectomy. The group treated with needle aspiration/incision was compared with those treated with mastoidectomy. One of the few significant differences found between the groups was a longer hospital stay in the group that had undergone mastoidectomy. Conclusions Retroauricular needle aspiration and/or incision combined with intravenous antibiotics and myringotomy was an effective first-line treatment for subperiosteal abscesses resulting from acute mastoiditis. In this retrospective study, no greater risk of further complications was seen in this group compared to the group in which mastoidectomy was performed. [ABSTRACT FROM AUTHOR]

The aim of the study described here was to evaluate experience in the diagnosis of a subperiosteal abscess secondary to mastoiditis by means of ultrasound. Ten consecutive cases in which an ultrasound examination of the retro-auricular region was performed for suspected mastoiditis were identified. In nine cases, we found a poorly demarcated, inhomogeneous, irregular, poorly perfused lesion abutting the outer table of the cranial vault, with elevation of the outer periosteum and a clearly delineated defect of the cortical layer. In one case, there was additional invasion of the insertion of the sternocleidomastoid muscle on the mastoid process of the temporal bone, raising the suspicion of Bezold mastoiditis. Ultrasound may help in selecting patients for further imaging and might spare computer tomography, especially in sensitive patient groups such as children and pregnant women, if a defect of the outer cortex of the temporal bone can be excluded with certainty. [ABSTRACT FROM AUTHOR]

Objective We assessed clinical, radiological, laboratory and microbiological findings in children with acute mastoiditis in order to improve the diagnostics and treatment of these patients. We also investigated whether different pathogens cause different clinical findings of mastoiditis. Methods A retrospective review of the medical records of all children aged 0–16 years treated as in-ward patients for acute mastoiditis at Helsinki University Central Hospital, Department of Otorhinolaryngology, between 2003 and 2012. Results Fifty-six patients met the inclusion criteria. The incidence of mastoiditis was 1.88/100 000/year. The most common pathogens were Streptococcus pneumoniae (38%), Streptococcus pyogenes (11%) and Pseudomonas aeruginosa (11%). Of S. pneumoniae , 48% had reduced susceptibility (intermediate or resistant) for the common antimicrobials; this was clearly overrepresented relative to the background population ( p < 0.001). Otalgia and retroauricular symptoms were common in the patients with S. pneumoniae . Otorrhoea was less common ( p = 0.03) in these patients relative to the other pathogens. Patients with S. pneumoniae had more destruction of the mastoid septa ( p = 0.05) than patients with any of the other pathogens. Mastoidectomy was performed in 34% of all cases, it was most common (60%) in the patients with S. pneumoniae with reduced susceptibility. The patients with S. pyogenes had less otalgia and seemed to have less retroauricular symptoms relative to other pathogens . P. aeruginosa especially affected children with tympanostomy tubes, caused otorrhoea in all patients and caused a milder form of disease with less retroauricular swelling ( p = 0.04) than the other pathogens, and there was no need for mastoidectomies. The younger children (<2 years) had less otorrhoea and more retroauricular symptoms of infection than the older patients. No significant differences emerged in outcome of the patient groups. Conclusions The clinical findings of acute mastoiditis differ according to the causative pathogen. S. pneumoniae , especially strains with reduced susceptibility, causes severe symptoms and leads to mastoidectomy more often than the other pathogens. S. pyogenes causes less otalgia than the other pathogens. P. aeruginosa particularly affects children with tympanostomy tubes and causes a less aggressive form of disease. [ABSTRACT FROM AUTHOR]

Objectives To describe the epidemiologic, microbiologic, clinical and therapeutic aspects of acute mastoiditis (AM) in children <15 years of age during the 4-year period (2009–2012) following the introduction of pneumococcal conjugate vaccines in Israel. Patients and methods The medical records of all children with a discharge diagnosis of AM were reviewed. Results A total of 66 AM episodes occurred in 61 patients. Forty-four (66.6%) cases occurred among patients <4 years, recent acute otitis media (AOM) history was reported in 27.1% and 28.8% patients received previous antibiotics for AOM. Postauricular swelling, postauricular sensitivity, protrusion of auricle and postauricular edema (93.8%, 90.6%, 85.9% and 95.7%, respectively) were the most common signs of AM. Leukocytosis >15 000 WBC/mm 3 was found in 39 (59.1%) cases. Cultures were performed in 52/66 episodes (positive in 27, 51.92% episodes), with recovery of 32 pathogens. The most frequently isolated pathogens were Streptococcus pneumoniae (15/52, 28.85%), Streptococcus pyogenes (9, 17.3%) and nontypeable Haemophilus influenzae (5, 9.62%). Eight (53.3%) S. pneumoniae isolates were susceptible to penicillin. Mean incidence of overall and pneumococcal AM were 11.1 and 2.58 cases/100 000, with no significant changes during the study years. Surgical intervention was required in 19 (28.8%) patients. Conclusions (1) AM occurs frequently in patients without previous AOM history and with no previous antibiotic treatment; (2) S. pneumoniae and S. pyogenes continued to be the main etiologic agents of AM during the postvaccination period; (3) No changes were recorded in overall AM incidence and in pneumococcal AM incidence during the postvaccination period. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To investigate the occurrence, clinical signs and outcome of acute mastoiditis in infants under the age of 6 months in Sweden between the years 1993–2007. Methods: All ENT departments in Sweden reported children 0–5 months treated for acute mastoiditis 1993–2007 and all records were reviewed. The clinical course and various characteristics were recorded. Results: Seventeen young infants with acute mastoiditis were identified. Three patients had suffered acute otitis media earlier, otherwise the children were previously healthy. Preceding the episode of acute mastoiditis, the children had an upper respiratory tract infection or fever for seven days in mean (median three days) and the mean number of days with ear-symptoms was three days (median two days). Three patients were treated with antibiotics prior to admittance. Almost all children presented with clear retroauricular signs with protruding ear and redness behind the ear. The children were hospitalised for six days (mean and median). Eight patients (47%) suffered from a subperiosteal abscess. All but one patient underwent surgery: myringotomy (13); incision or punction of the mastoid (5); mastoidectomy (3). Streptococcus pneumoniae was the most frequent bacterium identified in cultures. No intracranial complications or other severe complications were found. Conclusion: Acute mastoiditis is extremely rare in infants under the age of 6 months. The patients in this study did not have any predisposing diseases. An upper respiratory tract infection had preceded the episode of acute mastoiditis for some time in the majority of cases, but the time from first ear symptoms to hospitalization was very short. Acute mastoiditis is a potentially life-threatening disease, but the timely administration of intravenous antibiotics and surgical intervention prevented the occurrence of severe complications in these young infants. [Copyright &y& Elsevier]

Abstract: Objectives: Otogenic sigmoid sinus thrombosis is a rare complication of acute otitis media. Treatment remains controversial particularly regarding extent of surgical intervention. The aim of the study was to review the 12-year experience of a major medical center with the treatment of sigmoid sinus thrombosis in children. Methods: Retrospective case series identified by database review in a tertiary university-affiliated pediatric medical center. Twenty-four children aged 7–155 months were treated for sigmoid sinus thrombosis from 2000 through 2011. Results: The transverse sinus was also involved in 10 patients, and the jugular vein, in 4. Acute otitis media with mastoiditis was the causative factor in all cases. Subperiosteal abscess was diagnosed in 21 patients, 11 with epidural involvement. Treatment in all cases consisted of broad-spectrum antibiotics and ventilation tube insertion. Twenty-one children (87.5%) underwent mastoidectomy with removal of bone covering the sigmoid sinus to drain pus and remove granulations from the epidural cavity, without aspiration or sinus drainage. Twenty-two patients received low-molecular-weight heparin for 3–6 months postoperatively. Children infected with Fusobacterium necrophorum had a longer and more severe course with coexisting osteomyelitis. There were no neurologic sequelae or hematologic complications. Follow-up imaging, performed in 15 children, revealed partial or full recanalization in 87%. Conclusions: Relatively conservative surgical intervention appears to yield good results in children with sigmoid sinus thrombosis consequent to acute otitis media. Anticoagulants are safe if correctly administered and may prevent extension of the thrombus. [Copyright &y& Elsevier]

Septic arthritis of the Temporomandibular joint (TMJ) is a rare complication of acute middle ear infection. Presentation is elusive and could be easily missed. Often diagnosis is made only with consequential development of TMJ ankylosis. This study intends to characterize patients and course of disease and suggest a diagnostic and therapeutic strategy. Retrospective review of all children diagnosed with TMJ arthritis and/or TMJ ankylosis secondary to acute middle ear infection, treated in a tertiary pediatric medical center between the years 2005 and 2021. Seven patients were identified with otogenic TMJ arthritis. Median age at presentation was 1.14 years (IQ range 1.1–1.5). All seven were diagnosed with acute mastoiditis. CT scans demonstrated TMJ related collections in 5/7 and intracranial complications in 3/7. Treatment included cortical mastoidectomy for 5/7. One patient had a concomitant surgical washout of the TMJ. Two patients had drainage only of subperiosteal collections. Six of the seven patients went on to develop TMJ ankylosis that presented within a median of 2.8 years (IQ range 2.6–3.9) after the episode of acute mastoiditis. All six patients presented with trismus and facial growth anomalies, and all but one required surgery to release the ankylosis. Otogenic TMJ arthritis develops mostly in young children with acute mastoiditis and intratemproal and/or intracranial suppuration. Imaging is helpful in making the diagnosis, with TMJ related collections on CT being the most common finding. TMJ ankylosis can develop within a few years and present with trismus and abnormal facial growth. Cortical mastoidectomy does not seem to prevent ankylosis. It remains unclear whether focused treatment to the TMJ or physiotherapy could be beneficial in that. [ABSTRACT FROM AUTHOR]

Intracranial complications of sinusitis and acute otitis media (AOM) are rare but life-threatening events. In children with suppurative intracranial complications, concurrent neurosurgical and otolaryngological (ORL) intervention has been recommended to optimize outcomes. The aim of this study was to investigate outcomes following concurrent neurosurgical and ORL intervention. A retrospective cohort study of children undergoing neurosurgical intervention for intracranial complications of sinusitis or AOM in two neurosurgical centres in Ireland was conducted. 65 children were identified. Mean age was 11.9 years. The most prevalent symptoms were headache, pyrexia, altered level of consciousness, facial swelling, and vomiting. Subdural empyema (n = 24, 36.9%) and extradural abscess (n = 17, 26.2%) were the most common complications. 54 underwent same admission ORL intervention; 47 (87%) were performed concurrently or earlier. For rhinogenic infections, 35 (64.8%) underwent endoscopic sinus surgery (ESS), 13 (24.1%) underwent frontal sinus trephine, and 5 (9.3%) underwent maxillary sinus washout alone. For otogenic infections, 10 (90.9%) underwent mastoidectomy and 7 (63.6%) underwent tympanostomy tube placement. 19 (29.2%) had post-operative neurological deficits, of which 2 (3.1%) were permanent. Streptococcus intermedius was the most common pathogen (n = 30, 46.2%). Concurrent intervention reduced the prevalence of residual collection (p = 0.018) and the need for revision neurosurgical intervention (p = 0.039) for sinogenic complications. The same trends did not achieve statistical significance for the otogenic group. Mortality was 0%. Intracranial complications of sinusitis and AOM are best managed in a specialist centre with multidisciplinary input. Concurrent ORL and neurosurgical intervention reduces abscess recurrence and requirement for revision neurosurgery in sinogenic complications and should represent the standard of care. ESS is the ORL modality of choice in experienced hands. [ABSTRACT FROM AUTHOR]

Abstract: The deceased was an unidentified young male found unconscious on a walkway. On autopsy, outer and inner fistulae of the left temporal bone, subcutaneous abscess in the left side of the neck and head, and an intracranial abscess were noted. A portion of the left temporal bone was removed and scanned by cone-beam computed tomography (CT) (normally used for dentistry applications) to evaluate the lesion. The cone-beam CT image revealed roughening of the bone wall and hypolucency of the mastoid air cells, consistent with an inflammatory bone lesion. According to autopsy and imaging findings, the cause of death was diagnosed as intracranial abscess with Bezold’s abscess secondary to left mastoiditis as a complication of otitis media. Although determining the histopathology of bone specimens is time-consuming and costly work, we believe that use of cone-beam CT for hard tissue specimens can be useful in forensic practice. [Copyright &y& Elsevier]

We report two children with otitis media who developed facial palsy despite prompt antibiotic therapy. Brain images revealed silent mastoiditis. Persistent otorrhea may be a cautious sign of medical treatment failure or complication of acute otitis media, including mastoiditis or facial palsy. Delayed identification of coexisting mastoiditis or hesitation over surgical intervention may lead to treatment failure and complications. Adequate intravenous antibiotics and myringotomy provide reasonable and appropriate management to prevent permanent sequelae. [Copyright &y& Elsevier]

Abstract: Background: Anaerobic bacteria are uncommon etiologic agents of acute mastoiditis in children. However, recent studies suggest an increase in the incidence of Fusobacterium necrophorum mastoid infections in the last two decades. Methods: A surveillance study performed over 3.5 years in a tertiary pediatric medical center identified 7 children with acute F. necrophorum mastoiditis. Clinical, laboratory, and treatment data were collected by file review. Results: Five of the 7 children presented in the last year of the study. All 7 children were less than 26 months old on admission, and none had a history of otogenic infections. All cases were characterized by significantly elevated levels of inflammatory markers. All were diagnosed as complicated mastoiditis with abscess formation. Four children had an epidural abscess, three children had evidence of osteomyelitis beyond the mastoid bone, and four children had imaging evidence of sinus vein thrombosis. All seven children required cortical mastoidectomy with ventilatory tubes insertion and two children required more than one surgical intervention. During follow-up, two children had recurrent episodes of mastoiditis due to other pathogens. Conclusion: Our data support the literature suggesting that the occurrence of F. necrophorum mastoiditis among children is rising. Acute coalescent mastoiditis due to F. necrophorum is associated with a complicated course and warrants particular attention by pediatricians, infectious disease experts, and ear, nose and throat specialists. [Copyright &y& Elsevier]

Abstract: Infections play a major role in the practice of ear, nose and throat medicine. Microbial penetration into tissues of the head and neck can initiate a focal reaction causing superficial self-resolving infections. However, some of these have the potential to develop into life-threatening disease. We provide an overview of the most common ENT infections with focus on the presentation, diagnosis and management. Foreign bodies of the ear, nose and throat are a common presentation to primary and emergency care. Most commonly these are seen in children and include plastic toys, beads and foodstuffs inserted into the ears and nose. Diagnosis is often delayed as the insertion is usually not witnessed. However, in exceptional cases airway foreign bodies can present as an absolute emergency. Removal of foreign bodies can usually be achieved by a skilled practitioner with minimal complications. Methods of removal include suction catheters, syringing, and use of instrumentation. In adults, the treatment of oesophageal food bolus obstruction may require a combination of medical and surgical intervention. [Copyright &y& Elsevier]

Abstract: Objective: Septic thrombosis of the sigmoid and lateral sinus is a rare complication of acute otitis media, mastoiditis and cholesteatoma. Hence, the aim of this chat review was to analyze the demographics, presenting symptoms, diagnosis, and therapeutic management of otogenic sigmoid sinus thrombosis. Especially the role of low molecular weight heparin in the therapy of septic intracranial sinus thrombosis in children should be illuminated. Methods: A retrospective chart review was performed. Results: Six patients were included in this trial. One patient was treated completely conservatively. All other patients underwent surgical treatment consisting of mastoidectomy (n =5), additional thrombectomy (n =3) and ligation of the internal jugular vein (n =2). All patients received intravenous antibiotics and anticoagulants. Unfractionated heparin was administered for three days after surgery followed by an anticoagulant therapy with low-molecular weight heparin for three months. The activated partial thromboplastin time (aPTT) and the anti-factor-Xa-plasma-levels were monitored during anticoagulation in short term intervals. There were no complications related to the anticoagulant therapy. Recanalization was found in all patients who were treated without thrombectomy or ligation of the internal jugular vein and in the case of complete conservative treatment. Conclusion: Simple mastoidectomy combined with broad spectrum antibiotics is the therapy of choice. Our results indicate that anticoagulants represent a safe treatment option if they are administered correctly. [Copyright &y& Elsevier]

Abstract: Objectives: [1.] To discuss the presentation, work up, and treatment of a series pediatric patients presenting with acute otogenic lateral sinus thrombosis (OLST). [2.] To review the literature in discussing surgical treatment and the role of anticoagulation for sinus thrombosis from complicated otomastoiditis. Study design: Retrospective case series. Methods: Retrospective case series of seven patients with otomastoidits and lateral sinus thrombosis were included in the study. Type of anticoagulation used and both clinical and radiographic outcomes were compared. Pediatric literature review was conducted using PubMed search terms “thrombosis and otitis media and anticoagulation” limited to English. Results: Seven patients presented with acute otomastoiditis with sigmoid sinus thrombosis. Six patients were treated with anticoagulation for 1.5–12months. Six patients underwent myringotomy with tube and 4 patients underwent cortical mastoidectomy without thrombectomy. Six patients had resolution of thrombosis by imaging in less than 6months. Literature review of 19 pts with OLST showed that 95% had mastoidectomy and 84% had myrigotomy with tube. All 19 patients received anticoagulation. Sixteen patients had complete clinical recovery with recanalization or resolution of clot in 3 patients. Conclusions: The treatment of OLST is controversial. Most (23/26) patients had complete clinical recovery despite clot resolution in 9 of the 26 patients. Four patients had bleeding complication with anticoagulation. This series and literature review highlights the controversy of surgery and use of anticoagulation in the treatment of OLST and the need for further investigation. [Copyright &y& Elsevier]

Abstract: Infections caused by nontuberculous mycobacteria (NTM) have been reported increasingly. Rarely, NTM also cause chronic ear infections. We describe Mycobacterium abscessus mastoiditis in an immunocompetent child, whose painless chronic otorrhea failed to settle with routine antimicrobial and local therapy. Polyps and granulation tissue were noted on the tympanic membrane. The diagnosis was made with staining on acid-fast bacilli and culture of mycobacteria in biopsy material. The successful treatment consisted of surgery, removal of foreign material (tympanostomy tube), and antimicrobials. Chronic otorrhea unresponsive to standard therapy can be caused by NTM and should be examined for the presence of acid-fast bacilli. [Copyright &y& Elsevier]

Abstract: Gradenigo''s syndrome, one of the complications of middle ear infection, is characterised by persistent otorrhoea, pain in the region innervated by the first and second divisions of the trigeminal nerve and ipsilateral abducens nerve palsy. We report the case of a 4-year-old girl with Gradenigo''s syndrome. Computed tomography and magnetic resonance imaging provided evidence of infection of the apex of the petrous temporal bone. The patient received an appropriate antibiotic therapy but the recurrence of symptoms responded to the prolongation of a conservative treatment without surgical intervention. [Copyright &y& Elsevier]

A variety of conditions may result in maxillofacial swelling in children, prompting a visit to the emergency department. Some of these diagnoses are self-limiting, whereas others may be life-threatening. Furthermore, the pediatric population is at significant risk for problems that rarely occur in adults. Emergency medicine providers must be able to identify these conditions, especially if specialty consultation is required. Some of the most common and significant causes of maxillofacial swelling in children are reviewed to help familiarize the practitioner with their presentation, causes, and available treatment options. [ABSTRACT FROM AUTHOR]