© Borgis - New Medicine 2/2003, s. 18-21
Anna Bielicka, Małgorzata Dębska, Eliza Brożek, Mieczysław Chmielik
Complications of otitis media in children – a continuing problem
Department of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head: Prof. Mieczysław Chmielik M.D.
Complications of otitis media in children are usually divided into two groups: intracranial and intratemporal. In our study we assessed the frequency of complications of otitis media in children admitted to the Department of Paediatric Otolaryngology in Warsaw between 1990 and 2003. The most frequent complications were mastoiditis (82% of children) and peripheral facial nerve paresis (10%). In two children bacterial meningitis was diagnosed, and in single cases we found labyrinthitis, zygomatic bone inflammation, and torticollis. In this study we examine some aspects of mastoiditis. This complication, in spite of widespread use of cephalosporins and semisynthetic penicillin, remains a problem, and in many cases requires surgical intervention.
After the introduction of antimicrobial drugs in the treatment of acute otitis media (AOM) in children, a decreased frequency of complications of this disease was observed. In the pre-antibiotic era the frequency of intracranial complications of AOM was between 2.3-6.4 % and the resulting mortality was 76% (1). At the end of the seventies the frequency of intracranial complications had decreased to 0.04-0.15% (2), and mortality to 10- -31% (3).
Intracranial and intratemporal complications of AOM can appear as a consequence of:
– carriage of infection as a result of weakness of the osseous barrier during osteomyelitis, or the presence of a cholesteatoma,
– ascending infection as a result of thrombophlebitis,
– carriage of infection by the round window or congenital dehiscence (4).
The most frequent intratemporal complication of AOM is mastoiditis, which occurs as a result of the direct passage of purulent material to the mastoid process cells. Infection from the tympanic cavity and mastoid cells can spread laterally to the soft tissue of the postauricular region, anteriorly to the external ear canal, posteriorly towards the sigmoid sinus to the labyrinthine vestibule or apex of the petrous bone, superiorly to the middle cranial fossa, and inferiorly to the apex of the mastoid process (4).
Typical symptoms of acute mastoiditis are: reddening and oedema in the mastoid area, and smoothing of the retroauricular sulcus with anterior displacement of the pinna. In otoscopic examination signs of AOM are present, often with spontaneous perforation of the tympanic membrane and depression of the postero-superior wall of the external ear canal.
MATERIALS AND METHODS
We reviewed the records of 39 patients treated for complications of otitis media between January 1990 and July 2003. Age, sex, case history, treatment, type of complication, and the results of laboratory and bacteriological investigations were analysed. Among the 39 patients were 28 boys and 11 girls. The age ranged from 2 months to 14 years, with a mean of 4.4 months.
Acute mastoiditis was recognised in 32 children (82%), twice more in male patients (22 boys, 10 girls). Among these, 14 were below 2 years old (44% children with mastoiditis). The complication had arisen before recognition of AOM in 14 cases. In 71% of children of less than 2 years of age, mastoiditis was the first recognised symptom of an inflammatory condition of the middle ear.
Mastoiditis was diagnosed in 30 children with acute otitis media (AOM), and in 2 children with chronic otitis media (ChOM).
Peripheral paresis of the facial nerve was recognised in 4 children (10%), 3 with AOM and 1 with ChOM.
In one girl with chronic granulomatous otitis media, labyrinthitis was diagnosed. Fistulas in the semicircular canal were found during operation.
An intracranial complication was purulent meningitis, which occurred in 2 boys, 6 months old and 2 years old.
In single cases, as coexisting diseases, were zygomatitis, torticollis, pericarditis, bilateral pneumonia with pleural effusion, and agranulocytosis.
In 20 children (62.5%) with mastoiditis there was a bacteriological culture of pus obtained from the mastoid cavity during operation, from the external ear canal after spontaneous perforation, or after paracentesis. In 47% of cases the bacteriological cultures were positive. The most frequently isolated were Streptococcus pneumoniae (5 cases), Pseudomonas aeruginosa (3 cases), and Staphylococcus epidermidis (3 cases). In single cases Escherichia coli, Hemophilus influenzae, Staphylococcus coagulase – negative, and Staphylococcus aureus were found. In one child with meningitis, in a microscopic preparation of cerebro-spinal fluid Neisseria meningitis was found, but bacteriological culture of pus from the ear canal was negative.
Leukocytosis in patients ranged from 7.5 to 35 thousand per microlitre, mean 16.5. In one patient (6-month old boy with meningitis and mastoiditis) an agranulocytosis with 2% of granulocytes in blood smear was present. Erythrocyte sedimentation rate ranged from 5 to 165 mm/hr, mean 64mm/hr.
Fever above 38°C was present in 27 children (69%). Otopyorrhea on admission was found in 14 cases (36%).
In all children with mastoiditis reddening and oedema in the mastoid area, smoothing of the retroauricular sulcus, and different degrees of anterior displacement of the pinna were present.
A temporal bone x-ray was made in 13 patients, and computed tomography used in 5 others.
Radiological examination of 3 children revealed bone destruction and in two of these chronic otitis media with cholesteatoma was recognised, whereas one had chronic otitis media with granulation.
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