Myringotomy, Mastoidectomy Have Highest Cure Rates for Pediatric Acute Mastoiditis

by Amy E. Hamaker •

COMMENT: This study identified 33 articles with nearly 3,000 surgical patients and found that mastoidectomy is the gold standard for treatment with a 99.7% success rate. Conversely, the average cure rate with medical therapy alone in 990 patients studied was 71.7%. Of concern, complications arose during medical treatment in 5% of those treated. —Samuel H. Selesnick, MD

In absence of a standard of care for treatment of pediatric acute mastoiditis (AM), what is the efficacy of current pediatric AM treatment options?

BOTTOM LINE: Myringotomy with or without tube placement and mastoidectomy have the highest cure rates for pediatric AM. Medical treatment cured nearly 72% of children.

Background:  AM is a complication of acute otitis media (AOM), in which there is inflammation of the mastoid periosteum and air cells. AM treatment regimens include intravenous antibiotics alone or in combination with myringotomy or tympanostomy tube placement, subperiosteal abscess incision and drainage, or mastoidectomy, but there have been no systematic reviews addressing these treatment protocols.

STUDY DESIGN: Literature review of 55 articles from inception to January 2016.

SETTING: PubMed, Embase, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library.

SYNOPSIS: Nine hundred ninety patients were treated with medical therapy. The mean cure rate with intravenous antibiotics alone was 71.7%. The mean percentage of serious complications was 7.1%; 15 patients had either an epidural, brain, or intracranial abscess; six had a Bezold’s abscess; and 28 patients had sigmoid sinus thrombosis. Nine patients had facial paralysis, and 17 had meningitis. The reviewed studies showed 2,265 patients who underwent a surgical procedure, including myringotomy with or without tube placement, SPA incision and drainage, and mastoidectomy, and received intravenous antibiotics. Of 920 patients undergoing primary myringotomy with or without tube placement, 140 went on to further surgery; most proceeded to mastoidectomy and were cured. Of 142 patients undergoing primary SPA incision and drainage with concurrent myringotomy with or without tube placement, 29 underwent further mastoidectomy. Fifteen patients had an SPA incision and drainage without concurrent myringotomy or tube placement; all were cured. Of 215 patients undergoing mastoidectomy alone, only one failed treatment. Of 397 patients undergoing mastoidectomy and myringotomy with or without tube placement, all were cured. Of patients treated surgically, 5.8% had a serious complication, including epidural, brain, or intracranial abscesses; a Bezold’s abscess; or sigmoid sinus thrombosis; 1.1% had facial paralysis; and 0.9% developed meningitis. Limitations included the possibility of publication bias, level 4 evidence, and heterogeneous data.

CITATION: Anne S, Schwartz S, Ishman SL, Cohen M, Hopkins B. Medical versus surgical treatment of pediatric acute mastoiditis: a systematic review. Laryngoscope. 2019;129:754–760.