Acute coalescent mastoiditis in a 16-month-old child due to Streptococcus pneumoniae infection

Rationale:Acute otitis media is a common disease in early childhood,and is usually caused by Streptococcus pneumoniae(S.pneumoniae).Acute mastoiditis is a complication of acute otitis media and can involve not only the mucoperiosteum of the middle ear but can also spread to the periosteum by destroying the mastoid bone(acute coalescent mastoiditis).In addition,the infection can extend through the surrounding bones or the emissary veins beyond the mastoid’s air cells,leading to subperiosteal abscesses.Patient’s Concern:A 16-month-old female patient was hospitalized due to the purulent discharge of the left ear and the symptoms of right mastoiditis(swelling and redness of the skin).Diagnosis:Bilateral acute coalescent mastoiditis caused by S.pneumoniae infection.The computer tomography revealed bilateral bone destruction of the mastoid and abscesses found behind the auricle on both sides.Interventions:The patient underwent intravenous antibiotic therapy and surgical treatment.Outcomes:The patient was discharged 14 days after hospitalization with an improved condition.Lessons:Improperly treated acute coalescent mastoiditis can lead to extracranial and intracranial complications,sometimes serious and even life-threatening.Complications are prevalent in children under 2 years,in whom the disease progresses more rapidly and severely.The vaccination with a 13-valent vaccine may not result in sufficient immunity against S.pneumoniae,a predominant pathogen in children affected by acute coalescent mastoiditis.

Effects of Drilling in Mastoid Cavity over Hearing in the Contralateral Ear

In advanced otological surgeries, powered instruments form an indispensable part. The risk of deterioration to hearing in the operated ear is a commonly discussed issue, however, there remains a possibility of affecting the hearing in the contralateral ear due to transcranial vibration. So in this study we aimed to assess the possibility of the non-operated ear being affected by the noise generated during ear surgeries and whether it is temporary or permanent in nature. Methodology: This study included 63 patients diagnosed with unilateral disease who underwent mastoid surgery. Preoperatively all the patients were subjected to Pure tone audiometry (PTA), Transient evoked otoacoustic emission (TEOAE) and Distortion product otoacoustic emission (DPOAE). Patients were operated using both cutting and diamond burrs of ranging from sizes 1 - 6 mm. Total drilling time was recorded. Results: Post-operative hearing evaluation was done at 1 week, 4 weeks and 12 weeks. The sound emitted by various burrs was recorded by Sound Level Meter. Out of the total 58 patients that followed up, 46 showed change in at least one of the hearing parameters. Patients showing changes had a higher drilling time as compared to those with no changes. Of these, the changes associated with the total drilling time and with cutting burr time were found to be significant. The hearing changes seen on PTA, TEOAE and DPOAE were transient in nature with only one patient having a persistent decreased high frequency threshold at the end of 12 weeks. It was also found that cutting burrs produce more sound as compared to diamond burrs and a larger size burr of a type produces more sound than a smaller one of its type. Conclusion: The drilling of mastoid bone during ear surgeries can transiently impair the hearing in the contralateral ear which is of great significance in patients with only one hearing ear.

Acute Mastoiditis Clinical Course and Management in Patients Presented to Khartoumar Ear, Nose and Throat Hospital during the Period from November 2017 to November 2019

Introduction: Acute mastoiditis is the most common complication of Acute Otitis Media (AOM) and it’s the cause of serious morbidity. There is no standard universally agreed-upon management approach to acute mastoiditis. This study aims to view the clinical presentation and management approaches in Khartoum Ear, Nose and Throat Hospital. Methodology: This is a prospective case series and a hospital-based study conducted at Khartoum Ear, Nose and Throat Hospital during the period from November 2017 to November 2019. A total of 61 patients were included in the study. Results: The median age at presentation is 5 years old, males are more affected than females with a ratio of 1.35:1, and the mean duration of symptoms prior to hospital admission was 9.6 days. The most common presenting symptoms were otalgia (83.3%), ear discharge (83.3%) and post-auricular swelling (83.3%), and the most common signs at admission were tenderness over the mastoid (95.1%), retroauricular swelling and protrusion of the auricle (82%), and redness over the mastoid (77%). The abnormal tympanic membrane was found in all patients with central perforation being the commonest finding (73.8%), and bulging tympanic membrane (21.3%). 34.4% of patients received oral antibiotics before admission and the mean duration of symptoms prior to admission increased significantly in those who received antibiotics 12.7 days in comparison to those who didn’t 8.3 days. Only 52.5% of patients had a past history of recurrent acute otitis media, and 8.2% had a past history of acute mastoiditis. All the patients with recurrent mastoiditis had a past history of recurrent acute otitis media. Computed Tomography (CT) scans were obtained for 50.8% and 83.9% of those scans showed coalescent mastoiditis. Further evidence of intracranial extension was found in 6.5% and Magnetic Resonance Imaging (MRI) was obtained for them. Of the study group, 67.2% presented with subperiosteal abscess, 4.9% with facial nerve palsy and 3.3% with brain abscess. Thirteen patients with no complications were managed initially with injectable and topical antibiotics and were successful in only 6 of them (46%), abscess incisions and drainages were needed in 46 patients and were successful in 34 of them (73.9%). Eighteen patients (29.5%) needed mastoidectomy and all of them were managed successfully (100%). One patient (1.6%) was referred for intracranial abscess drainage in a specialized hospital, also one patient (1.6%) initially presented with intracranial abscess died on the second day of admission and 96.8% were discharged in good condition. The mean duration of hospital stay was 7.5 days. Conclusion: Patients present to the hospital after a prolonged period with a higher rate of complications, and the delayed presentation increased significantly in patients who received oral antibiotics prior to admission. Conservative medical treatment in non-complicated acute mastoiditis was ineffective in more than half of the patients and abscess incision and drainage and/or mastoidectomy are often necessary for the management.

Mastoid obliteration and reconstruction techniques:A review of the literature

Objective To review the published literature related to the different obliteration and reconstruction techniques in the management of the canal wall down mastoidectomy.Methods A PubMed(Medline)and LILACS databases as well as crossed references search was performed with the following Mesh terms:“cholesteatoma”,“cholesteatoma-middle ear”,“otitis media”,“otitis media,suppurative”,“mastoiditis”,“mastoidectomy”,“canal wall down mastoidectomy”,“radical mastoidectomy”,“mastoid obliteration”and crossed references.Inclusion criteria were adult patients subject to mastoid cavity obliteration and posterior canal wall reconstruction.The technique and materials used,anatomic and functional results,complications,recurrence rates,and changes in quality of life,were analyzed.A total of 94 articles were screened,38 were included for full-text detailed review.Results Twenty-one articles fulfilled the inclusion criteria.Techniques and materials used for canal wall reconstruction,tympanoplasty,and ossiculoplasty were varied and included autologous,biosynthetic,or both.Auditory results were reported in 16 studies and were inconsistent.Three studies reported improvement in the quality of life using the GBI scale.Follow-up time ranged from 1 to 83 months.Eleven articles used imaging studies to evaluate postoperative disease recurrence.The highest recurrence rate reported for cholesteatoma after obliteration was 19%.The most frequently reported complications were retraction pockets and transient otorrhea.Conclusion Plenty of techniques combining grafts and other materials have been used to overcome mastoidectomy cavity problems.So far,it is still not possible to standardize an ideal procedure.The available level of evidence for this topic is low and limited.

Persistent Pseudomonas Infection Mastoiditis—Local Antibiotic Treatment Is Superior than Systemic

Mastoiditis is a common complication of acute otitis media. It is common in younger age compared to adulthood. Mastoiditis occurs when an otitis media infection spread directly to involve the bone of mastoid air cell causing osteitis. Cholesteatoma can contribute to the development of mastoiditis. This typically leads to breakdown of some of the fine bony trabeculae of mastoid cells producing a coalescent mastoiditis with an emphyema in mastoid antrum. Cholesteatoma can contribute to the development of mastoiditis. The common treatment for mastoiditis is intravenous antibiotic. Our cases show that local antibiotic treatment is superior compared to systemic antibiotic in treating multi-drug resistant chronic. Pseudomonas mastoiditis compared to intravenous antibiotic. However, if it presents together with cholesteatoma the main treatment is still early mastoidectomy.

Does preoperative bacterial culture have bearing on healing of mastoid cavity:A prospective study

Objective： To study the bacteriological profile in a healing mastoid cavity. Methods： This study was a single centre prospective study. Culture swabs from granulations in the mastoid cavity were sent in 40 consecutive patients with squamosal chronic otitis media undergoing mastoidectomy. Cultures were processed for both aerobic and anaerobic bacteria. Results： Preoperatively： specimens from 26 out of 40 （60.5%） had growth on culture, with 22 （55%） showing only one organism while 4 showing multiple organisms. The commonest organism isolated was pseudomonas aeruginosa （n=15）. At 1 month after mastoidctomy, 11 patients had sterile culture while 29 had growth, of which 26 had aerobic growth and 3 had anaerobic growth. Pseudomonas was seen in 22 patients and staphylococcus aureus in 2 patients. The mean Merchant score was 2. At 3 months： 29 patients （72.5%） had sterile culture from mastoid cavity while 11 patients （27.5%） had growth on culture. All positive cultures were aerobic, including pseudomonas （n=9） and proteus （n= 2）. The mean Merchant score was 1.03. Of the 40 patients, 16 （40%） had a different organism cultured postoperatively compared to preoperative swabs. Conclusion： Pseudomonas and proteus seem to be the most common organisms responsible for persistent otorrhea after mastoidectomy. Persistent sterile otorrhea was seen in 4 patients （10%） in this group at the end of 3 months. Sterile cultures of preoperative swab are more likely to remain sterile in the postoperative period.

Postoperative surgical site infection in cholesteatoma surgery with and without mastoid obliteration, what can we learn?

Introduction:This study aims to describe the occurrence of postoperative complications related to cholesteatoma surgery and to determine factors influencing the most common complication,i.e.postoperative surgical site infection(SSI)in cases with and without mastoid obliteration.Materials and methods:Retrospective analyses were performed on surgically treated cholesteatomas in our hospital between 2013 and 2019.Patient characteristics,peri-and postoperative management and complications were reviewed.The cases were divided into two groups based on whether mastoid obliteration was performed or not.Results:A total of 336 cholesteatoma operations were performed,of which 248 cases received mastoid obliteration.In total 21 complications were observed,of which SSI was the most common(15/21).No difference in occurrence of any postoperative complication was seen between the obliteration and noobliteration group(p=0.798),especially not in the number of SSI(p=0.520).Perioperative and/or postoperative prophylactic antibiotics were not associated to the development of an SSI in both groups.In the no-obliteration group a younger age(p=0.015),as well as primary surgery(p=0.022)increased the risk for SSI.In the obliteration group the use of bioactive glass(BAG)S53P4 was identified as independent predictor of SSI(p=0.008,OR 5.940).Discussion:SSI is the most common postoperative complication in cholesteatoma surgery.The causes of SSI are multifactorial,therefore further prospective research is needed to answer which factors can prevent the development of an SSI in cholesteatoma surgery.

A large basal cell adenoma extending to the ipsilateral skull base and mastoid in the right parotid gland: A case report

BACKGROUND Basal cell adenoma (BCA) is a rare benign tumour that has unique histological characteristics and primarily arises in the parotid glands. According to published reports, nearby tissue destruction by BCA seems impossible. CASE SUMMARY We presented a case of a 54-year-old woman with a mass in the deep lobe of the right parotid gland involving the ipsilateral skull base and mastoid. The patient exhibited gradual right facial swelling but no other obvious symptoms. Combined resection of the total right parotid gland and partial skull base excision were performed. The biopsy conducted before the surgery and sections cut from intraoperatively obtained tissues were not definitive for identifying the character of the neoplasm. A final diagnosis of tubular BCA without malignant elements was established based on postoperative pathology results and immunohistochemical analysis. The tumour did not recur during the 12-mo follow-up period. CONCLUSION A diagnosis of BCA can only be established based on a histopathological examination after an excisional biopsy, and tubular BCA should carefully be considered as a destructive type.

Osteoma of mastoid process obstructing external auditory canal: A case report

Objective: To discuss the surgical treatment of recurrent osteoma of the mastoid process of the temporal bone, that obstructed external auditory canal causing unilateral conductive hearing loss. Setting: The study was carried out in ENT Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo. Design: Retrospective review of a clinical case. Patient, Intervention and Result: We treated surgically with success a 14-year-old boy with osteoma of mastoid process, obstructing the external auditory canal of the left ear and causing conductive hearing loss. Axial and coronal computed tomography scans revealed an compact bone lesion that obstructed the canal. Complete removal of the lesion was achieved by a retroauricular approach. Conclusion: In order to achieve complete removal of the osteoma, drilling of the lesion must be performed not through the tumor, but around the osteoma, in the surrounding bone tissue.

Regeneration of Mastoid Air Cells <i>in Vivo</i>Using Autologous Cortical Bone

Purpose: This was a preliminary study to assess surgical construction and regeneration of mastoid air cells in the treatment of cholesteatoma. Methods: Two-stage tympanoplasty with mastoidectomy was performed in four cases of unilateral cholesteatoma with sclerotic mastoid. During the first-stage operation, small fragments of autologous cortical bone were inserted into the cavity after mastoidectomy to form a honeycomb-like structure. Reconstruction of the lateral wall of the mastoid cavity was performed using the mastoid cortical bony plate. Pre- and postoperative mastoid volume was evaluated by three-dimensional reconstruction based on high-resolution computed tomography (HR-CT) images. Results: HR-CT images after the first-stage operation showed that mastoid volume had increased in all subjects. Macroscopic inspection during the second-stage operation revealed that the honeycomb-like structure made of bony fragments and covered by thin mucosa in the mastoid cavity was stable, with no evidence of effusion or granulation tissue. No retraction of the eardrum, middle ear effusion or recurrence of cholesteatoma was observed, and the hearing level on a pure-tone audiogram was improved in any subject 60 - 94 months after the second-stage operation. Conclusion: Surgical construction and regeneration of mastoid air cells using autologous cortical bone can be useful in treatment of cholesteatoma with arrested mastoid pneumatization.

Chordoma of petrosal mastoid region:A case report

BACKGROUND Chordoma is a rare low-grade malignant tumor originating from embryonic notochordal tissue mainly occurring in the axial bone,mostly in the sphenooccipital junction and sacrococcyx,which accounts for approximately 1%of all malignant bone tumors and 0.1%–0.2%of intracranial tumors.Chordoma in the petrous mastoid region is rare.CASE SUMMARY We describe a 36-year-old male patient with chordoma in the left petrous mastoid region.The main clinical manifestations were pain and discomfort,which lasted for 2 years.Magnetic resonance imaging showed a lobulated mass in the left petrous mastoid with an unclear boundary and obvious enhancement.The tumor was completely removed after surgical treatment,and a histological examination confirmed that the tumor was a chordoma.During 5 years of follow-up,no clinical or radiological evidence of recurrence or metastasis was found.CONCLUSION Chordoma in the petrosal mastoid region is rare but should be included in differential diagnosis of petrosal mastoid tumors.

Complicated Fusobacterium necrophorum mastoiditis–More than meets the eye

Otitis media is common in children and Fusobacterium species are an emerging causative pathogen.These species have virulence factors which increase the risk of complicated otitis media.We discuss a case of F.necrophorum infection resulting in significant intracranial disease to highlight the epidemiology of these infections,risk factors for complicated disease and signs and symptoms to guide diagnosis and investigation.

Morphometric Study of the Mastoid Process and its Role in Sex Differentiation:A Nigerian Computed Tomography Study

Background:The mastoid process can be utilized in forensic identification due to its resistance to alterations and population variations in its morphology.The study investigated the role of mastoid parameters in the determination of sex in a Nigerian population.Aims and Objectives:The aim of this study was to determine the gender differences in measurements of the mastoid process.Furthermore,the study aimed at assessing the percentage accuracy of using the mastoid variables in sex discrimination.Materials and Methods:This cross-sectional study used computed tomographic images of the brain,stored in the radiology unit of a referral hospital in Delta State,Nigeria.Permission was granted by the hospital’s Ethics Board.The measurements of the mastoid process were taken on images of 310 patients(170 males and 140 females)aged 20-80 years.Data were summarized using means and standard deviations.Gender,side,and age group comparisons were assessed using the independent t-test,paired t-test,and analysis of variance,respectively.The association between variables was probed using Pearson’s correlation test.The discriminant function analysis was used to determine the accuracy of correct sex allocation.The probability value was set at<0.05.Results:All the measurements were larger in males than in females(P<0.05).All except the conventional height,oblique sagittal diameter,and mediolateral inclination angle showed significant differences between age groups(P<0.05).The true height and oblique coronal diameter showed a significant positive correlation with age(0<r<0.05)(P<0.05).The lateral intermastoid distance was the best sex-discriminating variable(89.4%).Using all nine variables,the accuracy of sex prediction was 89.7%.Conclusion:The sexually dimorphic mastoid dimensions can collectively be used for sex determination with acceptable accuracies,in cases where only the fragmented parts of the temporal bone are available in Delta State,Nigeria.

Functional results of revision canal wall down mastoidectomy

In this retrospective study,we evaluated the preoperative and intraoperative findings and functional results of revision surgery after canal wall down mastoidectomy.We reviewed 34 patients(14 men,20 women;age,17–68 years)who underwent revision canal wall down mastoidectomy from March 2006 to March 2017 in the Department of Otology of the First Affiliated Hospital,Wenzhou Medical University,China.This study was approved by the Ethics Committee of the First Affiliated Hospital,Wenzhou Medical University,China(approval No.2008-05-02A11)on May 2,2008.The possible reasons for previous surgical failures were confirmed by the operative findings and included a narrow auditory meatus orifice(100%),recurrent or residual cholesteatoma(82%),high facial ridge(94%),residual air cells(47%),and labyrinthine fistula(12%).The mean time until achievement of dry ear after surgery was 5.8±2.4 weeks.After a mean 6-month follow-up,the mean postoperative air–bone gap decreased from 33.8±4.8 to 17.1±5.1dB in 30 patients who underwent mastoidectomy with simultaneous tympanoplasty.However,no significant postoperative hearing change had occurred in the other 4 patients with eustachian tube occlusion.All patients were followed up for>24 months with a disease-free dry ear and stable hearing results.The main reasons for lack of dry ears after mastoidectomy were a narrow auditory meatus orifice,recurrent or residual cholesteatoma,high facial ridge,and residual air cells.Early dry ear and hearing promotion are obtainable in most patients using revision canal wall down mastoidectomy.

Endoscopic transcanal modified canal-wall-down mastoidectomy for cholesteatoma

Attic cholesteatoma with antral extension in tight sclerotic mastoid cavities is a common presentation that creates difficult decision-making intraoperatively.Drilling through a sclerotic and small mastoid cavity,keeping the canal wall intactis often difficult and increases the risk of serious injury.Consequently,a canal-wall-down mastoidectomy is often performed.The endoscopic transcanal modified canal-wall-down mastoidectomy approach al lows the benefits of an open cavity for cholesteatoma resection and the benefits of a closed cavity for better long-term care and a more normal ear canal and middle ear reconstruction.

A Toddler with Rhabdomyosarcoma Presenting as Acute Otitis Media with Mastoid Abscess

Rhabdomyosarcoma （RMS） is a malignant tumor which involves the striated muscle, and it is most common in the pediatric age group. Usually, children with RMS present with persistent ear discharge, aural polyp and hearing loss which are similar to the symptoms seen in chronic otitis media （COM）. This similarity with COM often delays the diagnosis. The histological diagnosis of RMS is always a challenge because there are many other conditions which exhibit similar characteristic features such as an aural polyp. We discussed an unusual case of RMS in a 1 5-month-old girl who presented with acute otitis media （AOM） and mastoid abscess. The biopsy of the aural polyp confirmed the diagnosis.

骨振子对良性阵发性位置性眩晕残余症状的疗效评估

目的 探讨骨振子乳突振荡治疗手法复位成功后的良性阵发性位置性眩晕(benign positional paroxysmal vertigo,BPPV)患者残余症状的疗效。方法 前瞻性选取2022年5月至12月贵州省人民医院听力科门诊确诊为特发性BPPV并成功进行手法复位后有残余症状的93例患者,通过计算机随机分为治疗组47例和对照组46例。治疗组采用骨振子乳突振荡治疗,对照组不予任何治疗。门诊随访1周,采用眩晕障碍量表(dizziness handicap inventory,DHI)、前庭症状指数(vestibular symptom index,VSI)评价骨振子乳突振荡治疗手法复位成功后的BPPV患者残余症状的疗效。结果 复位前,对照组和治疗组DHI评分及VSI评分比较,差异无统计学意义(P>0.05);复位后,对照组和治疗组DHI总分、躯体分值、情感分值、功能分值、VSI评分低于复位前,且治疗组明显低于对照组,差异均有统计学意义(P<0.05)。结论 复位成功后应用骨振子乳突振荡能进一步改善患者的残余症状,缓解患者恐惧心理,提高生活质量。

骨振子对良性阵发性位置性眩晕的疗效影响

目的观察联合骨振子乳突振荡(mastoid oscillation,MO)治疗首诊手法复位后仍然再发眩晕的BPPV患者的疗效。方法选取2022年4月至2022年11月贵州省人民医院首诊手法复位治疗后仍发作眩晕的118例患者作为研究对象,除去3例不能耐受MO和11例失访者,最终纳入104例,其中(canalithrepositioning procedure,CPR)组53例,CRP+MO组51例。104例首诊BPPV经手法复位治疗CRP后仍再发眩晕的患者分为CRP组及CRP联合MO治疗的CRP+MO组。随访观察两组患者的眩晕障碍量表、总体视觉模拟量表评分、眼震消失时间、残余症状时间及不良反应。结果CRP+MO组治疗过程中DHI评分为12.79±3.67,VAS评分为2.34±1.31,低于CRP组19.44±2.12和4.58±1.29,结果有统计学意义(t=8.35,t=13.62,P<0.05);CRP+MO组复位后位置实验证实眼震阴性平均需要3.34±1.31 d,较CRP组5.58±1.29 d短(t=8.23,P<0.05);CRP+MO组治疗后残余症状平均持续7.85±3.37 d,与CRP组11.62±2.27 d相比,结果有统计学意义(t=15.32,P<0.05);两组不良反应率差异无统计学意义(χ^(2)=0.53,P>0.05)。结论联合MO治疗可缩短首诊未痊愈BPPV患者的疗程,改善治疗舒适度,提高生活质量。

许芝银教授从中焦气机论治非哺乳期乳腺炎经验

总结许芝银教授从中焦气机论治非哺乳期乳腺炎经验,认为非哺乳期乳腺炎病变脏腑在肝脾胃,与中焦气机失调关系密切,根据临床表现分为肿块期、脓肿期和瘘管期,主要病机为肝郁脾虚,痰阻乳络;日久郁热,热盛肉腐;气虚邪滞,缠绵阻遏。治疗上应根据疾病不同时期明辨病机,药随机转,以调畅中焦气机为关键分期化裁论治,肿块期辛开苦降,抑木扶土;脓肿期降浊升清,泻火平木;瘘管期运转中州,培土荣木,从而获得满意疗效。

耳内镜下中耳乳突胆脂瘤手术55例

目的探讨经外耳道耳内镜下中耳乳突部胆脂瘤切除术的效果。方法外耳道内C形切口,分离外耳道皮瓣,暴露鼓环,若松弛部穿孔,掀开鼓环;若紧张部大穿孔,保留前下方鼓环,暴露鼓室,清除鼓室内肉芽组织。持续灌流模式下磨除上鼓室外侧壁骨质,清除上鼓室胆脂瘤、听小骨周围病变,磨除乳突表面骨质,清除乳突腔胆脂瘤。内置明胶海绵支撑,视听小骨破坏程度置入不同类型人工听骨,乳突腔及上鼓室表面放置耳屏软骨,外覆软骨膜或生物膜。耳屏软骨膜内置法或耳屏软骨-软骨膜夹层法修补鼓膜,铺平外耳道皮瓣,术腔填塞。结果术前气导听阈中位数52.0(33.8~67.5)dB HL,显著高于术后6个月25.0(15.0~50.0)dB HL(Z=-6.454,P=0.000);术前气骨导距中位数35.0(21.2~52.5)dB HL,显著高于术后6个月15.0(3.8~27.5)dB HL(Z=-6.453,P=0.000)。55例术后2周,1、3、6个月复诊,以后每隔3个月进行一次复诊,随访24个月,55例鼓膜愈合良好,2例术后1年复发,均无面瘫、感音神经性耳聋等并发症。结论结合持续与非持续灌流模式,耳内镜下经外耳道入路行中耳乳突部胆脂瘤手术,鼓膜愈合良好,并发症少,术后患者听力改善明显,是一种微创、安全有效的手术方式。