Facial Nerve Palsy Complicated by Masked Tuberculous Mastoiditis in a Recently Transplanted Patient.

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.

A 27-year-old man with recurrent sinopulmonary and cutaneous infections.

The increasing availability of genetic testing for modern immunologists in the evaluation of immune diseases could provide a definite diagnosis in elusive cases. A 27-year-old white male patient presented to the clinic with recurrent sinopulmonary and cutaneous infections since childhood. The patient's mother had seronegative polyarthritis, and one of two sisters of the patient had chronic sinopulmonary infections. Serum immunoglobulins, immunoglobulin G (IgG) subclasses, lymphocyte subset markers, mannose-binding lectin, mitogen and antigen stimulation, bacteriophage study, and Streptococcus pneumoniae titers to 23 serotypes were all normal. B-cell phenotyping revealed a decrease in both nonswitched memory B cells (CD19+CD27+IgD+) and switched memory B-cells (CD19+CD27+IgD-). Genetic testing and the improvement of clinical symptoms after IgG replacement led to the final diagnosis.

Pediatric acute mastoiditis in the era of pneumococcal vaccination.

OBJECTIVES/HYPOTHESIS: The objective was to describe trends in the annual prevalence of hospitalization for pediatric acute mastoiditis since introduction of the 7-valent pneumococcal vaccine in 2000 and the 13-valent vaccine in 2010. STUDY DESIGN: Cross-sectional retrospective data analysis. METHODS: The Kids' Inpatient Database from years 2000 to 2012 was analyzed. To determine the annual prevalence of hospitalization for acute mastoiditis, nationally weighted frequencies of hospitalization for children <21 years with acute mastoiditis diagnoses were collected. Trend analysis of hospitalization rates from 2000 to -2012 was performed. RESULTS: From 2000 to 2012, there was no significant trend in hospitalization rates for acute mastoiditis overall (1.38 and 1.43 per 100,000 persons in 2000 and 2012, respectively; P = .86) or by age group. When comparing hospitalization rates at time points 2000 and 2012, children <1 year (4.65 and 3.27 per 100,000 persons, P = .0023) and 1 to 2 years of age (3.95 and 3.18 per 100,000 persons, respectively; P = .0107) demonstrated declines in hospitalization over time. Between 2009 and 2012, hospitalization rates also significantly declined for children aged <1 year (4.50 to 3.27 per 100,000 persons, P = .0056) and 1 to 2 years (4.30 to 3.18 per 100,000 persons, P = .0002) but increased for children 5 to 9 years (1.10 to 1.81 per 100,000 persons, P < .0001) and 10 to 20 years of age (0.41 to 0.72 per 100,000 persons, P < .0001). CONCLUSIONS: Despite introduction of two pneumococcal vaccines, rates of hospitalization for pediatric acute mastoiditis did not decline between 2000 and 2012. Between 2009 and 2012, however, children 0 to 2 years of age showed declining hospitalization rates, possibly reflecting the protective benefit of the 13-valent pneumococcal vaccine. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1480-1485, 2018.

Recent advances in knowledge regarding the head and neck manifestations of IgG4-related disease.

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.

A case of hypertrophic cranial pachymeningitis associated with invasive Aspergillus mastoiditis.

We report a rare case of hypertrophic cranial pachymeningitis (HCP) associated with invasive Aspergillus mastoiditis. A 63-year-old man with diabetes mellitus underwent mastoidectomy because of chronic discharge from his left ear. The mastoidectomy was unsuccessful in resolving purulent otorrhea; moreover, 7 months later, the patient developed left abducens nerve palsy. Magnetic resonance imaging revealed HCP at the left middle cranial fossa. Although the pathogen could not be identified, an Aspergillus infection was considered based on elevated serum ß-d-glucan and a positive Aspergillus antigen test result. Voriconazole treatment resolved diplopia and left otorrhea and dramatically improved HCP.

Acute mastoiditis in the pneumococcal conjugate vaccine era.

Following the introduction of the 7- and 13-valent pneumococcal conjugate vaccines, we observed an inverse relationship between the increasing rate of immunized children and the proportion of middle ear fluid cultures collected during acute mastoiditis episodes that tested positive for Streptococcus pneumoniae among a subset of children 0 to 6 years old who had initially presented with severe acute otitis media and had bacterial cultures collected during tympanocentesis or from spontaneous otorrhea.

Expression of toll-like receptors 2, 4 and nuclear factor kappa B in mucosal lesions of human otitis: pattern and relationship in a clinical immunohistochemical study.

OBJECTIVES: The objectives were to detect and compare the expression of toll-like receptors (TLRs) 2, 4 and nuclear factor kappa B in mucosal lesions of chronic otitis. METHODS: Fifty-five tissue samples obtained from children and adults operated on for otitis were investigated by semiquantitative immunohistochemical methods using polyclonal antibodies for TLR 2, 4 and NFkappaB. Kruskal-Wallis, Mann-Whitney, and Kendall's tau rank correlation tests were used. RESULTS: Stronger expression of TLR2, 4 was found in inflamed mucosa than in the control for children and adults (TLR2: H = 23.86, P < .0011; TLR4: H = 22.80, P < .00 1) (TLR2: H = 17.53, P < .001; TLR4: H = 11.99, P < .001); in cholesteatoma perimatrix compared to tubotympanic lesions in children (TLR2: H = 11.06, P = .004; TLR4: H = 10.61, P = .005) and adults (TLR2: H = 10.73, P = .013; TLR4: H = 9.65, P = .021). No differences were found in NFkB expression (H = 0.042, P = .99). Significant correlations were found for all pairs of molecules in cholesteatoma and tubotympanic mucosa of adults (TLR2, 4: P = .002, P < .001; TLR2-NfkappaB: P = .032, P = .021; TLR4-NFkB: P = .035, P = .0013), only TLR4-NFkappaB in tubotympanic otitis of children (P = .026). CONCLUSIONS: Toll-like receptors 2,4 and NFkB mediate inflammation in cholesteatoma and mucosal lesions oftubotympanic otitis in children and adults. Significant correlations betweenall pairs of molecules in all samples were detected in adults, but only TLR4-NFkappaB in children.

Aspergillus mastoiditis in an immunocompetent patient: a case report and review of the literature.

Aspergillus mastoiditis usually occurs in immunocompromised patients. There are a few isolated reports in the literature involving immunocompetent patients. We hereby describe the case of an immunocompetent patient diagnosed with invasive Aspergillus mastoiditis, which was treated successfully, and review the literature pertaining to this condition. The common clinical presentations, putative pathophysiology, and recommended therapy are discussed.

Mastoiditis aguda en la época de la vacuna antineumocócica / Acute mastoiditis in the pneumococcal vaccine era

Introducción y objetivos: La mastoiditis aguda (MA) es la complicación más frecuente de la otitis media aguda. Estudios recientes muestran un incremento de su incidencia en los últimos años. El objetivo de este estudio fue revisar los casos diagnosticados en nuestro hospital en menores de 14 años. Material y métodos: Estudio retrospectivo de pacientes menores de 14 años ingresados por MA entre 1996 y 2008. Se analizaron diversas variables epidemiológicas, analíticas y clínicas. Resultados: Se revisaron 61 casos, 55,7% varones. La edad media fue de 28 meses. El 79% de los casos se presentaron después del año 2002, la mayoría en los meses de otoño e invierno, y con el antecedente de proceso catarral de vías altas. El 60,7% refería diagnóstico clínico previo de otitis media aguda, tratada en el 55,7% con antibiótico. Se realizó cultivo en 48 pacientes, aislándose en ellos: Streptococcus pneumoniae en el 39,7%, Haemophilus influenzae en el 2%, Staphylococcus aureus en el 12,5%, y Pseudomonas aeruginosa en el 8,3%. El cultivo fue estéril en 18 pacientes (37,5%). De los neumococos aislados, el 26,2% presentaron resistencia a penicilina o cefalosporinas. La mayoría (93,4%) de los pacientes fueron tratados con antibióticos solos o asociados a miringotomía, realizándose mastoidectomía en 4 casos. En 7 casos de mastoiditis se presentaron complicaciones (11,5%). Conclusiones: La MA muestra una incidencia en aumento en los últimos años. El germen más frecuentemente aislado es el neumococo, destacando las altas tasas de resistencias antibióticas en nuestro estudio. Los tratamientos con antibióticos solos o asociados con miringotomía son efectivos en las formas menos severas (AU)

Introduction and objectives: Acute mastoiditis is the most common complication of acute otitis media. Recent studies have noticed an increase in cases. The goal of this study was to review acute mastoiditis cases diagnosed in children younger than 14 years old. Material and methods: A retrospective study of all patients under 14 years old admitted with a diagnosis of mastoiditis between 1996 and 2008 was performed. Epidemiological, laboratory and clinical variables were analysed. Results: Sixty-one charts were reviewed. The mean age was 28 months; 55.7% of the patients were male. Most cases were in the autumn and winter; 79% occurred from 2002 to 2008. Most cases (82%) had antecedents of an upper airway catarrhal process and 60.7% had a clinical diagnosis of acute otitis media. Prior antibacterial agent therapy had been administered in 55.7% of the cases. Culture of middle ear effusions was performed in 48 patients, revealing Streptococcus pneumonia in 39.7%, Haemophilus influenzae in 2%, Staphylococcus aureus in 12.5% and Pseudomonas aeruginosa in 8.3%. Cultures were sterile in 18 patients (37.5%). Of the pneumococcal isolates, 26.2% were resistant to penicillin or third generation cephalosporins. Most cases (93.4%) responded well to antibacterial therapy alone or with myringotomy. There were complications in 7 patients (11.5%). Mastoid surgery was performed in 4 patients. Conclusions: Acute mastoiditis shows a rising incidence in recent years. The most commonly isolated form is the pneumococcus, the high rates of antibiotic resistance in our study being notable. Treatments with antibiotics alone or in combination with myringotomy are effective in less severe forms (AU)

Aspergillus mastoiditis, presenting with unexplained progressive otalgia, in an immunocompetent (older) patient.

Aspergillus mastoiditis and skull-base osteomyelitis are extremely rare, even in immunocompromised patients. We report a case of an 81-year-old immunocompetent man, who underwent a mastoidectomy because of unexplained, progressive otalgia in spite of a noninflamed and air-containing middle-ear space. Histopathology yielded Aspergillus fumigatus. When confronted with otitis with an unexpected clinical course a high index of suspicion is required to facilitate early diagnosis and appropriate therapy of a potential lethal Aspergillus infection, even in immunocompetent patients. This seems to be more so in older patients with an open middle-ear cavity and/or when there is facial nerve involvement.

Fungal mastoiditis in immunocompromised children.

The immunocompromised host is subject to a variety of opportunistic infections. Mycotic infections, including invasive fungal sinusitis, are a dreaded complication in immune deficient children. Fungal mastoiditis has rarely been described in this population. Our experience with 2 cases of fungal mastoiditis in immunocompromised children is reviewed. Case histories describing aggressive medical management with and without surgical intervention and a review of the literature are presented.

Study on adhesion factors in lymphocyte migration to the middle ear mucosa.

We investigated influences of adhesion factors on the migration of antigen-specific IgA-forming cells (ASAFCs) to the middle ear mucosa by means of an in vitro lymphocyte binding assay. Peyer's patch (PP) lymphocytes from guinea pigs with mucosal immunization, which are rich in ASAFCs, more frequently bound with the inflamed middle ear mucosa than those of PP and spleen cells from animals with systemic immunization, in which antigen-specific IgG-forming cells (ASGFCs) were induced (p > .001). The bindings were not affected by antigenic and nonantigenic stimuli to the middle ear mucosa for producing otitis media. On human middle ear mucosa from 10 patients with acute mastoiditis and chronic otitis media, endothelial cells of newly grown vessels were stained strongly with intercellular adhesion molecule (ICAM)-1, and weakly with vascular cell adhesion molecule (VCAM)-1, platelet endothelial cell adhesion molecule (PECAM), and endothelial leukocyte adhesion molecule (ELAM)-1. Many lymphocytes bound mainly to these endothelial cells, and a few cells were observed bound to the basal portion of epithelial cells. The binding of lymphocytes was significantly, but not completely, inhibited by anti-ICAM-1 antibody (p < .001). These findings suggest that PP lymphocytes with activated mucosal immunity more frequently migrate to the inflamed middle ear mucosa, and that those migrations, after extravasation, may be regulated by the interaction between various binding factors and their receptors on lymphocytes, which is different from that of adhesion molecules and their ligands in the extravasation.

[Protein analytic studies in children with mastoiditis]. / Eiweissanalytische Untersuchungen bei Kindern mit Mastoiditis.

Protein analysing examinations were carried through in children--fit to be compared to their age--suffering from inflammable ear diseases (acute middle ear inflammation, mastoiditis) and those who were healthy as to their ears. The obtained values statistically analysed resulted in significant differences as to the acute phase and those of closely associated proteins in the sense that haptoglobin, C3c and C1-inactivators in patients with a mastoiditis and partially in those who suffered from an acute middle ear inflammation were increased but prealbumin and transferrin in the same group were decreased. Subsequently the correlative connections of the parameters with singled-out clinical findings in the mastoiditis-group were examined. A factor of the acute phase, a factor of the subacute phase and the immunoglobulin factor could have been marked off, whereby the two first-mentioned are significant for mastoiditis, a fact that will help to facilitate the decision on further therapeutical practice. Presently there are no specific proteins for diagnostics of 'mastoiditis', so that to clinical expertness and experience of the therapeutist will come up the most significant role for the ill child.

[Serum immunoglobulins in otitis and otoantritis in infants].

In 46 breast-fed children affected with otitis or otoantrite, it was investigated on the role of seric immunoglobulines which necessarie are in e transitory lacking period. In the 50% of the tested cases in has been checked a lack of IgG particularly remarkable, beyond the limits of range of the values specific in the breastfed child. As e conclusion, the lack in gammaglobulines is a factor which favours the rising of infection.