Cuando los vómitos no son causados por un virus / When vomiting is not caused by a virus

La otitis media aguda (OMA) es un diagnóstico muy frecuente en Atención Primaria, a veces se complica con supuración y, en otras ocasiones, menos frecuentemente, con mastoiditis. Se presenta el caso de una niña de 6 años que, tras ser diagnosticada de OMA supurada e instaurarse tratamiento antibiótico, comienza con vómitos, mareos y cefalea, así como con un mal control del dolor con la analgesia habitual y posterior fotofobia. Tras varias visitas, acaba por diagnosticarse una mastoiditis con trombosis del seno transverso, sigmoideo y yugular. La importancia del caso radica en una rápida sospecha de las posibles complicaciones de una otitis media para realizar un diagnóstico y tratamiento precoz de las mismas. (AU)

Acute otitis media (AOM) is a very frequent diagnosis in Primary Care, sometimes complicated with suppuration, and less frequently, with mastoiditis. We present the case of a 6-year-old girl who, after being diagnosed with suppurative AOM and starting antibiotic treatment, began with vomiting, dizziness and headache, as well as poor pain control with the usual analgesia and subsequent photophobia. After several visits, a mastoiditis with thrombosis of the transverse, sigmoid and jugular sinuses was finally diagnosed. The importance of the case lies in a rapid suspicion of possible complications of otitis media in order to diagnose and treat them early. (AU)

Multicentric Case Series and Literature Review of Coccidioidal Otomastoiditis.

Coccidioidomycosis involving the ear, mastoid bone, or both is uncommon. We describe 5 new cases from the United States and review 4 cases reported in the literature of otomycosis and mastoiditis caused by Coccidioides. Of the 9 cases, 8 were linked to residence in or travel to California. Two patients had poorly controlled diabetes mellitus, 7 had otomastoiditis, 1 had otitis externa without mastoid involvement, and 1 had mastoiditis without otic involvement. Four patients had concurrent or prior pulmonary coccidioidomycosis. Ipsilateral facial nerve palsies developed in 2 patients. All patients received antifungal treatment for varying durations, and 8 of the 9 patients underwent surgical debridement. Clinicians should consider coccidioidomycosis as a differential diagnosis for otomastoiditis in patients with geographic risks.

Otomastoiditis por Corynebacterium amycolatum / Otomastoiditis caused by Corynebacterium amycolatum

Se presenta el caso de un varón de 33 años que ingresó por otomastoiditis complicada tras manipulación quirúrgica con aislamiento de Corynebacterium amycolatum, un microorganismo que está cobrando interés por su papel como patógeno en los últimos años. El interés del caso radica en lo infrecuente del mismo, ya que no se han descrito en la literatura revisada casos de otomastoiditis por esta bacteria. En el caso se describe cómo se llegó al diagnóstico y el manejo que se realizó, así como una revisión de la literatura publicada hasta el momento de infecciones por C. amycolatum. Consideramos de interés el caso, así como la revisión realizada, ya que es una entidad poco conocida y revisada previamente, por lo que este documento puede aportar información sobre la misma. (AU)

[Outpatient Antibiotic Prescription Rates and Mastoiditis in Children and Adolescents, Saarland, 2014-2019]. / Ambulante Antibiotika-Verordnungsrate und Mastoiditis-Fälle bei Kindern und Jugendlichen im Saarland, 2014­2019.

BACKGROUND: Infections of the respiratory tract are the main indication for outpatient antibiotic therapy in children and adolescents. In recent years the antibiotic prescription rate (APR) in the pediatric population has decreased significantly. OBJECTIVES: The aim of the retrospective mastoiditis audit in the PaedineSaar network is to investigate the incidence of inpatient acute mastoiditis (AM) in Saarland (2014-2019) regarding to the decreasing APRs in children, as well as to gather data of the clinical course of AM. METHODS: All inpatient AM cases 2014-2019 were analyzed retrospectively from 6 hospitals for pediatrics and/or otorhinolaryngology in Saarland and Trier. Children and adolescents aged 0-17 years and residing in Saarland were included in the study. RESULTS: 2014-2019 53 inpatient treated AM cases have been recorded. During the study period there was no significant increase of AM incidence (mean incidence 2014-2019: 6.1/100,000). 34% (18/53) of the patients received prehospital antibiotic treatment (main indication: acute otitis media (AOM) 15/18, 83%). At least one complication occurred in 30% of the patients (16/53). There was a slight trend to more complications in children without oral antibiotic treatment before admission (14/35 (40%) vs. 2/18 (11%) p=0.056). CONCLUSIONS: The incidence of AM leading to inpatient treatment in children in Saarland did not increase 2014-2019 despite a significant and sustained decline in the outpatient APRs. The results of this audit should be used for the development of a more standardized approach concerning the diagnostics and treatment of children with AM.

Epidemiology and variability in management of acute mastoiditis in children.

BACKGROUND: To evaluate the epidemiology, management and outcome of acute mastoiditis (AM) in children and to improve strategies for antimicrobial stewardship. METHODS: We conducted a retrospective observational study of children aged >6 months to ≤18 years of age admitted to a tertiary care hospital with AM over an 8-year period (2011-2019). Electronic medical records were reviewed to collect data. RESULTS: A total of 129 patients met inclusion criteria for AM during this time period. Eighty-one (63 %) were males with 110 (81 %) White and 67 (52 %) non-Hispanic. The median age at presentation was 6.4 years (3-10.1 years). Ear protrusion was associated with reduced odds of having AM with intracranial extension (ICE) (OR 0.307, 95 % CI = 0.107-0.883) whereas presence of headaches and/or neck pain increased the odds of having AM with ICE (OR = 3.96, 95%CI 1.29-12.1). The most common etiologies were Streptococcus pyogenes (n = 23, 19.2 %), Pseudomonas aeruginosa (n = 20, 17 %), and Streptococcus pneumoniae (n = 15, 12.5 %). Empiric antibiotic selection and duration of therapy was highly variable. The most common empiric antibiotic used was intravenous vancomycin with a third generation cephalosporin (n = 45, 34.8 %). Majority completed course (n = 92; 73 %) with an oral antibiotic. Shorter (≤10 and ≤14 days) versus longer courses (>10 and >14 days) did not affect readmission rates for AM without ICE. CONCLUSION: There is high variability of treatment of AM in children. Broad spectrum antibiotics, especially vancomycin were used most frequently despite low rates of Methicillin Resistant Staphylococcus aureus. The use of antibiotic stewardship is essential for judicious antibiotic use.

Scedosporium apiospermum infections in the middle ear and mastoid: case series and review of the literature.

OBJECTIVES: To present our case series and management of Scedosporium apiospermum infections of the middle ear and mastoid, and review the current literature on this rare yet potentially life-threatening condition. METHODS: Medical records of patients treated at the Royal Victorian Eye and Ear Hospital for S apiospermum middle ear and mastoid infections between 2009 and 2019 were reviewed. A literature search was conducted using PubMed, Medline and Cochrane Library databases. RESULTS: Two patients were identified in our institution: a 62-year-old diabetic woman with otogenic skull base osteomyelitis, and a 12-year-old boy with unilateral chronic suppurative otitis media which developed after tympanostomy tube insertion. The persistence of otalgia and otorrhoea despite prolonged antibiotic treatment characterised these cases. Both patients received voriconazole, and achieved disease resolution without complications. Ten relevant cases were identified after review of the literature. Despite treatment, there were three patient deaths, and four patients with otological or neurological complications. CONCLUSION: The presence of a middle ear or mastoid infection refractory to appropriate topical and systemic antibiotics should prompt clinicians to consider a fungal infection. The role of surgical debridement in the treatment of S apiospermum infection of the middle ear and mastoid is equivocal.

Complicated Trichosporon asahii mastoiditis in immunocompetent child.

BACKGROUND: Trichosporon asahii is an opportunistic fungus that causes infections in immunosuppressed patients. It is rarely seen in children and immunocompetent hosts. The mortality rates are still high despite early treatment with proper antifungal drugs. Trichosporon asahii mastoiditis in an immunocompetent child makes this case challenging. CASE PRESENTATION: This report presents a case of Trichosporon asahii mastoiditis which was complicated by transverse sinus thrombosis, in an otherwise healthy 21-month-old girl, and successfully treated with voriconazole. Trichosporon asahii was isolated, in three different occasions, from ear discharge of an immunocompetent healthy child, who presented with prolonged history of fever and received appropriate dosages of multiple types of antimicrobials as an outpatient but without improvement. After 48 h of starting the Voriconzole; post auricular swelling and ear discharge improved significantly. CONCLUSION: A high index of clinical and microbiological suspicion is needed for optimal diagnosis of Trichosporon infection. Trichosporon asahii can also cause infection in immunocompetent individual even without previous history of hospitalization or intervention. We emphasize the importance of early pediatric infectious evaluation and intervention.

IgG4-related pachymeningitis and mastoiditis, associated with cerebral venous thrombosis: A case report.

IgG4-related disease (IgG4-RD) is a multisystem fibroinflammatory condition; this can be a challenging diagnosis that requires clinico-pathologic correlation. We report a young woman, presenting with cranial nerve palsy. The work-up revealed pachymeningitis, cerebral venous thrombosis (CVT), and a destructive lesion in the mastoid. We diagnosed IgG4-RD through mastoidectomy. Thus, a biopsy of asymptomatic, infrequently affected organs, like the mastoid, can meet all histopathological criteria. In neuro-meningeal presentations, CVT may be secondary to the local inflammatory environment of pachymeningitis. Since our patient had a deep vein thrombosis one year prior, we discuss a possible higher risk of thrombosis in IgG4-RD patients.

Is Multidrug Resistance in Acute Otitis Media with Streptococcus pneumoniae Associated with a More Severe Disease?

OBJECTIVES: Streptococcus pneumoniae is the leading bacterial etiologic agent in acute otitis media (AOM), and it produces a more severe inflammatory response than other otopathogens. Additionally, the presence of multidrug-resistant (MDR) S. pneumoniae is an important issue in the management of AOM. The present pilot study aimed to ascertain whether MDR S. pneumoniae is associated with a higher inflammatory response and/or a more severe disease. METHODS: This was a prospective, single-center study on nonpneumococcal conjugate vaccine-immunized pediatric patients with severe AOM. Demographic and clinical characteristics were recorded. Middle ear fluid was obtained and cultured for each patient; antibiotic-resistance profiling was tested for S. pneumoniae isolates. The C-reactive protein (CRP) level and complete blood count were determined. Patients with positive middle ear fluid culture for S. pneumoniae were divided into 2 groups according to antibiotic resistance profile: MDR and non-MDR. RESULTS: MDR S. pneumoniae was identified in 15 (35.7%) of the 42 eligible patients. Children in this group had significantly higher CRP levels (72.23 ± 62.92 vs. 14.96 ± 15.57 mg/L, p < 0.001), higher absolute neutrophil count (8.46 ± 3.97 vs. 5.22 ± 4.5 × 103/mm3, p = 0.004), higher percentage of neutrophils (52.85 ± 13.49% vs. 38.34 ± 16.16%, p = 0.004), and were more prone to develop acute mastoiditis (p = 0.01). Receiver operating characteristic analysis identified CRP as the best biomarker to discriminate between the 2 groups of patients (AUC = 0.891). CONCLUSION: MDR S. pneumoniae was associated with a more severe inflammatory response and a higher incidence of mastoiditis.

Chronic suppurative otomastoiditis due to nontuberculous mycobacteria: A case series.

INTRODUCTION: Eight new cases of chronic otomastoiditis due to nontuberculous mycobacteria were reported at Center Hospitalier Universitaire Sainte-Justine (CHUSJ) between 2008 and 2018. In the literature, only 89 cases have been described since 1972. This case series aims to define the clinical presentation, infectious pathogens, as well as diagnostic and therapeutic means employed in cases of nontuberculous mycobacteria otitis media encountered in our tertiary pediatric reference center. METHODS: All cases of otitis media caused by nontuberculous mycobacteria diagnosed at Sainte-Justine between 2008 and 2018 were reviewed. Species identification was retrieved from the Laboratoire de Santé Publique du Québec, Quebec's provincial public health and reference laboratory. RESULTS: All 8 cases occurred in immunocompetent children. Clinical features on presentation were chronic tympanostomy tube otorrhea with abundant granulation tissue in 7 cases. CT scan demonstrated coalescent mastoiditis in 3 cases. The median delay between initial presentation and identification of nontuberculous mycobacteria was 81 days. Seven patients had a Mycobacterium (M.) abscessus complex infection. Treatment consisted of weekly microscopic granulation debridement, a combined systemic antibiotic therapy for an average duration of 21 weeks, as well as instillation of boric acid into the middle ear. While 3 cases required at least one mastoidectomy, 2 cases were treated only medically. CONCLUSION: Nontuberculous mycobacteria otitis media is a rare clinical entity, for which high clinical suspicion and specific microbiological analyses could minimize diagnostic delay. The use of boric acid as a desiccating agent may allow for a better local control.

Medical and surgical characteristics of fusobacterium necrophorum mastoiditis in children.

OBJECTIVES: To evaluate and compare characteristics of Fusobacterium necrophorum mastoiditis (FnM) to characteristics of acute mastoiditis (AM) caused by other bacteria in tertiary children hospital Methods : Children with FnM (N=43) and non FnM (N=88). Assess medical, microbiologic and imaging characteristics, surgical findings and postoperative recovery. RESULTS: Children with FnM had a positive history of otitis media, ear discharge and sub-periosteal abscess (p=0.0004, 0.09, 0.0003, respectively) at presentation. Their temperature, WBC and CRP were significantly higher (39.8 vs. 37.9, 19.4K vs. 16.1K, 21 vs. 8.7, p=0.0001). Positive culture was found in 46% of patients; 64% were diagnosed by PCR. CT scan was indicated in 95% and surgical intervention in 93% of children with FnM, compared to 15% and 9.7% of children in the non-FnM group (p=0.0001). Complex post-operative course was frequent for the FnM group: 88% of children had persistent fever, 46% had additional imaging and 14% additional surgical intervention. Children with FnM were treated with IV antibiotics for an average of 22 compared to seven days for non-FnM children (p=0.0001). CONCLUSIONS: Fusobacterium should be suspect in a child presenting with AM, a septic appearance, high fever and increased inflammation markers. A regimen of two antibiotics should be empirically started, then proceed to imaging and early surgical intervention. A relatively slow post-operative recovery process should be expected; however, prognosis is good.

Mastoiditis aguda con complicación intracraneal. Reporte de un caso pediátrico / Acute mastoiditis with intracranial complication in a pediatric patient

La mastoiditis aguda es una infección de las celdillas mastoideas, generalmente, secundaria a la progresión de una otitis media aguda. Las bacterias aisladas con más frecuencia en las mastoiditis son Streptococcus pneumoniae, Streptococcus pyogenes y Staphylococcus aureus. La infección mastoidea puede extenderse por contigüidad, afectar a estructuras vecinas y dar lugar a complicaciones intra- o extracraneales. Las más frecuentes son las intracraneales, entre las que se incluyen la meningitis, el absceso cerebeloso o del lóbulo temporal, el absceso epi- o subdural y la trombosis de senos venosos.Se presenta el caso de una niña de 4 años que desarrolló dos complicaciones intracraneales (absceso epidural y trombosis de senos venosos transverso y sigmoideo) a partir de una mastoiditis aguda producida por Streptococus pyogenes

Acute mastoiditis is an infection that affects the mastoid air-cell system, usually due to the progression of an acute otitis media. The bacteria most frequently isolated in acute mastoiditis are Streptococcus pneumoniae, Streptococcus pyogenes and Staphylococcus aureus. The mastoid infection can extend affecting contiguous structures and producing intra or extracranial complications. The most frequent ones are intracranial complications, including meningitis, temporal lobe or cerebellar abscess, epidural or subdural abscess and venous sinus thrombosis.We present the case of a 4-year-old girl who developed two intracranial complications (intracranial epidural abscess and transverse and sigmoid sinus thrombosis) initiated in an acute mastoiditis produced by Streptococcus pyogenes.

Acute mastoiditis in children.

Acute mastoiditis is the most common complication of acute otitis media. Although rare, the disease is carefully studied by otolaryngologists because it usually affects very young children with severe clinical course and sometimes causes serious complications. Most important risk factors are the young age (often>2 years), high fever, alteration of the laboratory findings (very high values of WBC count, absolute neutrophil count and C-reactive protein), while less important are previous antibiotic therapy or previous middle ear infections. The main pathogen of the acute mastoiditis is Streptococcus pneumoniae, followed by Streptococcus piogenes, Haemophilus influentiae, and Staphylococcus aureus. The finding of Pseudomonas aeruginosa is not uncommon, but often its presence is often considered a contamination or simultaneous infection. The complications can be extracranial (subperiosteal abscess, Bezold's abscess); intratemporal (facial nerve palsy, labyrinthitis) and intracranial (subdural abscess). The complications have often a very serious clinical course and potentially life-threatening. Antibiotic therapy is the main treatment in not complicated forms. Considering the prevalence of Streptococcus pneumoniae, cephalosporins are the antibiotic of choice, but they have to be administrated intravenously in hospitalized patients. Combinations with other antibiotic are suggested when multibacterial flora is present. In complicated forms of acute mastoiditis, the antibiotic treatment can be particularly important, in combination with other specific drugs (i.e. anticoagulants and/or corticosteroids). Surgical treatments, such as incision of abscesses, mastoidectomy, and neurosurgical procedures, are sometimes performed in combination with medical therapy in very severe complications. Data from our experience are briefly reported.