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Suppurative Complications of Acute Otitis Media in the Era of Antibiotic Resistance
Jeffrey S. Zapalac, MD;
Kathleen R. Billings, MD;
Nathan D. Schwade, PhD;
Peter S. Roland, MD
Arch Otolaryngol Head Neck Surg. 2002;128:660-663.
ABSTRACT
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Objective To review our experience with suppurative complications of acute otitis
media (AOM) in the era of antibiotic resistance, given a perceived increase
in the number of such cases in recent years requiring surgical intervention.
Design Retrospective review of pediatric patients presenting with suppurative
complications of AOM from January 1993 to June 2000.
Setting Academic tertiary care children's medical center.
Patients A total of 90 pediatric patients, ranging in age from 3 months to 16
years (mean age, 45 months).
Results A total of 104 suppurative complications of AOM occurred in 90 patients
over the 7.5-year study period. The incidence of noncoalescent, coalescent,
and total cases of mastoiditis and total number of suppurative complications
all increased over the study period, with coalescent outpacing noncoalescent
disease during the last 3 years of the study. A trend toward an increasing
number of cases requiring surgical intervention was noted during the study
period, corresponding to an increasing number of resistant Streptococcus pneumoniae isolates. Ten of 16 S pneumoniae isolates were resistant, primarily collected from younger children
ranging in age from 4 to 24 months (mean age, 11.9 months).
Conclusion The rising incidence of resistant S pneumoniae
corresponded to the increasing number of suppurative complications of AOM
during the study period and seemed to contribute to more aggressive infectious
processes requiring surgical intervention.
INTRODUCTION
THE INCIDENCE of suppurative complications of acute otitis media (AOM)
has declined dramatically in the postantibiotic era. Antibiotic therapy has
not only decreased morbidity and mortality, but has concomitantly decreased
the need for mastoid surgery.1 The emergence
of antibiotic-resistant middle ear microorganisms, however, has prompted a
reevaluation of the approach to both uncomplicated otitis media and its suppurative
sequelae.2-3
In 1997, Thornsberry et al4 evaluated
more than 11 300 respiratory isolates from 434 institutions in 45 states
and the District of Columbia and demonstrated resistance in 30% to 40% of Haemophilus influenzae and Streptococcus
pneumoniae isolates and 90% of Moraxella catarrhalis isolates.4 Resistance patterns of S pneumoniae vary widely and are geographically and seasonally
dependent. Furthermore, S pneumoniae is a more virulent
organism than H influenzae or M catarrhalis, which are rarely implicated in suppurative complications
of AOM.5 The rising incidence of resistant S pneumoniae is alarming, prompting establishment of guidelines
for management of AOM when resistant organisms are suspected.2-3
Suppurative complications of AOM might be expected to increase in incidence
with the escalation of antibiotic resistance.6
Various reports in the recent literature have noted an apparent increase in
mastoiditis, although this was not definitively linked to the rising incidence
of S pneumoniae resistance.7-8
In recent years at our institution, a perceived increase in both the incidence
of suppurative complications and the need for acute mastoid surgery was noted.
To analyze this apparent trend, we undertook a review of patients with suppurative
complications of AOM, paying particular attention to cases involving resistant S pneumoniae and those requiring surgical intervention.
PATIENTS AND METHODS
A retrospective chart review was performed for patients with suppurative
complications of AOM admitted to the Children's Medical Center of Dallas from
January 1993 to June 2000. Medical records were obtained by searching databases
for the International Classification of Diseases, Ninth
Revision codes corresponding to inpatient diagnoses of acute mastoiditis,
subperiosteal abscess, facial nerve paralysis, labyrinthitis, petrositis,
otitic hydrocephalus, sigmoid sinus thrombosis, or intracranial abscess. All
cases of chronic suppurative otitis media or known cholesteatoma were excluded.
Standardized data forms were used to extract information on patient
demographics, prior therapy, culture results including antimicrobial susceptibilities,
medical treatment, surgical intervention, and outcome. Operative reports were
used to confirm diagnoses and elucidate extent of intervention. Minimal audiometric
and follow-up data were available for review and were not included.
Statistical analysis of age at presentation within the subset of children
with S pneumoniae–related complications was
performed using JMP Statistical Discovery Software, version 4.01 for Microsoft
Windows (SAS Institute Inc, Cary, NC). A t test was
run, and statistical significance was reported with a P value less than .01, with 102 df. To evaluate
trends in the incidence of suppurative complications of AOM over the 7.5-year
study period, 3 equal periods of 2.5 years (30 months) were established. Patients
presenting from January 1993 to June 1995 were designated group 1; those presenting
from July 1995 to December 1997, group 2; and those presenting from January
1998 to June 2000, group 3. An exact test for directional (1-tailed) linear
trend in ordered binomial proportions, available in the StatXact statistical
software package (CyTel, Cambridge, Mass), was used to estimate whether rates
of total suppurative complications, surgical intervention, and S pneumoniae resistance expressed as proportions of total otolaryngology
admissions increased linearly over the given time intervals.
RESULTS
DEMOGRAPHIC DATA
Over the 7.5-year study period, 90 patients with a total of 104 suppurative
complications of AOM were treated. Age at presentation ranged from 3 months
to 16 years (mean age, 45 months). The subset of children with S pneumoniae–related complications was significantly younger,
ranging from 4 to 24 months (mean age, 11.9 months; P
= .003). There were 55 boys and 36 girls, yielding a male-female ratio of
1.52:1.
Acute noncoalescent mastoiditis occurred in 51 patients (49%), while
acute coalescent mastoiditis occurred in 24 (23%). All but 4 cases of coalescent
mastoiditis demonstrated a subperiosteal abscess. Facial nerve paralysis occurred
in 14 patients (13%), 7 each of complete and incomplete paralysis. Epidural
abscess occurred in 7 patients (7%), sigmoid sinus thrombosis in 5 (5%), petrositis
in 2 (2%), suppurative labyrinthitis in 1 (1%), and otitic hydrocephalus in
1 (1%).The total number of complications (N = 104) exceeds the number of patients
(N = 90) because some patients manifested concurrent complications.
MICROBIOLOGY
Microbiologic results of specimens taken from the middle ear or mastoid
are given in Table 1. Streptococcus pneumoniae was isolated in 16 cases, while resistant S pneumoniae was isolated in 10 cases. For the entire study
group, antibiotics were taken within 1 month of presentation by 53 patients
(59%). Within the subset of S pneumoniae isolates,
10 patients (63%) had taken antibiotics within the last month while 8 (80%)
had done so in the subset of resistant S pneumoniae
isolates.
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Table 1. Microbiologic Profile of Noncoalescent, Coalescent, and Total
Cases of Mastoiditis*
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In 11 cases of noncoalescent mastoiditis (22%), no culture material
was obtained. In these cases, intravenous antibiotics were given and no myringotomy
performed. The microbiologic profile of the remaining cases of noncoalescent
mastoiditis revealed 5 S pneumoniae isolates (13%).
Gram-positive cocci accounted for 24 isolates (60%). There were no cases of
either H influenzae or M catarrhalis. Resistant strains were recovered in 3 of 5 isolates of S pneumoniae, for a resistance rate of 60%.
In the coalescent mastoiditis subset, the microbiologic profile revealed
10 S pneumoniae isolates (42%) while gram-positive
cocci accounted for 16 (67%). There was only 1 case of H influenzae, which was ß-lactamase negative. Resistant strains
of S pneumoniae were recovered in 6 of 10 cases,
yielding a resistance rate of 60%. In cases of facial nerve paralysis, 7 cultures
revealed no growth (50%). There was 1 case of resistant S pneumoniae. Gram-positive cocci accounted for 4 (29%). The case of
suppurative labyrinthitis resulted from Staphylococcus aureus. Patients with petrositis, epidural abscess, or sigmoid sinus thrombosis
tended to have multiple complications. In 2 cases, no organism was isolated.
The remaining 9 cases were due to gram-positive cocci, and resistant S pneumoniae was recovered in 1 case.
TREATMENT
Noncoalescent mastoiditis was treated with intravenous antibiotics alone
or in combination with myringotomy and tubes in 46 cases (90%). Three cases
required incision and drainage of a subperiosteal abscess, and 2 cases required
mastoidectomy secondary to failure of initial therapy. Coalescent mastoiditis
was treated with cortical mastoidectomy in 22 patients (92%), canal wall–down
mastoidectomy in 1 patient with cholesteatoma, and mastoidectomy with facial
nerve decompression in 1 patient with evidence of both coalescence and facial
nerve paralysis.
Facial nerve paralysis was treated with intravenous antibiotics and
myringotomy with or without tubes in 10 cases (71%), whereas 4 patients (29%)
required mastoidectomy with facial nerve decompression. In those requiring
mastoidectomy, 3 patients presented with multiple complications (coalescent
mastoiditis, epidural abscess, subperiosteal abscess, or sigmoid sinus thrombosis)
and 1 patient failed to improve with intravenous antibiotic treatment and
myringotomy. There were 10 patients with multiple concurrent suppurative complications,
all of whom required mastoid surgery.
STATISTICAL ANALYSIS
The incidence of noncoalescent and coalescent mastoiditis increased
over the study period. The proportion of mastoiditis manifesting as coalescent
disease increased steadily over the study period from 29% of patients in group
1 (n = 5) to 31% in group 2 (n = 8) and 34% in group 3 (n = 11). The incidence
of coalescent disease increased to a greater extent than that of noncoalescent
disease toward the latter years of the study (Table 2).
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Table 2. Rising Incidence of Coalescent and Noncoalescent Mastoiditis
During the Study Period*
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Both the total number of patients presenting with suppurative complications
and those requiring surgical intervention increased over the study period.
Surgical intervention was more prevalent during the later years. Consequently,
the proportion of cases requiring surgical intervention increased over the
study period from 31% of patients in group 1 (n = 7) to 34% in group 2 (n
= 11) and 38% in group 3 (n = 14). The incidence of S pneumoniae and resistant S pneumoniae increased during
the study period. All but 2 cases in group 3 of pneumococcal-related disease
resulted from resistant strains. This yielded a resistance rate of 75% in
the final 2.5 years of the study (Table
3).
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Table 3. Rising Incidence of Total Suppurative Complications, Surgical
Therapy, andStreptococcus pneumoniae Resistance*
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Cases of suppurative complications, surgical intervention, and resistant S pneumoniae might be expected to rise as the population
served by a given hospital increases. To relate these increases to a measure
of the population as a whole, total otolaryngology admissions for the corresponding
time periods were obtained (group 1, 540 admissions; group 2, 420; and group
3, 636). To facilitate statistical analysis, rates of suppurative complications,
surgical intervention, and S pneumoniae resistance
(as proportions of total otolaryngology admissions) were established for the
given time intervals. A linear trend approaching statistical significance
was noted for increases in the rate of suppurative complications (P = .11), surgical intervention (P = .17),
and S pneumoniae resistance (P = .15).
COMMENT
Otitis media is one of the most commonly diagnosed pediatric illnesses.
Before modern antibiotics, the sequelae of AOM contributed to significant
morbidity and mortality. In the antibiotic era, however, suppurative complications
of AOM have declined dramatically.1 The emergence
of resistant bacteria has generated concern over the past 20 years. Some have
predicted a concomitant rise of suppurative complications and requisite need
for surgical intervention as a consequence of antimicrobial resistance.6
The breakdown of suppurative complications in this study revealed a
preponderance of acute mastoiditis, followed by facial paralysis, epidural
abscess, sigmoid sinus thrombosis, petrositis, suppurative labyrinthitis,
and otitic hydrocephalus. Epidural abscess, sigmoid sinus thrombosis, and
petrositis occurred in patients with multiple concurrent complications.
Acute mastoiditis is classified as either noncoalescent or coalescent,
representing a continuum of the disease process. Coalescent mastoiditis is
considered a more virulent process, manifesting as destruction of mastoid
trabeculae and/or cortex, and typically portends a worse prognosis.9 Cortical mastoidectomy is regarded as the standard
of care for coalescent mastoiditis. In this study, coalescent mastoiditis
was diagnosed in patients with bony erosion of the mastoid, which was demonstrated
radiographically by computed tomography and confirmed in all cases during
mastoidectomy.
In 46 patients with noncoalescent mastoiditis (90%), intravenous antibiotics
alone or in combination with myringotomy and tubes were effective. Five patients
required acute surgical intervention for subperiosteal abscess or failure
to improve under treatment with intravenous antibiotics. All cases of coalescent
mastoiditis underwent mastoid surgery. In total, 29 patients with acute mastoiditis
(39%) required surgery. In 1998, Goldstein et al10
documented their 15-year experience with intratemporal complications of AOM
in the Pittsburgh, Pa, area. Twenty-five percent of patients with acute mastoiditis
required surgery. Antonelli et al7 reported
that 34% of patients with mastoiditis required mastoidectomy for coalescence,
development of additional complications, or failure to improve under treatment
with intravenous antibiotics. The present study is notable for the higher
rate of surgical intervention for patients presenting with acute mastoiditis.
Isolated facial nerve paralysis resulting from AOM responded well to
intravenous antibiotics and myringotomy with or without tubes in most patients.
Despite poor long-term follow-up, all patients displayed significant improvement
prior to hospital discharge and, ultimately, most experienced excellent recovery
of facial function. Similar to other studies, mastoidectomy with facial nerve
decompression was performed infrequently, primarily in those with multiple
concurrent suppurative complications or those failing to improve after treatment
with parenteral antibiotics and myringotomy.10
All patients with multiple suppurative complications required mastoid
surgery. In the present series, factors dictating the need for mastoid surgery
were coalescent disease, multiple suppurative complications, and failure to
improve under treatment with intravenous antibiotics.
The incidence of acute mastoiditis and total suppurative complications
increased over the study period. The rise in coalescent mastoiditis outpaced
a similar rise in noncoalescent mastoiditis. Additionally, the percentage
of cases requiring surgical intervention increased over the study period.
This particular trend has not been documented in the literature.
Resistant S pneumoniae was isolated more frequently
over the last years of the study. All but 2 cases of pneumococcal-related
suppurative complications were attributable to resistant strains during the
final 2.5 years. For this group, resistant organisms were isolated in 75%
of patients. Local rates of S pneumoniae resistance
have been established at 50% to 60%.11 Our
study population was composed of patients with severe and sometimes refractory
sequelae of AOM; therefore, a higher prevalence of more virulent organisms
than found in general inpatients or outpatients was expected. The mean age
of the S pneumoniae population was significantly
younger than that observed for the total study group. Factors such as young
age, day care attendance, and antibiotic exposure are known risk factors for
pneumococcal disease.12-13
Gathering microbiologic data was hindered by several factors. First,
culture material was not obtained in a large number of patients with noncoalescent
mastoiditis. This occurred typically in those patients whose condition improved
rapidly under treatment with intravenous antibiotics. Therefore, myringotomy
and culture were not performed. Second, 90% of the specimens exhibiting no
growth occurred in those patients who received oral antibiotics just prior
to admission. Culture material yields diagnostic information vital to therapeutic
decision making in this time of high antibiotic resistance. Given that antibiotics
suppress bacterial growth, obtaining a specimen prior to implementing intravenous
antibiotic treatment is preferable and improves the diagnostic yield of the
laboratory tests. Because myringotomy with aspiration and subsequent culture
of middle ear contents is both diagnostic and therapeutic, all patients with
suppurative complications should benefit from this intervention.
Gram-positive organisms such as S pneumoniae, Staphylococcus species, and group A Streptococcus constituted most of the bacteria cultured from isolates
in this study. All cases manifesting multiple suppurative complications occurred
as a result of these organisms. The increased virulence of gram-positive cocci
compared with H influenzae and M catarrhalis is substantiated by the prevalence of these organisms
in suppurative complications of AOM.
In conclusion, the increasing incidence of resistant S pneumoniae seems to parallel the rising number of cases of acute
mastoiditis and other suppurative complications of AOM at our institution.
Mastoidectomy is necessary in the management of many of these infections,
possibly because of the increased virulence of the infectious process. Early
acquisition of middle ear cultures for laboratory evaluation is recommended
to assist in management decisions. Coalescence, concomitant suppurative complications,
and clinical regression dictate the need for timely surgical intervention.
AUTHOR INFORMATION
Accepted for publication November 8, 2001.
This study was presented at the American Society of Pediatric Otolaryngology
Meeting, Scottsdale, Ariz, May 11, 2001.
We thank William H. Frawley, PhD, for his assistance in the statistical
analysis of our data.
Corresponding author: Peter S. Roland, MD, Department of Otolaryngology–Head
and Neck Surgery, The University of Texas Southwestern Medical Center, 5323
Harry Hines Blvd, Dallas, TX (e-mail: peter.roland{at}mednet.swmed.edu).
From the Department of Otolaryngology–Head and Neck Surgery,
The University of Texas Southwestern Medical Center, Dallas.
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