Protocolo diagnóstico y terapéutico de mastoiditis aguda en pacientes pediátricos

Abstract

Introduction and objective: with the word mastoiditis we mean suppurative infection of mastoid cells, being the most frequent complication of acute otitis media, but that sometimes is the main manifestation of it. There is no unified consensus on the diagnosis, medical-surgical treatment and follow-up of this pathology. Our objective has been to establish a diagnostic and therapeutic protocol for acute mastoiditis in children, between the otorhinolaryngology and pediatric services in a tertiary care hospital.

Method: a review of the literature available to date and of the recommendations of the national and international scientific societies of pediatrics and otorhinolaryngology has been made.

Results: the clinical diagnosis is established by the presence of 3 of the 4 following signs: protrusion of the auricle, postauricular erythema, painful postauricular palpation, and postauricular swelling with or without fluctuance. If this diagnosis is made, blood tests will be requested and a bacterial culture will be performed if there is otorrhea. The patient will be admitted by the Pediatric Service and there will be a joint follow-up with the Otorhinolaryngology Service, and under sedation in the operating room, a myringotomy will be performed, with ear tube insertion, checking both ears. If there is suspicion of a subperiosteal abscess without another complication, it will be confirmed by puncture and will be drained in the same surgery. Treatment will be parenteral, prioritizing amoxicillin-clavulanate or cefuroxime, and as an alternative ceftriaxone/cefotaxime, using quinolone (levofloxacin) in allergic patients. In very selected cases, outpatient treatment may be done. We will request computed tomography, when there is no improvement after 48 hours of treatment, if the diagnosis is in doubt or with a possible extracranial complication (except in the case of subperiosteal abscess, where ultrasound can be performed); also, if we suspect intracranial complication, severe disease or toxic appearance, recurrent mastoiditis or cholesteatoma. We will request magnetic resonance in case of sensorineural hearing loss, facial paralysis, vertigo or vascular complications.

Discussion: currently, acute mastoiditis is an infrequent complication but it is associated with high morbidity and mortality. The clinical spectrum varies from the absence of symptoms and spontaneous resolution, to progressive disease with serious complications of nearby structures. The unification of diagnostic and therapeutic criteria among the different specialists allows a more adequate management of these patients, avoiding interventions and complementary tests that increase costs without providing greater benefit.

Conclusions: We believe that in the absence of single criteria, it is convenient to develop and implement a multidisciplinary diagnostic and therapeutic protocol for pediatric patients with acute mastoiditis, in order to more accurately assess its effectiveness and the risk of possible complications.