ENT USA - Ear, Nose and Throat Acute Coalescent Mastoiditis
Acute Coalescent Mastoiditis
Acute Coalescent Mastoiditis
  
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Acute coalescent mastoiditis
is a rare infection of the mastoid bony process (the bone behind the ear).    It is a severe infection which can spread to the brain causing disability or death.  It is usually caused by Streptococcal Pneumonia.  This bacteria is becoming more and more resistant to antibiotics.  The mechanism of penicillin resistance in this organism is by producing a penicillin binding protein and not by producing penicillinase (an enzyme which breaks down penicillin).  Thus, this organism will also be resistant to Amoxcillin/Clavulanate and Amoxcillin/Sulbactam.  The bacterial resistance is transmitted on a plasmid between the bacteria.  A single plasmid can carry the genes for resistance to both the penicillin and macrolide antibiotics. 

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  Before the era of antibiotics, this disease was very common and the treatment was with surgery.  A mastoidectomy operation was routine and was one of the most frequent operations at medical centers.  With the advent of antibiotics, the cases of acute coalescent mastoiditis declined dramatically.  However, when it occurred a complete mastoidectomy was performed.  With the newer stronger generation of antibiotics this disease was treated with a wide myringotomy ( surgically creating a large hole in the eardrum ) and  IV antibiotics, reserving mastoidectomy for those cases with a cholesteatoma, intracranial complications, vertigo, facial weakness or a sub-periosteal abscess.  Several articles have reported successful treatments with the local drainage of the subperiosteal abscess, IV antibiotics and a wide myringotomy, and NOT initially performing a mastoidectomy.        View Abstract    View Abstract     View Abstract

MRI (Magnetic Resonance Imaging) scans may detect a fluid signal in the mastoid sinus on T2 studies.  This is often described as "mastoiditis" by the radiologist.   However, in the absence of pain, fever and an abnormal ear exam this finding should not considered diagnostic of mastoiditis and is usually considered a normal variant.      View Abstract
 
The case presented below is a child which developed
acute coalescent mastoiditis with a sub-periosteal abscess.  Almost all cases develop from patient non-compliance or an untreated acute otitis media The child had been treated with multiple antibiotics including Augmentin ( Amoxcillin / Clavulanate  ), none of which eradicated the infection.  Bacterial resistance was suspected and it was elected to perform complete surgical drainage by performing a mastoidectomy
    

lateral_child_coallescent_mastoiditis.jpg (25000 bytes)ap_child_coallescent_mastoiditis.jpg (20332 bytes)Preoperative Appearance of the Child.  Note the protrusion of the auricle from a sub-periosteal abscess.  The abscess at the time of surgery was found to contain 6 cc of pus and had direct communication with the mastoid air cells through a small bony dehiscence. 

He cultured Streptococcal Pneumonia resistant to penicillin, trimethoprim/sulfamethoxazole, erythromycin and intermediate susceptible to Ceftriaxone. 

 

Acute Otitis Media.jpg (9620 bytes)Examination of the child's ear showed an acute otitis media.  The posterior-superior canal was not collapsed, as is sometimes seen in this disease.

 

ct_scan_mastoid.jpg (17591 bytes)A CT-Scan was done which showed coalescence of the mastoid air cells.

 
 
coallescent cell.JPG (15206 bytes)During the operation, the
mastoid cortex was removed, exposing a large area of coalescent air cells. 
 
complete mastoidectomy graphic.jpg (16130 bytes)A complete mastoidectomy was performed.  Most of the bone was osteotic and soft, allowing removal with a curette.  Other areas had to be removed with a drill.  A Penrose drain was placed and the patient was started on IV Antibiotics, Vancomycin and Cefuroximine.     (The picture to the right is taken at 1/2 the magnification of the above picture.  The black outlined area represents the area of initial bone removal shown in the picture above.)
    
   
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