algorithmic mastoiditis

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Algorithmicmanagementofpediatricacutemastoiditis

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International Journal of Pediatric Otorhinolaryngology xxx (2012) xxx–xxx

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PEDOT-6122; No. of Pages 6

Algorithmic management of pediatric acute mastoiditis§

Ioannis M. Psarommatis a,*, Charalampos Voudouris a, Konstantinos Douros b, Polyvios Giannakopoulos a,Theodoros Bairamis a, Charalampos Carabinos a

a ENT Department, ‘‘P. & A. Kyriakou’’ Children’s Hospital of Athens, Thivon & Levadias St, 11527-Goudi, Athens, Greeceb 3rd Department of Pediatrics, Athens University Medical School, University General Hospital ‘‘Attikon’’, 1 Rimini St, 12464 – Chaidari, Athens, Greece

A R T I C L E I N F O

Article history:

Received 11 December 2011

Received in revised form 11 February 2012

Accepted 13 February 2012

Available online xxx

Keywords:

Acute mastoiditis

Management

Children

A B S T R A C T

Objective: Today, no uniformly accepted diagnostic and therapeutic criteria have been established for the

management of pediatric acute mastoiditis. The aim of this study is determine the efficacy and safety of

an algorithmic approach for treating pediatric acute mastoiditis.

Methods: The medical records of all children (n = 167) with a diagnosis of AM admitted in our center

during the period 2002–2010 were retrospectively studied. Data concerning medical history,

symptomatology, laboratory and imaging findings, presence of complications, treatment methods

and final outcomes were reviewed and analyzed. Parenteral antibiotics and myringotomy were applied

to all children on the day of admission. Initial surgical approach also included drainage or simple

mastoidectomy for subperiosteal abscesses and simple mastoidectomy for children suffering from

intracranial complications. Finally, simple mastoidectomy was performed as a second line treatment in

children showing poor response to the initial conservative approach.

Results: All children were cured after a mean hospitalization of 9.8 days. The rate of intracranial

complications at admission was 6.5% and the overall rate of the use of mastoidectomy 42%. Following the

presented treatment scheme in all cases, no child developed additional complications while in-hospital

and under treatment or after discharge.

Conclusions: Although simple mastoidectomy represents the most reliable and effective surgical method

to treat acute mastoiditis, a more conservative approach consisting of adequate parenteral antibiotic

coverage and myringotomy can be safely adopted for all children suffering from uncomplicated acute

mastoiditis. Non-responsive cases should undergo simple mastoidectomy within 3–5 days in order to

avoid further in-hospital acquired complications. Simple mastoidectomy should also be performed in

every case of unsuccessful subperiosteal abscess drainage or presence of intracranial complications.

� 2012 Elsevier Ireland Ltd. All rights reserved.

Contents lists available at SciVerse ScienceDirect

International Journal of Pediatric Otorhinolaryngology

jo ur n al ho m ep ag e: ww w.els evier . c om / lo cat e/ i jp o r l

1. Introduction

Acute mastoiditis (AM) is the most common complication ofacute otitis media which mainly affects pediatric age with anestimated incidence between 1.2 and 4.2/100,000 children/year[1]. AM should be treated effectively and without delay becausesevere intratemporal and potentially lethal intracranial complica-tions can arise from further spreading of the disease.

Despite the extended bibliography relating to pediatric AM,there are still many areas of controversy. Up to this point nouniformly accepted diagnostic and therapeutic criteria have beenestablished. Concerning its management, simple mastoidectomy

§ Part of this work (years 2002–2009) was presented at 10th International

Congress of the E.S.P.O., 5–8 June 2010, Pamplona, Spain.

* Corresponding author at: 162 El. Venizelou Str, 13231-Petroupoli, Athens,

Greece. Tel.: +30 2105060696.

E-mail addresses: [email protected] (I.M. Psarommatis),

[email protected] (K. Douros).

Please cite this article in press as: I.M. Psarommatis, et al., AlgorithOtorhinolaryngol. (2012), doi:10.1016/j.ijporl.2012.02.042

0165-5876/$ – see front matter � 2012 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.ijporl.2012.02.042

has historically represented the standard surgical treatment ofacute mastoiditis [2]. However, currently the rates of use of simplemastoidectomy in treating pediatric AM show considerablevariations among reported series [3,4]. Besides, during the lastyears, several centers have adopted a rather conservativemanagement for AM and its accompanying complications [5–8].Even minor surgical interventions, like myringotomy, have beenquestioned, since parenteral antibiotics are considered sufficientfor the treatment of AM [9–11]. Such a conservative approach maybe successful for a considerable proportion of the cases but maynot be adequately safe for all patients. Development of intratem-poral and life-threatening intracranial complications or deteriora-tion of pre-existing ones has been reported in children undertreatment that were suffering from AM [12–15].

Although every case of AM may have its specific needs, itbecomes obvious that some basic directions must be set so as tomaximize treatment safety. In our institution – a tertiary carepediatric center – a considerable experience on the management ofAM has been gathered during the last decades. The aim of this

mic management of pediatric acute mastoiditis, Int. J. Pediatr.

http://dx.doi.org/10.1016/j.ijporl.2012.02.042

mailto:[email protected]

mailto:[email protected]


http://www.sciencedirect.com/science/journal/01655876


Fig. 1. Annual (above) and seasonal (bellow) distribution of cases (n = 155). No

significant change in the incidence during the study years has been noted.

Expectedly, monthly distribution shows a significantly lower incidence during the

summer season, from June to September (p = 0.0034).

I.M. Psarommatis et al. / International Journal of Pediatric Otorhinolaryngology xxx (2012) xxx–xxx2

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study is to evaluate the effectiveness and safety of the manage-ment of pediatric AM we employ in our department for more than15 years. An attempt is also made to develop an algorithmicapproach in order to formalize the treatment of this disorder.

2. Patients and methods

The medical records of all children (n = 167) admitted to ourdepartment with the diagnosis of AM between January 1st 2002and December 31st 2010 were retrospectively reviewed. AnInstitutional Scientific Board approved the review of the medicalcharts of children admitted to our center with the diagnosis ofacute mastoiditis for the period of the study.

Data concerning children’s age, gender, history of pre-admis-sion middle ear infections, clinical signs, treatment before and afteradmission, surgical, bacteriological and radiological findings andthe final outcome were manually collected and analyzed. Exclusioncriteria included the presence of chronic otitis media withcholesteatoma, otitis externa and any non-infectious etiology ofmastoiditis.

The diagnosis of AM was based on clinical signs and symptomsand the criteria applied were recent history/symptoms/signs ofacute otitis media accompanied by retroauricular inflammatorysigns (erythema/swelling/pain) and/or antero-inferior protrusionof the auricle.

Diagnostic imaging, in the form of computed tomographyscan (CT) and/or magnetic resonance imaging (MRI) and/ormagnetic resonance venography (MRV), was performed only inchildren with suspected intracranial complications, in recurrentAMs and in non-typical presentations of AM, when diagnosis wasin doubt.

All children were managed with intravenous (IV) antibioticsand wide-field myringotomy with or without ventilating tubeplacement within the first day of hospitalization. Myringotomywas also performed in cases presented with otorrhea at admission.Depending on the presence of further intratemporal or intracranialcomplications, initial surgical approach also included subperios-teal abscess drainage by incision or aspiration and simplemastoidectomy. Selecting between abscess drainage and mastoid-ectomy in children suffering from mastoid subperiosteal abscesswas at the discretion of the attendant ENT surgeon, since bothapproaches were used – and still are – during the years of thisstudy. However, the presence of an otogenic epidural and perisinusabscess or lateral sinus thrombosis was considered an indicationfor mastoidectomy in this series.

Blood tests, including white blood cell count (WBC) anddifferential, C-reactive protein (CRP) and erythrocyte sedimenta-tion rate (ESR), were performed in all cases. Pus specimens wereobtained from all middle ears during myringotomy and from mostmastoid cavities during mastoidectomy and sent for culture/sensitivity.

All children were closely followed daily while the decisive re-evaluation about the effectiveness of the applied therapeuticmeasures was taking place 2–3 days after admission. Initialmanagement was considered as successful or not on the basis ofboth clinical and laboratory criteria: progressive restoration ofauricular displacement, regression of retroauricular local signs,partial or complete recovery of the laboratory values of inflamma-tory markers and absence of fever. Cases with persistent clinicaland/or laboratory findings of AM required further surgicalintervention. Persisting otorrhea for 2–6 days after myringotomyand initiation of antibiotic therapy was not considered a definitecriterion for mastoidectomy if the rest of the clinical and laboratoryfindings had been improving or had returned to normal.Nonetheless, long-lasting otorrhea (�7 days) was considered apositive criterion for performing mastoidectomy.


2.1. Statistical analysis

Time to discharge was depicted with a Kaplan–Meier plot. Weused Cox proportional hazards models and tried to identifyindependent factors (age, sex, nonspecific inflammatory param-eters, such as WBC, CRP, and ESR on admission, and kind of isolatedbacteria) associated with time to discharge, since the latter may beconsidered an indirect marker of disease severity.

3. Results

3.1. Epidemiology – clinical presentation

From the total of 167 children, 5 children (3%) withcholesteatoma and 4 children (2.5%) suffering from non-infectiouspathology (two cases of hystiocytosis X and two with acuteleukemia) were excluded from the review. Two children with otitisexterna, who initially were misdiagnosed as suffering from AM andone cochlear implant recipient, were also excluded from the study.The remaining 155 children consisted of 106 male and 49 female(ratio 2.2:1, p = 0.001) with a mean age of 36.7 months (range 2–130 months, median 30 months). Yearly and seasonal distributionof cases is shown in Fig. 1.

A complete personal history was available for 126 children andthe following information was obtained. Positive anamnesis for arecent episode of AOM prior to AM was present in 73% of cases. Themean duration of AOM symptoms before admission was 6.1 days(range 1–17 days) and 68% of children had been treated for AOMwith oral antibiotics in an outpatient basis. The most frequentlyprescribed oral antibiotics were low and high dose amoxicillin (24/126), amoxicillin/clavulanate (17/126), 2nd generation cephalos-porins (35/126) and clarithromycin (16/126). The average timefrom the onset of AM until admission was 1½ days (ranging from acouple of hours to five days).



Fig. 2. Presenting symptoms and signs of 155 patients with acute mastoiditis.

I.M. Psarommatis et al. / International Journal of Pediatric Otorhinolaryngology xxx (2012) xxx–xxx 3

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Presenting symptoms and signs for the whole population areshown in Fig. 2. All children had some evidence of post-auricularinflammation (redness and/or swelling and/or tenderness) andmost of them presented with auricular protrusion. Twenty threecases showed an active ipsilateral otorrhea at presentation.Fourteen children were presented with neurologic symptomssuggesting CNS involvement and 4 with facial nerve palsy. Theaverage value for WBC, CRP and ESR on admission was 18,350/ml(range 4900–35,400), 103 mg/dl (range 3–308) and 86.9 mm/h(range 10–152), respectively.

Computed tomography scan was performed in 18, MRI in 7, andCT plus MRI/MRV in 5 children. Imaging studies revealed 9 childrenwith intracranial complications, three of whom showed multifocalintracranial lesions. Epidural abscess was revealed in 3, brainabscess in 1 and sigmoid sinus thrombosis in 2 children. Cases withmultiple intracranial complications involved brain abscess plusepidural abscess (n = 1), brain abscess plus perisinus abscess/sigmoid sinus thrombosis (n = 1) and epidural abscess plussigmoid sinus thrombosis (n = 1, Fig. 3). Additionally, in one childwho had not been subjected to any imaging evaluation, an epiduralabscess was incidentally disclosed during simple mastoidectomy.Intratemporal complications included 34 subperiosteal abscesses(one of them was associated with epidural abscess) and 4 caseswith facial nerve paralysis.

3.2. Medical treatment – microbiology

Empiric intravenous antibiotics were initiated in all patientsshortly after admission. One hundred forty nine children received acombination of antibiotics and only 6 cases were treated withmonotherapy. Combination therapy consisted of a third generationcephalosporin (cefotaxime or ceftriaxone) and clindamycin. The3rd generation cephalosporin was replaced by aztreonam in threepenicillin allergic children and the combination amoxicillin/clavulanate plus clindamycin was used in two children. Brainabscesses were initially treated with ceftriaxone plus vancomycinplus metronidazole and steroids. Monotherapy included amoxicil-lin/clavulanate (n = 3), ampicillin/sulbactam (n = 2) and 2ndgeneration cephalosporin (n = 1).

Antipyretics and analgesics were given on an individual basis.The most common bacteria recovered from pus specimens

collected during myringotomy were Streptococcus pneumoniae

(40.6%), Staphylococcus coagulase negative (16.1%), Streptococcus

pyogenes (10.3%), Haemophilus influenzae (9%), anaerobes (5.8%)


and Staphylococcus aureus (5.2%). Mixed infections were found in 8cases while no microorganisms were isolated from 20 specimens(13%).

Modification of the initial empiric antibiotic regimen wasdeemed to be necessary in four cases due to in vitro bacterialresistance revealed in the sensitivity tests.

All children were given oral antibiotics for another 7–10 daysafter discharge. Children with intracranial complications received�15 days of oral antibiotic therapy.

Anticoagulation therapy was given in 2 (out of 4) cases ofsigmoid sinus thrombosis.

3.3. Surgical treatment

Surgical treatment involved wide-field myringotomy (inferior–posterior quadrat of the tympanic membrane) in all children,including those presented with otorrhea, on the day of admission.Ventilating tubes were inserted in 23 cases.

Initial surgical treatment in children with SA also includedsimple mastoidectomy (n = 12) or abscess drainage (n = 21), usingincision or aspiration. From the latter subgroup, 12 children werecured without any supplementary treatment while 9 requiredmastoidectomy in the end (Fig. 4). Bony erosion responsible forabscess formation was observed in most children during mastoid-ectomy (19 out of 22).

Most cases (9/10) suffering from an intracranial complicationwere subjected to myringotomy and simple mastoidectomy on theday of admission, through which epidural and perisinus puscollections were accessed and drained. Only in one case withsevere CNS involvement was the initial surgical approach delayedand performed on the 3rd in-hospital day. Sigmoid sinus wascompletely uncovered in all (n = 4) children with sigmoid sinuspathology and punctured in 3 cases. The presence of a neurosurgi-cal team was requested in seven cases with intracranialcomplications. However, neurosurgical intervention was notnecessary except in the cases of brain abscesses (n = 3).

Finally, simple mastoidectomy was performed in 34 cases ofuncomplicated AM who showed a poor response to initialapproach. This second surgical session took place between 3rdand 5th day of hospitalization.

Overall mastoidectomy rate for the whole population (n = 155)reached 42% while mastoidectomy rate for cases of uncomplicatedAM was 30.3%. No child included in this study was subjected torevision simple mastoidectomy or radical/modified radical mas-toidectomy.

3.4. Final outcomes

All children were cured and discharged after an averagehospitalization of 9.8 days (range 4–29 days, median 9 days).

A detailed illustration of hospital length of stay is depicted inthe Kaplan–Meier plot of estimated time to discharge (Fig. 5). Noneof the examined variables (age, sex, WBC, CRP, and ESR onadmission, and kind of isolated bacteria) were predictive of thetime of hospitalization.

Except for those present on admission, no additional intracra-nial or intratemporal complications related to further spread of thedisease developed in this series during hospitalization. Likewise,after a regular postoperative follow-up of all children for at least 5months, no long-term intratemporal or intracranial complications,sequelae or cases of ‘‘masked’’ mastoiditis were noted. Theobserved small number of in-hospital acquired complicationswere directly related to mastoidectomy and consisted of threeminor and one moderate surgical trauma infections and twopostoperative facial nerve palsies (6/65 or 9.2%). All of them weremanaged conservatively with success.



Fig. 3. Large bi-lobed epidural abscess (A, hollow arrow), pushing the ipsilateral sigmoid infero-medially (A, white long arrow) on brain contrast-MRI at presentation. The

enhanced and thickened overlying dura can also be visualized (A, white short arrow). At the same time, on MR phlebography complete occlusion of right sigmoid sinus can be

seen (B, double arrow). On pre-discharge follow-up imaging study, 20 days after simple mastoidectomy, hyperintense (inflammatory) material is still filling the right mastoid

cavity (C, arrow) while partial recanalization of the right sigmoid can be observed (D, double arrow).


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It is noteworthy that no child showed a temporary improve-ment 3–5 days after the initial therapeutic approach and a re-worsening thereafter.

Five children suffered a second episode of uncomplicated AMwithin 8–16 months after the first episode, showing an asymp-tomatic in-between period. Three of them belonged to initiallymastoidectomized patients. All five recurrences were furthermanaged following the same protocol. All cases of lateral sinusthrombosis displayed evidence of complete recanalization onfollow-up magnetic resonance venography.

None of our patients was managed on an outpatient basis. Therewere no deaths in this series.

4. Discussion

Depending on the presentation, extent of the disease, presenceof further complications and surgeons’ personal experience andattitude, the management of pediatric AM may greatly vary among


different pediatric centers. One of the most characteristicdifferences represents the contradictory rates of the use ofmastoidectomy for the treatment of AM, which fluctuate between9% and 88% [3,4,16]. Currently, many researchers seem to adopt aconservative approach to pediatric mastoiditis which consists ofantibiotics alone or antibiotics plus myringotomy when a poorresponse to antibiotics is observed [5,6,8–11].

It is true that many patients suffering from uncomplicated AMwill respond well to a purely conservative approach (antibioticsonly) but, unfortunately, we are still unable to reliably anticipatewhich cases will show a poor response. Furthermore, we cannotpredict which cases will develop fatal intracranial complications.The latter may vary greatly between 1 and 72.7% of AM cases andthey are usually present on admission but some of them may bedeveloped during hospitalization, while the patients are undertreatment [8,11–20]. In a recent large multicenter study thecomplication rate of AM on admission was 22%, among which 7.2%intracranial [12]. In the same study, an alarming rate of in-hospital



Fig. 4. Graphic representation of the patients/methods/results of the study. AM,

acute mastoiditis; CI, cochlear implant; VT, ventilating tubes; IV, intravenous; SA,

subperiosteal abscess (*children with intracranial complications had a longer

hospitalization).

I.M. Psarommatis et al. / International Journal of Pediatric Otorhinolaryngology xxx (2012) xxx–xxx 5

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developed intracranial and intratemporal complications (8.5%) hasbeen reported. Logically, the use of more effective and reliablemethods of treatment should be sought.

This series differs from several reported ones in that nocomplications related to further extent of the disease afterinitiation of the in-hospital treatment have been observed withinan extended time period (9 years). Additionally, a close and longterm postoperative follow-up failed to identify cases with long-term sequelae or ‘‘masked’’ mastoiditis. These reassuring findingshave driven us to conclude that the applied therapeutic measureswere toward the right direction, safe and effective. A straightfor-ward algorithmic approach was followed in every case, whosemain steps can be summarized as follows: all children underwentat least one surgical procedure for pus pressure relief and receiveda combination of parenteral antibiotics on the day of admission. Inthe case of good clinical and laboratory response after 2–3 days, nofurther surgical treatment was applied and the child wasdischarged when he/she was completely cured, usually in 8–10days. Uncomplicated mastoidites and drained mastoid abscesseswith poor response to initial approach were further subjected tosimple mastoidectomy within 3–5 days after admission. Clinicalsuspicion of an intracranial complication was always followed by

Fig. 5. Kaplan–Meier plot of estimated time to discharge for the population of the

study.


proper imaging studies and, when positive, myringotomy plussimple mastoidectomy in clinically and neurologically stablechildren were applied (Fig. 6).

It is the authors’ belief that initial surgical approach to pediatricAM plays a vital role in the final outcomes. In this series the firstsurgical step consisted of myringotomy alone for the cases ofuncomplicated AM (in 112/155 children or 72.3%), myringotomyplus simple mastoidectomy or abscess drainage for mastoidsubperiosteal abscesses (in 33/155 children or 21.3%) andmyringotomy plus simple mastoidectomy for AM associated withextradural or lateral sinus/perisinus pathology (in 10/155 childrenor 6.4%). Although a minor surgical intervention, early myringot-omy seems to represent a key therapeutic action, which helps inpreventing further major operations or complications. Seventypercent of our children (78/112) who were subjected tomyringotomy only were cured without additional surgicalmeasures. We found myringotomy useful even in children withotorrhea at the time of presentation. In these cases a wider openingof the tympanic membrane would offer better drainage, pussampling and a thorough ear assessment for excluding otherpathologies. Ventilation tubes were inserted in cases where apositive previous history of middle ear problems was present.

Repeat myringotomies or abscess drainages were not employedin this study. Instead, failure of the initial surgical approach forced usto make use of simple mastoidectomy – as the standard method oftreating AM – within 3–5 days. In this way our patients remainedexposed to an inadequately controlled severe infection only for ashort time period and under the safeguard of broad spectrumantibiotics. Whenever used, simple mastoidectomy proved anextremely effective method for treating AM and its complications,yielding the maximum success rate. In our series, none of the casesrequired a revision simple mastoidectomy. Additionally, no need forconverting it to a radical/modified radical mastoidectomy wasnoted, even in cases with contracted and sclerotic mastoid bones.Subperiosteal, epidural and perisinus abscesses can also be safelydrained through this approach. No major complications related tosimple mastoidectomy have been noted in our population while thefew minor complications were treated conservatively.

The choice of the antibiotics to treat pediatric AM mightrepresent another reason for the presented favorable clinicaloutcomes. Although effective in most cases, monotherapy alwaysleaves open some possibility of microbial growth while thepatients remain exposed to the toxicity of an infectivemicroorganism. Practically all children in our series (149/155or 96.2%) received a combination of IV antibiotics a few hoursafter admission which, theoretically, almost totally covered thewhole spectrum of microorganisms known to be involved in AM.To our experience and based on the current level of knowledgeon the subject, combined antibiotic therapy (cefotaxime orceftriaxone + clindamycin) is a safer option for the patients thanmonotherapy, without necessarily having more adverse effectsor a higher cost.

Finally, the duration of hospitalization may also play animportant role, affecting the final outcomes. In some pediatriccenters a very short duration of hospitalization has been employed,ranging between 1 or 2 and >15 days [5,7,15,21,22]. The optimal in-hospital therapy for the disease has not yet been specified. However,in our opinion an extremely short hospitalization (1 or 2 days) seemsinadequate for a safe management of the disease. This is particularlytrue in cases of young infants suffering from complicated AM andsubjected to mastoidectomy. Furthermore, one can hardly make areliable prognosis for the progression of the disease after only 1 dayof treatment, because no sufficient time for substantial change of thepresenting symptomatology is offered, even if the proper initialtherapeutic approach has been used. For these reasons we neverused such a short duration of hospitalization on our patients. The



Fig. 6. Recommended algorithmic management to pediatric acute mastoiditis.

Notes: (1) with/without ventilating tubes; (2) in clinically and neurologically stable

children; (3) using clinical and laboratory criteria; (4) children with intracranial

complications may need longer in-hospital stay.


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mean duration of hospitalization for the whole population of thisstudy was 9.8 days, which is higher than that reported by many otherresearchers. It is our standard practice to discharge the children onlyafter a clean, non-inflamed postauricular surgical trauma and a dryand translucent tympanic membrane is restored. Adherence to sucha practice may possibly lengthen the hospital stay of the patients butit may also protect them from some unpleasant complications. Only3 cases who presented with the clinical picture of AM with periostitishad 4 days of hospital stay, while a hospitalization of �14 days wasnecessary in AMs associated with intracranial complication.

In acute infections, the nonspecific inflammatory parametersmeasure the severity of the acute phase reaction and reflect tissuedamage caused by microbes. Nevertheless, we failed to show thatWBC, CRP, or ESR on admission are related to the length of hospitalstay. This may happen because length of stay is related mainly tothe spread of the disease and especially to the intracranial orintratemporal complications and not to the severity of inflamma-tion per se. The kind of isolated bacteria was also not associatedwith the length of stay, probably because all bacteria weresensitive to the administered IV antibiotics.

Overall, most children of the study (n = 78 + 12 = 90 or 58%,Fig. 4) were successfully treated by applying a conservative initialapproach, consisting of antibiotics plus myringotomy or abscessdrainage while in the remaining 42% a more aggressive surgicaltreatment, in the form of simple mastoidectomy, was performed.The relatively high rate of simple mastoidectomies probablyreflects our efforts toward the direction of safety rather than otherstatistical results. Using the presented algorithmic approach, bothtreatment schemes (conservative or aggressive) were found to bemaximally safe, given that no mortality, in-hospital developedmorbidity and long-term sequelae were noted in this series.

5. Conclusions

The question of ‘‘how much conservative is safe?’’ in thetreatment of pediatric AM must be answered with randomizedprospective clinical studies. Till then, the less risky managementmust be applied because the development of its life-threateningcomplications should not be an option.


In our population we found that simple mastoidectomy is themost reliable and effective surgical option for AM with/withoutassociated complications. However, a more conservative approachconsisting of adequate parenteral antibiotic coverage and myr-ingotomy could be safely adopted for all children suffering fromuncomplicated AM. A similar initial treatment option has also beensuggested by other researchers [18,23,24]. Non-responsive casesshould undergo a simple mastoidectomy within 3–5 days in orderto avoid further in-hospital acquired complications. Simplemastoidectomy should also be performed in every case ofunsuccessful subperiosteal abscess drainage or presence ofintracranial complications.

Conflict of interest

The authors declare that they have no conflict of interest.

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