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Background Acute mastoiditis (AM) is the most common complication of acute otitis media (AOM) and could lead to serious complications if not diagnosed early and treated appropriately. Nowadays, there is no definitive consensus about the diagnostic algorithm and the optimal therapeutic management for patients with AM. The purpose of this study is to analyze the management of children admitted for AM and complicated AM (CAM) in a referral children’s hospital, evaluating differences in clinical presentation and management to outline a diagnostic and therapeutic pathway. Moreover, the incidence over time was assessed. Methods Retrospective study of children admitted for AM at Meyer University Hospital– IRCCS, Florence from January 2016 to December 2023. Results Eighty-five patients were included in the study (60% male, median age 4 years), the microbiological examinations were carried out in 68% of them. The most frequent isolated pathogens were Pseudomonas aeruginosa in AM and Streptococcus pyogenes in CAM. Seventeen patients developed a CAM. An elevated CRP value is associated with an increased risk of CAM ( p  = 0.043). Management of patients with AM was mainly medical with intravenous antibiotics. Surgical intervention was required only in one case (1 out of 68). In contrast, surgical intervention was required in 76% of CAM cases (13 out of 17). The most common procedure was mastoidectomy combined to abscess drainage, according to the predominance of this complication in our study group. Only one patient had a recurrence leading to a second surgery. No significant statistical correlation was found between the occurrence of complications and younger age, personal history of otitis or leukocyte count. A significant increase in AM case was found during the study period. Conclusions AM and CAM are infrequent but potentially life-threatening complications of AOM. A marked rise in AM cases was observed in 2023, likely due to the lifting of pandemic restrictions. A heterogeneous management of mastoiditis was observed, even within a single center. Elevated CRP levels are the only identified parameter associated with the complicated form. Pediatricians should be aware of the importance of a prompt diagnosis and guidelines should be developed to support effective management.

Acute mastoiditis remains the commonest intratemporal complication of otitis media in the paediatric population. There has been a lack of consensus regarding the diagnosis and management of acute mastoiditis, resulting in considerable disparity in conservative and surgical management. To review the current literature, proposing recommendations for the management of paediatric acute mastoiditis and appraising the treatment outcomes. A systematic review was conducted using PubMed, Web of Science and Cochrane Library databases. Twenty-one studies were included, with a total of 564 patients. Cure rates of medical treatment, conservative surgery and mastoidectomy were 95.9 per cent, 96.3 per cent and 89.1 per cent, respectively. Mastoidectomy may be the most definitive treatment available; however, reviewed data suggest that conservative treatment alone has high efficacy as first-line treatment in uncomplicated cases of acute mastoiditis, and conservative therapy may be an appropriate first-line management when treating acute mastoiditis.

Acute mastoiditis is a serious condition that carries with it a high rate of morbidity and mortality. This review highlights the pearls and pitfalls of mastoiditis, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence. Acute mastoiditis most commonly affects pediatric patients and is a suppurative infection of the mastoid air cells. It is often associated with otitis media, and common bacteria include Streptococcus and Staphylococcus. History and examination may reveal tympanic membrane erythema, pinna protrusion, postauricular erythema, mastoid tenderness with palpation, external canal swelling, otorrhea, fever, and malaise. The disease should be suspected in those who fail treatment for otitis media and those who demonstrate the aforementioned abnormalities on examination and systemic symptoms. Laboratory analysis may reveal evidence of systemic inflammation, but a normal white blood cell count and other inflammatory markers should not be used to exclude the diagnosis. Computed tomography (CT) of the temporal bones with intravenous contrast is the recommended imaging modality if the clinician is unsure of the diagnosis. CT may also demonstrate complications. Treatment includes antibiotics such as ampicillin-sulbactam or ceftriaxone as well as otolaryngology consultation. Complications may include subperiosteal and intracranial abscess, deep neck abscess, facial nerve palsy, meningitis/encephalitis, venous sinus thrombosis, and seizures. An understanding of acute mastoiditis can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Among acute mastoiditis (AM) complications, cerebral venous sinus thrombosis (CVST) is particularly severe, leading to increased intracranial pressure and potential neurological sequelae. Predicting the development of such complications is challenging. The aims of the present study were to evaluate the incidence, clinical characteristics, and risk factors for the development of CVST in AM. A retrospective study was conducted on children hospitalized with AM at the Meyer Children’s Hospital between 2016 and 2024. Patients were divided into two groups: those with CVST (group A) and those without (group B), comparing demographic, clinical, and laboratory data. CVST was diagnosed using computed tomography (CT) and cerebral magnetic resonance angiography (MRA). To identify predictors of CVST complications, univariate and bivariate binary regression models were used. Out of 100 patients with AM, 15 (15%) developed CVST. Patients with CVST more frequently presented with fever, neurological symptoms (headache, vomiting), elevated CRP, and white blood cell counts compared to those who did not ( p  < 0.001, p  < 0.001, p  < 0.001, and p  = 0.001, respectively). Streptococcus pyogenes and Streptococcus pneumoniae were more commonly encountered in patients with thrombotic complications ( p  = 0.024 and p  = 0.05). Multivariate regression identified white blood cell (WBC) count and elevated C-reactive protein (CRP) as independent predictors of CVST in AM patients (OR: 1.14, 95% CI: 1.03–1.26, and OR: 1.10, 95% CI 1.00–1.21, p  = 0.010 and p  = 0.049, respectively). Conclusions : CVST is a frequent and serious complication of AM. Neurological symptoms and systemic inflammation (WBC count and CRP) are predictive indicators of CVST. Further studies are needed to develop risk algorithms for early diagnosis and to reduce sequelae. What is known: • Cerebral venous sinus thrombosis (CVST) are severe complications of acute mastoiditis, potentially leading to neurologic sequelae What is new: • An elevated inflammatory burden, namely a high C-reactive protein level and white blood cell count predict thrombotic complications in children with acute mastoiditis

BACKGROUND: Acute mastoiditis (AM), a complication of acute otitis media, remains a concern despite medical advancements and often leads to severe complications such as cerebral sinus vein thrombosis (CSVT). This study aimed to characterize the clinical, microbiological, and hemato-logical aspects of CSVT secondary to AM in children while assessing the necessity of thrombophilia evaluation in these patients. METHODS: A retrospective analysis was conducted on pediatric patients with CSVT secondary to AM between January 2015 and December 2022. This study examined clinical data, laboratory and microbiological results, imaging studies, treatment approaches, and patient outcomes. RESULTS: Seventeen pediatric patients with a mean age of 3 years were included in this study. Most patients were female (76.5%) and of Jewish ethnicity (82.4%). Group A Streptococcus is the primary pathogen responsible for this condition. The treatment plan involved the administration of intravenous antibiotics and surgical intervention, including cortical mastoidectomy and ventilation tube insertion. Additionally, anticoagulation therapy with Clexane[R] was initiated and continued for at least 3 months post event. Follow-up imaging revealed recanalization in most cases within an average of 3 months. Hematologic follow-up revealed no recurrent thrombotic events and low thrombophilia incidence. CONCLUSION: Cerebral sinus vein thrombosis following AM is a provoked thrombotic event effectively managed with Clexane[R]. Thrombophilia evaluation may be reserved for patients with a high suspicion of underlying hematological conditions. Follow-up imaging within 3 months post event may be premature. KEYWORDS: Acute mastoiditis, anticoagulation therapy, cerebral sinus vein thrombosis, thrombophilia

Objective To determine whether the incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome is higher in general practices that prescribe fewer antibiotics for self limiting respiratory tract infections (RTIs).Design Cohort study.Setting 610 UK general practices from the UK Clinical Practice Research Datalink.Participants Registered patients with 45.5 million person years of follow-up from 2005 to 2014.Exposures Standardised proportion of RTI consultations with antibiotics prescribed for each general practice, and rate of antibiotic prescriptions for RTIs per 1000 registered patients.Main outcome measures Incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome, adjusting for age group, sex, region, deprivation fifth, RTI consultation rate, and general practice.Results From 2005 to 2014 the proportion of RTI consultations with antibiotics prescribed decreased from 53.9% to 50.5% in men and from 54.5% to 51.5% in women. From 2005 to 2014, new episodes of meningitis, mastoiditis, and peritonsillar abscess decreased annually by 5.3%, 4.6%, and 1.0%, respectively, whereas new episodes of pneumonia increased by 0.4%. Age and sex standardised incidences for pneumonia and peritonsillar abscess were higher for practices in the lowest fourth of antibiotic prescribing compared with the highest fourth. The adjusted relative risk increases for a 10% reduction in antibiotic prescribing were 12.8% (95% confidence interval 7.8% to 17.5%, P<0.001) for pneumonia and 9.9% (5.6% to 14.0%, P<0.001) for peritonsillar abscess. If a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then it might observe 1.1 (95% confidence interval 0.6 to 1.5) more cases of pneumonia each year and 0.9 (0.5 to 1.3) more cases of peritonsillar abscess each decade. Mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome were similar in frequency at low prescribing and high prescribing practices.Conclusions General practices that adopt a policy to reduce antibiotic prescribing for RTIs might expect a slight increase in the incidence of treatable pneumonia and peritonsillar abscess. No increase is likely in mastoiditis, empyema, bacterial meningitis, intracranial abscess, or Lemierre’s syndrome. Even a substantial reduction in antibiotic prescribing was predicted to be associated with only a small increase in numbers of cases observed overall, but caution might be required in subgroups at higher risk of pneumonia.

Mycoplasma pneumoniae, a frequent respiratory pathogen, can cause neurological disease manifestations. We here present a case of M. pneumoniae as cause of meningitis and occurrence of an intracranial abscess as a complication of mastoiditis with septic cerebral venous sinus thrombosis in a patient with multiple sclerosis on anti-CD20 therapy.

: Acute mastoiditis is the most frequent suppurative complication of acute otitis media in children. AM can lead to both extracranial complications and intracranial complications. Recent studies suggest an increase in cases after the COVID-19 pandemic. : To compare the epidemiological and clinical characteristics of pediatric patients diagnosed with acute mastoiditis admitted to Santobono-Pausilipon Children's Hospital before and after COVID-19. : We conducted a retrospective study including all patients aged 0-16 years with AM admitted to our hospital between January 2017 and December 2024. Patients were stratified into three groups: pre-COVID-19: 1 January 2017-28 February 2020; COVID-19: 1 March 2020-31 December 2021; and post-COVID-19: 1 January 2022-31 December 2024. Demographic data, clinical presentations, complications, laboratory findings, and treatment modalities were analyzed and compared between groups. : A total of 276 children (153 males and 123 females; median age: 49 months, age range: 1-177 months) were included. Hospital admissions for AM increased in the post-COVID-19 period, reaching more than a threefold increase in 2024 compared with the pre-COVID-19 years. Similar to the overall number of AM cases, the absolute number of complications, especially IC, such as thrombosis and empyema, increased. The rate of surgical procedures increased during the post-COVID-19 period, with an overall increase of 88.5%. Both the duration of antibiotic therapy and hospital stay were significantly longer in the post-COVID-19 period. : The COVID-19 pandemic has been associated with epidemiological and clinical changes in pediatric AM patients. These findings highlight the need for effective preventive strategies, including enhanced vaccination coverage and the promotion of early diagnosis. Additionally, implementing standardized clinical protocols could support more efficient and consistent management, reducing hospital stays and recurrence rates.

Background Central nervous system (CNS) infections caused by Actinomyces spp . including brain abscess, actinomycoma, subdural empyema and epidural abscess are well described, however reports of Actinomyces-associated meningitis are scarcely reported. Case report We present the case of a 43-year-old Hungarian male patient with poor socioeconomic status who developed acute bacterial meningitis caused by Actinomyces turicensis originating from the left side mastoiditis. The bacterial cultures of both cerebrospinal fluid (CSF) and purulent discharge collected during the mastoid surgery showed slow growing Gram-positive rods that were identified by automated systems (API, VITEK) as A. turicensis The bacterial identification was confirmed by 16S rRNA PCR and subsequent nucleic acid sequencing. No bacterial growth was detected in blood culture bottles after 5 days of incubation. Hence, multiple antibacterial treatments and surgical intervention the patient passed away. Conclusions Anaerobes are rarely involved in CNS infections therefore anaerobic culture of CSF samples is routinely not performed. However, anaerobic bacteria should be considered as potential pathogens when certain risk factors are present, such as paranasal sinusitis, mastoiditis in patients with poor socioeconomic condition. To the best of our knowledge, our case report is the first description of A. turicensis meningitis that has been diagnosed as consequence of purulent mastoiditis.

Most US children with acute otitis media [AOM] receive prompt antibiotic treatment, though guidelines encourage watchful waiting. Previous systematic reviews of antibiotics versus watchful waiting have focused on symptom resolution and RCTs, limiting the assessment of serious, rare complications. We sought to evaluate these complications by including observational studies. RCTs and observational studies that compared antibiotics to placebo or watchful waiting for pediatric clinician diagnosed AOM were identified [PubMed/MEDLINE, Embase, Cochrane Database of Systematic Reviews, Central Register of Controlled Trials, and Web of Science] and reviewed for meta-analysis. Two reviewers independently extracted study characteristics, patient characteristics, and outcomes. We assessed publication bias, study bias with ROBINS-1 and RoB-2 and used random-effects models to assess treatment effects. 24 studies were included. Antibiotics decreased the risk of acute mastoiditis [incidence 0.02%, RR 0.48, 95% CI 0.40-0.59; NNT 5,368]. This protective effect may be underestimated because of misclassification of non-suppurative conditions as AOM. Intracranial complications remained too rare to assess. Antibiotics markedly increased the risk of adverse effects [incidence 10.5%, RR 1.49, 1.27-1.73; NNH 23]. Studies used non-specific criteria for acute mastoiditis, potentially underestimating treatment effects. Prompt antibiotic therapy reduces the risk for some AOM complications. The NNT to prevent serious, rare complications is high, while the NNH is relatively low. Large-scale population-based observational studies using real-world datasets with validated measures of severe complications are needed to improve understanding of risk factors for serious AOM complications, facilitate more selective antibiotic therapy, and optimize individual outcomes and public health.