This study aimed to form astute deductions regarding the presentation, treatment and mortality of otogenic brain complications.

A systematic literature search of four medical databases (PubMed, Embase, Web of Science and Scopus) was conducted. Studies associated with otogenic brain complications were considered eligible. Fixed- and random-effects model meta-analysis was developed to assess the proportion estimate for each outcome individually.

Twenty-eight studies, with 1650 patients in total, were included. In 66 per cent of patients there was a known history of chronic otitis media. The most common symptoms were purulent otorrhoea (84 per cent), headache (65 per cent) and otalgia (45 per cent). A brain abscess was observed in 49 per cent of patients, followed by meningitis (34 per cent) and sinus thrombosis (22 per cent). A combination of surgical and conservative therapy was chosen in 84.3 per cent of cases and the mortality rate approached 11.1 per cent.

Otogenic brain complications are a possibly life-threatening condition. Prompt imaging examination may set the final diagnosis and lead to an effective treatment.

Paediatric otogenic cerebral venous sinus thrombosis is a rare, heterogeneous and life-threatening condition, with possible otological, neurological and ophthalmological sequelae. Its course and outcomes can be widely variable. The publications available often consider individual aspects of paediatric otogenic cerebral venous sinus thrombosis management. The condition itself and the nature of the currently available guidance can lead to uncertainties when holistically managing patients with paediatric otogenic cerebral venous sinus thrombosis.

Clear recommendations for the comprehensive assessment and management of paediatric otogenic cerebral venous sinus thrombosis are presented, along with the literature review upon which they are based. Its clinical and radiological assessment are discussed.

A multidisciplinary approach to assessment and management is recommended, inclusive of infectious diseases, ENT surgery, neurology, ophthalmology and haematology. On balance, anticoagulation is recommended for three months. Follow-up imaging is not recommended in the absence of clinical concern. Follow up by ENT surgery, neurology and ophthalmology departments is recommended.

Bibliographic data for the management of acute mastoiditis in infants aged six months or less are very limited. This study investigated the presenting symptomatology, diagnostic and treatment options, and final outcomes in this age group.

A retrospective review was conducted of all infants aged six months or less suffering from acute mastoiditis, admitted to our department between 2007 and 2017.

Eleven infants were identified. All of them developed the typical symptomatology of acute mastoiditis, while a higher rate of subperiosteal abscess formation was observed. Imaging was necessary in three cases only. Parenteral antibiotics and myringotomy were applied in all infants. A drainage procedure was also included in the infants with a subperiosteal abscess. Antrotomy was reserved for non-responsive cases. No intracranial complications were observed. All infants were cured without further complications or sequelae.

Acute mastoiditis in infants aged six months or less can be safely diagnosed and treated using a standardised algorithmic approach, similar to that used for older children.

Mastoiditis is the most common intra-temporal complication of acute otitis media. Despite potentially lethal sequelae, optimal management remains poorly defined.

A retrospective case review was conducted of children diagnosed with mastoiditis at a tertiary referral centre, in North East England, between 2010 and 2017.

Fifty-one cases were identified, 49 without cholesteatoma. Median patient age was 42 months (2 months to 18 years) and median hospital stay was 4 days (range, 0–27 days). There was no incidence trend over time. Imaging was conducted in 15 out of 49 cases. Surgery was performed in 29 out of 49 cases, most commonly mastoidectomy with (9 out of 29) or without (9 out of 29) grommets. Complications included sigmoid sinus thrombosis (3 out of 49) and extradural abscess (2 out of 51), amongst others; no fatalities occurred.

A detailed contemporary description of paediatric mastoiditis presentation and management is presented. The findings broadly mirror those published by other UK centres, but suggest a higher rate of identified disease complications and surgical interventions.

To analyse the data for patients with otogenic intracranial complications during the study period and draw a comparison with internationally published literature.

A retrospective, observational study was conducted, covering a 10-year period between 1 January 2002 and 31 December 2012.

The study comprised 108 patients (66 males (61.1 per cent) and 42 females (38.9 per cent)), of which 75 per cent were aged less than 20 years. Post-auricular swelling, otorrhoea and a decreased level of consciousness were the most frequently reported symptoms in patients with otogenic intracranial complications. Patients with human immunodeficiency virus did not show any different patterns in terms of presentation and outcome.

A triad of post-auricular swelling, otorrhoea and a decreased level of consciousness should make the clinician more heedful of otogenic intracranial complications. Patients with human immunodeficiency virus and human immunodeficiency virus negative patients were equally affected and had similar presentations. Early surgical management of patients was associated with shorter hospital stays and better outcomes.

Mastoiditis is an otological emergency, and cross-sectional imaging has a role in the diagnosis of complications and surgical planning. Advances in imaging technology are becoming increasingly sophisticated and, by the same token, the ability to accurately interpret findings is essential.

This paper reviews common and rare complications of mastoiditis using case-led examples. A radiologist-derived systematic checklist is proposed, to assist the ENT surgeon with interpreting cross-sectional imaging in emergency mastoiditis cases when the opinion of a head and neck radiologist may be difficult to obtain.

A 16-point checklist (the ‘mastoid 16’) was used on a case-led basis to review the radiological features of both common and rare complications of mastoiditis; this is complemented with imaging examples.

Acute mastoiditis has a range of serious complications that may be amenable to treatment, once diagnosed using appropriate imaging. The proposed checklist provides a systematic approach to identifying complications of mastoiditis.

Acute mastoiditis is a clinically diagnosed suppurative infection of the mastoid air cells and is the most common complication of acute otitis media. Opacification of the mastoid air cells is a commonly reported radiological finding and patients are often erroneously diagnosed with acute mastoiditis when this is present.

This study aimed to quantify incidental findings of mastoid opacification in the asymptomatic paediatric population and contribute to the epidemiological data.

A retrospective cohort study was conducted of all paediatric patients who underwent relevant computed tomography imaging for a non-otological indication.

Data were collected from 767 patients in total. Mastoid opacification was reported in 82 patients. The prevalence was highest in patients aged zero to one year (n = 25, prevalence = 20.3 per cent), followed by those aged two to three years (n = 17, prevalence = 19.5 per cent).

Mastoid opacification is a common incidental finding in the asymptomatic paediatric population, with prevalence rates between 5 per cent and 20 per cent depending on age. The prevalence peaks in patients aged zero to four years (19–20 per cent) and is inversely correlated with increasing age.

This study gives details of a rare case of petrous apicitis that presented as Gradenigo's syndrome and was managed surgically.

This study presents a case report and review of the literature.

A four-year-old female was admitted for failure to thrive following recent sinusitis. Physical examination was positive for right sided facial pain, photophobia and right abducens nerve palsy. Subsequent magnetic resonance imaging revealed a 1.3 × 1.7 × 1.4 cm abscess encompassing the right Meckel's cave. A computed tomography scan showed petrous apicitis and otomastoiditis, confirming Gradenigo's syndrome. The patient was taken to the operating theatre for right intact canal wall mastoidectomy with myringotomy and tube placement. She was discharged on six weeks of ceftriaxone administered by a peripherally inserted central catheter line. At a two-week post-operative visit, she showed notable improvement in neuropathic symptoms.

This study presents a rare case of petrous apicitis managed surgically without the need for a craniotomy or transcochlear procedure.

To determine: (1) the incidence of incidental ‘mastoiditis’ reported on magnetic resonance imaging scans performed in patients with asymmetrical sensorineural hearing loss and/or unilateral tinnitus; (2) how many of those patients have actual otological pathology and/or require treatment; and (3) the financial implications of such a reporting practice.

Retrospective case series.

Between October 2015 and November 2016, 500 patients underwent magnetic resonance imaging of the internal auditory meatus to rule out cerebellopontine angle lesions. There was an incidental finding of increased mastoid signalling in 5.8 per cent (n = 29), of which 20.7 per cent (6 of 29) were reported as bilateral cases. The diagnosis of ‘mastoiditis’ was found in 39.7 per cent (29 of 73). None of these patients had any pathology identified clinically. Other significant pathology was identified in a further 8.8 per cent (n = 44).

The diagnosis of mastoiditis is primarily clinical. An incidental finding of high signalling in the mastoid region on magnetic resonance imaging is highly unlikely to represent actual clinical disease. In patients who are scanned for other reasons and who do not complain of otological symptoms, such findings are unlikely to require otolaryngology input.

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.

To evaluate the effect of pre- and post-admission antibiotic treatment in paediatric acute mastoiditis.

Retrospective study.

Eighty-eight children with acute mastoiditis, from 2003 to 2012, were studied to investigate the effect of antibiotic therapy on short and long-term sequelae.

The median period of antibiotic therapy immediately following hospital discharge was 10 days (range, 5–49 days; standard deviation = 7.46). There were no sequelae within the fortnight following antibiotic therapy completion, but 14 of 40 patients had significant sequelae thereafter, including recurrent otorrhoea, acute otitis media and ventilation tube insertion requirement. Complication rates were significantly higher among patients who had pre-admission antibiotic therapy (52 per cent), compared to patients previously untreated (27 per cent).

Paediatric acute mastoiditis patients treated with antibiotic therapy prior to admission are at higher risk for complication development. The advised time period for oral antibiotic therapy following hospital discharge remains as 10 days in all cases of uncomplicated acute mastoiditis.

Acute mastoiditis is a significant cause of morbidity in the paediatric population. This paper reviews our experience with this condition over the last 10 years and compares it with historical data from Alder Hey Children's Hospital, Liverpool, UK.

A retrospective case note review of patients who presented between 2003 and 2012 was performed.

Forty-six patients with acute mastoiditis were identified. Imaging with computed tomography and magnetic resonance imaging was carried out in 14 cases (30.4 per cent). Intracranial complications were identified in six patients (13.0 per cent), one of whom required neurosurgical intervention. In 27 cases (58.7 per cent), a surgical procedure was performed. Data from 1995 to 2000 revealed similar rates of imaging (30.0 per cent), but significantly lower rates of surgical intervention (23 per cent). A lower rate of intracranial complications (4.8 per cent) in the historical cohort did not prove to be statistically significant (p = 0.419).

The numbers of paediatric patients presenting with acute mastoiditis appears essentially unchanged. Improvement in imaging technology and aids to interpretation may explain the apparent increase of intracranial complications.

To analyse the clinical presentation, treatment and outcome in patients diagnosed with otomastoiditis caused by non-tuberculous mycobacteria.

A retrospective case review of 16 patients diagnosed with otomastoiditis caused by non-tuberculous mycobacteria from 2000 to 2012 was conducted in a hospital and tertiary referral centre in Sweden. The main outcome measures were microbiology findings, and surgical and medical interventions and outcomes. In addition, the relevant literature was reviewed.

In three patients with otomastoiditis, the disease had spread intracranially. The bacteriological findings revealed Mycobacterium abscessus (n = 12), Mycobacterium fortuitum (n = 2) and Mycobacterium avium complex (n = 2). Surgical treatment was undertaken in all but three patients, including exploration of the temporal lobe in one patient. Systemic antibiotic treatment was given to all but one patient. Eight patients healed completely. Eight patients developed hearing loss. Two patients had relapse of the mycobacterial infection several months after the antibiotic treatment had been discontinued.

Non-tuberculous otomastoiditis is a severe ear disease with challenging considerations, and should be treated aggressively in order to avoid morbidity.

Animate foreign bodies in the ear are frequent occurrences in otology practice. Such foreign bodies may lead to hazardous complications.

This paper describes a retrospective study of six patients with a recent history of an insect in the ear who presented with various complications following intervention received elsewhere.

An insect was retrieved from the external auditory canal in four cases and from the antrum in two cases. The patients presented with progressive otological complications: two patients who presented with orbital apex syndrome and cavernous sinus thrombosis succumbed to the disease; three patients suffered sensorineural hearing loss; and two patients had persistent facial palsy. One patient with sigmoid sinus thrombosis, who presented early, experienced complete recovery.

Insects in the ear can lead to hazardous complications. Animate foreign bodies should preferably be managed by a trained otologist, even in an emergency setting. Patients with delayed presentation and complications have a guarded prognosis.

To present the first case of middle-ear actinomycosis in the UK in the last 60 years. The diagnosis and management of actinomycosis of the middle ear is also presented, as well as a review of the recent literature.

This paper reports the case of a nine-year-old girl who presented with recurrent otorrhoea caused by actinomycosis. Mastoid exploration with clearance of the infected tissue, in conjunction with six months amoxicillin, resulted in long-term disease remission. Histology revealed Gram-positive, silver avid (on Grocott staining) and diastase-resistant periodic acid-Schiff negative staining of colonies; this profile was in keeping with the characteristic ‘sulphur granules’ of actinomycosis.

Actinomycosis of the middle ear and mastoid is rare, with less than 45 cases presented in the worldwide literature. This case confirms that the disease should be treated with full surgical clearance and long-term antibiotics.

Streptococcus pneumoniae is a frequent cause of acute mastoiditis. Despite the recent (2005) introduction of pneumococcal vaccination, mastoiditis incidence and severity may be increasing. This study aimed to assess the incidence, severity and microbiology of acute mastoiditis over an 11-year period.

Retrospective review of paediatric acute mastoiditis cases seen at our institution (2000–2010), comparing patients seen prior to vaccination introduction (period one, 2000–2004), around the time of vaccine introduction (period two, 2005–2007) and post-vaccination (period three, 2008–2010).

We reviewed 84 children. In periods one, two and three, respectively: mean annual case load was 8.4, 5 and 9 children; pneumococcal isolates were seen in 40.5, 6.7 and 29.6 per cent of cases; highest recorded fever was 38.6, 38.9 and 38.2°C and highest leukocyte count 18.9, 15.0 and 15.6 × 109/l; incidence of intracranial complications was 11.9, 0 and 7.4 per cent; mean duration of intravenous antibiotics was 6.0, 4.1 and 4.2 days; proportion treated surgically was 71.4, 60.0 and 48.1 per cent; and mean length of in-patient stay shortened.

Pneumococcal mastoiditis admission rates appeared to fall when vaccination was introduced, with concomitant reduction in overall mastoiditis incidence and intracranial complications; subsequently, however, admission rates rapidly returned to pre-vaccination levels.

To evaluate the management of mastoid subperiosteal abscess using two different surgical approaches: simple mastoidectomy and abscess drainage.

The medical records of 34 children suffering from acute mastoiditis with subperiosteal abscess were retrospectively reviewed. In these cases, the initial surgical approach consisted of either myringotomy plus simple mastoidectomy or myringotomy plus abscess drainage.

Thirteen children were managed with simple mastoidectomy and 21 children were initially managed with abscess drainage. Of the second group, 12 children were cured without further treatment while 9 eventually required mastoidectomy. None of the children developed complications during hospitalisation, or long-term sequelae.

Simple mastoidectomy remains the most effective procedure for the management of mastoid subperiosteal abscess. Drainage of the abscess represents a simple and risk-free, but not always curative, option. It can be safely used as an initial, conservative approach in association with myringotomy and sufficient antibiotic coverage, with simple mastoidectomy reserved for non-responding cases.

Acute otitis media is very common, but diagnostic criteria and treatment recommendations vary considerably.

Medline, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were searched using the key words ‘acute otitis media’ AND ‘diagnosis’ OR ‘diagnostic criteria’ OR ‘definition’, and by combining the terms ‘acute otitis media’ AND ‘guidelines’. PubMed was searched using the key words ‘mastoiditis’ and ‘prevalence’.

The 11 most recently published guidelines unanimously agreed that adequate analgesia should be prescribed in all cases. The majority recommended that routine antibiotic prescription should be avoided in mild to moderate cases and when there was diagnostic uncertainty in patients two years and older. Antibiotics were recommended in children two years and younger, most commonly a 5-day course of amoxicillin (or a macrolide in patients allergic to penicillin).

Level 1A evidence shows that selected cases of acute otitis media benefit from antibiotic prescription.

We report a case of bilateral acute mastoiditis and subperiosteal abscesses successfully managed with simultaneous surgery.

A case report and literature review are presented.

A two-year-old boy presented with fever, otalgia, otorrhoea and bilateral protruding ears. He was treated for 72 hours with intravenous antibiotics but failed to improve. Computed tomography confirmed bilateral mastoid abscesses with destruction of the mastoid cortex. Bilateral drainage of the subperiosteal abscesses and bilateral cortical mastoidectomies were carried out. Post-operatively, he recovered well, and free field audiometry showed a normal hearing threshold of 20 dB across all test frequencies.

This is only the second reported case of bilateral mastoiditis and subperiosteal abscesses. This case illustrates the use of bilateral cortical mastoidectomy in the successful management of this condition following failed antibiotic therapy, and highlights important management considerations.

The temporal bone may be the first involved site in cases of systemic disease, and may even present with acute, mastoiditis-like symptomatology. This study aimed to evaluate the incidence of such non-infectious ‘acute mastoiditis’ in children.

Retrospective chart review of 73 children admitted to a tertiary referral centre for acute mastoiditis.

In 71 cases (97.3 per cent), an infectious basis was identified. In the majority of cases (33 of 73; 45 per cent), the responsible bacteria was Streptococcus pneumoniae. However, histopathological studies revealed a non-infectious underlying disease (myelocytic leukaemia or Langerhans' cell histiocytosis) in two atypical cases (2.7 per cent).

‘Acute mastoiditis’ of non-infectious aetiology is a rare but real threat for children, and a challenging diagnosis for otologists. A non-infectious basis should be suspected in every atypical, persistent or recurrent case of acute mastoiditis.