耳源性颅内并发症的诊断及治疗

耳源性颅内并发症虽已少见,但死亡率仍较高。抗生素的应用可改变其自然病程,特别是隐匿性中耳乳突炎诊断较困难,以至延误治疗。本文就其发病、症状、诊断及治疗的有关资料进行综述。     

耳源性颅内积气

依腔内存在气体称颅内积气[1]，颅内积气产生的必要条件是颅腔出现裂孔。气体的来源有3种：①颅腔与外界相通，外界空气通过裂口如开放性骨折处、骨壁缺损处进入颅腔；②含气颅骨骨折或破坏缺损后，颅骨内所含气体经裂口处进入颅内[2]；③产气菌所致的感染引起颅内积气“’。Chiari（1884）尸解时首先发现颅内积气，Luckett1913）首先报道了1例X线诊断的颅内积气。Markham对295例颅内积气病例进行回顾性分析，发现218例（73．9％）继发于外伤，38例（12．9％）继发于肿瘤，26例（8．8％）继发于炎症，2例病因不明。炎症中42％是因为中耳疾…     

耳源性颅内外并发症的CT诊断

目的：探讨耳源性颅内外并发症的ＣＴ特征与诊断。材料与方法：临床与Ｘ线拟诊慢性中耳乳突炎、胆脂瘤及耳源性颅内外并发症患者６５例行中耳乳突ＣＴ薄扫，３１例３４耳经手术及病理证实。结果：中耳乳突溶骨性改变１８例１９耳（５５８８％，１９／３４）；中耳乳突胆脂瘤１３例１５耳（３３１２％，１５／３４）；乳突气房、鼓窦、听骨破坏３４耳（１００％，３４／３４）；天盖、乙状窦板破坏２３耳（６７６５％，２３／２４）；乙状窦血栓性静脉炎６耳（１７６５％，６／３４）；脑脓肿２耳（５８８％，２／３４）。结论：根据中耳乳突骨质破坏及软组织密度影，基本上可以明确诊断与鉴别诊断。同时为中耳乳突手术路径、范围、重建提供参考资料。     

耳源性脑积水

古希腊希波克拉底时期即认为颅内感染的根源为耳（转引自参考文献【1】）。中耳乳突炎的并发症有耳源性脑脓肿、侧窦栓塞、脑膜炎、脑积水等。耳源性脑积水为耳源性颅内感染的罕见并发症。其特点为颅内压增高，而无神经系统的定位体征。1940年以后，由于新的抗生素不断问世，中耳炎的并发症显著减少，耳源性脑积水更为罕见。由于其发病率低，常易延误诊断，给病人带来不可弥补的后果。     

慢性中耳乳突炎手术的医源性并发症

对有经验的耳科医师,慢性中耳乳突炎手术常见并发症的发生率低于1％。本文重点讨论面神经损伤,其次为血管损伤,鼓室与鼓窦盖损伤,半规管损伤及迷路窗损伤。不包括中耳手术所致的颅内感染,脑水肿及其他脑神经损伤。     

儿童急性乳突炎并发症治疗策略北大核心CSCD

目的探讨儿童急性乳突炎并发症的治疗策略。方法回顾性分析23例至少并发一项并发症的急性乳突炎患儿的临床资料,包括骨膜下脓肿16例,周围性面瘫5例(其中1例合并骨膜下脓肿),乙状窦血栓1例,骨膜下脓肿、迷路炎及败血症1例,所有并发症均于住院治疗前发生。所有患儿均住院行手术治疗,19例行乳突切开术,3例行改良乳突根治术,1例重症患儿行乳突根治术;其中11例患儿同时行鼓膜置管术,5例面瘫患儿同时行面神经减压术。结果 23例患儿中22例痊愈,1例患儿因并发败血症家属放弃治疗,自行出院后失访。9例患儿取乳突腔分泌物行细菌病原学检查,其中5例肺炎链球菌阳性。结论治疗儿童急性乳突炎并发症的首要目标为清除病灶,应首选手术治疗,辅以全身应用抗生素,绝大部分患儿预后良好,极少数因病灶累及颅内或并发全身症状预后不良。     

胆固醇肉芽肿性中耳乳突炎

为了探讨对胆固醇肉芽肿性中耳乳突炎的及时诊断和正确处理，回顾性分析了经手术和病理证实的胆固醇肉芽肿性中耳乳突炎６例患者的临床资料。６例中均长期或既往中耳炎病史，其中２例呈典型慢性分泌性中耳炎病史，２例为特发性蓝芭鼓膜改变，另２例则表现为似原发中耳占位病变。     

耳源性脑脓肿并发脑疝8例报告并文献复习

耳源性脑脓肿并发脑疝的死亡率较高,本文报告的8例全部治愈,对脑疝的形成机理、分期诊断、定位诊断及治疗方法等进行了讨论,并复习文献提出对晚期脑疝争取在半小时内施行减压手术有助于提高治愈率。     

急性额窦炎的颅内并发症

鼻窦炎引起的颅内并发症已超过中耳乳突疾病,额窦是颅内感染最常见的窦腔,其次是筛窦、蝶窦和上颌窦。如今由于抗生素的应用鼻窦炎及其并发症已不存在大的问题,但它的使用也可延迟和掩盖颅内感染的神经学症状和体征。感染通常是通过额窦和颅腔之间的静脉交通支扩散到颅内。额窦炎最常见于青少年患者,最常见的病原菌有流感嗜血杆菌。肺炎链球菌、     

Acute mastoiditis: increase in the incidence and complications

OBJECTIVE: Acute mastoiditis is a serious complication of acute otitis media, but it can be treated successfully in most of the cases with broad spectrum intravenous antibiotics and myringotomy. In the last 5 years we have perceived that there have been more complicated cases in the otic infectious pathology and the frequency was also higher. METHODS: We reviewed the cases of mastoiditis in the last 10 years (1996-2005) in The Ni?o Jesús University Children Hospital in Madrid to confirm the clinic impression, the bacteriology, treatments and evolution of the children and analyze the causes of this clinic situation. RESULTS: We have studied 215 cases of mastoiditis (0.6-17 years), 67.4% less than 3 years old and 69.3% males. The number of cases every year was the double since 1999 with the same percentage of admissions in the Pediatric service, and the triple in 2005. The percentage of surgical treatment grew from 4.3% to 33% in the last years and to 70% in 2005. Most cases (80%) have received prior antibacterial agent therapy, but individual pathogens and current complications of periostitis or subperiosteal abscess formation were equally distributed between the two groups. We have detected a 28.57% of Streptococcus pneumoniae and a significative high rate of Staphylococcus aureus (16.32%). A 53.68% of cases had negative cultures. CONCLUSIONS: There is a progressive increase in the incidence of acute mastoiditis in our medium, and an increase of the surgical treatments. Ten years ago the process was controlled with antibiotic therapy only, but now the number of interventions has been eight times the previous years. Most cases of acute mastoiditis have responded well to medical management alone. But if higher levels of resistance predominate, more severe forms of pneumococcal or other pathogen like S. aureus disease are likely to be seen, these would be less likely to respond to oral or parenteral antibiotic therapy, so, tympanocentesis for middle ear culture may become more valuable and more frequently used in cases of antibiotic treatment failures, and surgical therapy may be necessary more often in the future. Our hospital seems to be in this tendency now.     

Surgical management of acute mastoiditis with epidural abscess

Abstract

The prevalence of intracranial complications of acute coalescent mastoiditis in children has decreased significantly; however, this clinical problem persists, with a relatively high mortality. The common practice for management of acute mastoiditis with epidural abscess is mastoidectomy, drainage and placement of a ventilation tube, which means that the main pathology is confined to the mastoid cavity. We suggest that tympanic exploration is mandatory in certain cases, an example of which we present here. We report one case of acute mastoiditis with epidural abscess, in which mastoidectomy with tympanic exploration was needed to ensure drainage throughout the cavities and to prevent pressure rebuilding in the mastoid and tympanic cavities. We stress that if the tympanic membrane is thickened and no fluid is drained when placing a pressure equalization tube, there could be granulation tissue in the tympanum and tympanic exploration is mandatory, especially in a case of acute mastoiditis with intracranial complications accompanied by prolonged symptoms.     

Acute mastoiditis in children with a cochlear implant

ObjectivesCochlear implantation is performed at a young age, when children are prone to acute otitis media. Acute mastoiditis is the most common complication of otitis media, but data on its management in the presence of a cochlear implant are sparse. The objective of this study was to assess the characteristics, treatment, and outcome of acute mastoiditis in children with a cochlear implant.MethodsThe medical files of all children who underwent cochlear implantation at a pediatric tertiary medical center in 2000–2014 were retrospectively reviewed. Those diagnosed with acute mastoiditis after implantation were identified, and data were collected on demographics, history, presentation, method of treatment, complications, association with untreated otitis media with effusion, and long-term middle-ear sequelae.ResultsOf the 370 children (490 ears) who underwent cochlear implantation, 13 (3.5%) were treated for acute mastoiditis (median age at acute mastoiditis, 32 months). Nine had a pre-implantation history of chronic secretory or acute recurrent otitis media, and 5 had been previously treated with ventilation tubes. In all 9 children who had unilateral cochlear implant, the acute mastoiditis episode occurred in the implanted ear. The time from implantation to mastoiditis was 5–61 months. The same treatment protocol as for normal-hearing children was followed, with special attention to the risk of central nervous system complications. Primary treatment consisted of myringotomy with intravenous administration of wide-spectrum antibiotics. Surgical drainage was performed in 8 out of 13 patients, with (n = 7) or without (n = 1) ventilation-tube insertion, to treat subperiosteal abscess or because of lack of symptomatic improvement. There were no cases of intracranial complications or implant involvement or need for a wider surgical approach. No middle-ear pathology was documented during the average 3.8-year follow-up.ConclusionsThe relatively high rate of acute mastoiditis and subperiosteal abscess in children with a cochlear implant, predominantly involving the implanted ear, supports the suggestion that recent mastoidectomy may be a risk factor for these complications. Despite the frequent need for drainage, more extensive surgery is usually unnecessary, and recovery is complete and rapid. As infections can occur even years after cochlear implantation, children with otitis media should be closely followed, with possible re-introduction of ventilation tubes.     

Conservative management of acute mastoiditis in children

OBJECTIVE: To review the current management of acute mastoiditis with critical emphasis on the role of myringotomy. DESIGN: A retrospective chart review. SETTING: Tertiary-care, university affiliated children's hospital. PATIENTS: One hundred and forty-four consecutive children hospitalized for acute mastoiditis between the years 1991 and 2002. INTERVENTIONS: All children were treated with parenteral antibiotics (conservative management). Myringotomy was performed at the discretion of the otolaryngologist on-call. MAIN OUTCOME MEASURES: Comparing outcomes of children with or without myringotomy regarding hospital stay, complications and the need for surgical interventions. RESULTS: Myringotomy was performed in 34.6% of episodes. The children who underwent myringotomy were found to be significantly younger (22.4 compared to 28.8 months, p=0.028) and had more complications (n=17 vs. n=8, p<0.001). Complications overall occurred in 16.3% of episodes. Performing myringotomy had no significant effect on the duration of hospital stay. Children pretreated with antibiotics underwent significantly less myringotomies p=0.027. There were no significant differences between children who underwent myringotomy and those who did not with regard to WBC count, or ESR. CONCLUSIONS: These findings suggest that myringotomy may not be required in all cases of acute mastoiditis. Parenteral antibiotics is sufficient in most cases. Criteria for myringotomy may include a younger age. Conservative management resulted in good outcomes in this series.     

Acute mastoiditis in children: a retrospective study of 188 patients

Objective

The aim of this study is to define the clinical and bacteriological characteristics of acute mastoiditis (AM) in children in order to optimize diagnostic work-up and treatment.

Methods

In this retrospective study, 188 children between 3 months and 15 years of age (15 ± 24 months; median ± SD) were referred to our pediatric ENT emergency center for AM during a 7-year period (December 2001-January 2008).

Results

Fifty seven percent were male and 43% were female. Clinical follow-up duration was 3.9 ± 0.7 months (mean ± SEM). The incidence of AM remained stable during the whole study period. Microbiological samples (n = 236) were negative in 33% of cases. The most frequently isolated germs were Streptococcus pneumoniae (51%), Streptococcus pyogenes (11.5%), Anaerobes (6.5%), and coagulase-negative Staphylococcus (6.5%). Paracentesis, puncture of retro auricular abscess under local anesthesia, and peroperative samples all contributed to isolate the involved germ(s). All the patients were hospitalized and received intravenous antibiotics, and 36.2% (n = 68) underwent surgery. Several surgical procedures were necessary in 4 cases (2.1%). AM recurrences requiring a second hospitalization were observed in 8 patients (4.3%). The only observed complication was lateral sinus thrombosis (n = 6; 3.2%). Surgical failures, requiring more than one surgical procedure, were more frequent in case of: (i) presence of Anaerobes (p ≤ 0.001) or Gram-negative bacteria (p ≤ 0.05) in microbiological samples; (ii) surgical drainage without mastoidectomy (p ≤ 0.001). Recurrences were more frequent in AM due to Streptococcus pneumoniae.

Conclusions

Based on our findings and on literature data, a protocol was established in order to standardize the management of pediatric AM in our center. The mains points are: no systematic surgery; if surgery is indicated, it must encompass a mastoidectomy; broad-spectrum intravenous antibiotic treatment covering the most commonly involved germs (3rd generation cephalosporin) and secondarily adapted to the results of microbiological samples. If the infection is not controlled after 48 h of intravenous antibiotherapy, a mastoidectomy had to be performed.